Soft Tissue Injury, Repair,

8/3/2019 Soft Tissue Injury, Repair,

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SOFT TISSUE INJURY, REPAIR,AND MANAGEMENT

Prepared by:Maria Christina M. Gutierrez, PTRP


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SOFT TISSUE LESIONS

Examples of Soft Tissue LesionsMusculoskeletal Disorders Sprain vs. Strain

Dislocation vs Subluxation

Synovitis, Bursitis, Tendinitis, Tenosynovitis,Tenovaginitis and tendinosis

Hemarthrosis

Muscle/tendon rupture/lesion

Ganglion

Contusion

Overuse Syndromes


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Clinical Conditions Resulting

from Trauma or Pathology Joint Dysfunction

Contracture

Adhesion

Reflex Muscle Guarding

Intrinsic Muscle Spasm

Muscle Weakness Myofascial compartment syndromes


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Severity of Tissue Injury

Grade 1 (first-degree). Mild pain at the time of injury or

within the first 24 hours. Mild swelling, local tenderness,

and pain occur when the tissue is stressed.

Grade 2 (second-degree). Moderate pain that requiresstopping the activity. Stress and palpation of the tissue

greatly increase the pain. When the injury is to ligaments,

some of the fibers are torn, resulting in some increasedjoint mobility.

Grade 3 (third-degree). Near-complete or complete tearor avulsion of the tissue (tendon or ligament) with severe

pain. Stress to the tissue is usually painless; palpation mayreveal the defect. A torn ligament results in instability ofthe joint.


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Irritability of Tissue: Stages

of Inflammation and Repair Acute Stage (Inflammatory Reaction) During the

acute stage, the signs of inflammation are present;they are swelling, redness, heat, pain at rest, andloss of function. When testing the range of motion

(ROM), movement is painful, and the patient usuallyguards against the motion before completion of therange is possible . The pain and impaired movementare from the altered chemical state that irritates thenerve endings, increased tissue tension due to

edema or joint effusion, and muscle guarding, whichis the bodys way of immobilizing a painful area. Thisstage usually lasts 4 to 6 days unless the insult isperpetuated


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of Inflammation and Repair Subacute Stage (Repair and Healing) During the

subacute stage, the signs of inflammationprogressively decrease and eventually are absent.When testing ROM, the patient may experience pain

synchronous with encountering tissue resistance atthe end of the available ROM . Pain occurs onlywhen the newly developing tissue is stressed beyondits tolerance or when tight tissue is stressed. Musclesmay test weak, and function is limited as a result of

the weakened tissue. This stage usually lasts 10 to 17days (14 to 21 days after the onset of injury) but maylast up to 6 weeks in some tissues with limitedcirculation, such as tendons.


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of Inflammation and Repair Chronic Stage (Maturation and Remodeling)

There are no signs of inflammation during thechronic stage. There may be contractures oradhesions that limit range, and there may bemuscle weakness limiting normal function.Connective tissue continues to strengthen andremodel during this stage. A stretch pain may befelt when testing tight structures at the end of

their available range . Function may be limitedby muscle weakness, poor endurance, or poorneuromuscular control. This stage may last 6months to 1 year depending on the tissueinvolved and amount of tissue damage.


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of Inflammation and Repair Chronic Inflammation (Overuse Syndrome)

An overuse syndrome is a state of prolongedinflammation.There are symptoms of increased pain,swelling, and muscle guarding that last more than several

hours after activity. There are also increased feelings ofstiffness after rest, loss of ROM 24 hours after activity, andprogressively greater stiffness of the tissue as long as theirritation persists.

Chronic Pain Syndrome

Chronic pain syndrome is a state that persists longer than 6months. It includes pain that cannot be linked to a source ofirritation or inflammation and functional limitations anddisability that include physical, emotional, and psychosocialparameters.


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MANAGEMENT DURING

THE ACUTE STAGE Management GuidelinesProtection Phase

The therapists role during the protection phase ofintervention is to control the effects of the

inflammation, facilitate wound healing, and maintainnormal function in unaffected tissues and bodyregions

Patient Education

Protection of the Injured Tissue

Prevention of Adverse Effects of Immobility

Tissue-specific movement

Intensity

General movement


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MANAGEMENT DURING

THE ACUTE STAGE P R E C A U T I O N : If the movement

increases pain or inflammation, it is either oftoo great a dosage or it should not be done.Extreme care must be used with movementat this stage.

Passive range of motion.

Low-dosage joint mobilization techniques Muscle setting

Massage


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MANAGEMENT DURING

THE SUBACUTE STAGE Management Guidelines Controlled Motion Phase

The therapists role during this stage is critical. The patientfeels much better because the pain is no longer constant,and active movement can begin. It is easy to begin too

much movement too soon or be tempted to approachintervention cautiously and not progress rapidly enough.Understanding the healing process and tissue response tostresses underlies the critical decisions that are madethroughout this phase of intervention. The key is to initiateand progress nondestructive exercises and activities (i.e.,

exercises and activities that are within the tolerance of thehealing tissues, which can then respond without reinjury orinflammation).


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MANAGEMENT DURING

THE SUBACUTE STAGE Patient Education Management of Pain and Inflammation

Monitor activities and exercises

P R E C A U T I O N : The new tissue being developed is fragile and easilyinterrupted. The patient often feels good and returns to normal activitytoo soon, causing exacerbation of symptoms. Exercises progressed toovigorously or functional activities begun too early can be injurious to thefragile, newly developing tissue and therefore may delay recovery byperpetuating the inflammatory response.22,26However, if movement is notprogressed, the new tissue adheres to surrounding structures andeventually becomes a source of pain and limited tissue mobility.

Initiation of Active Exercises Multiple-angle, submaximal isometric exercises

Active range of motion exercises

Muscular endurance


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MANAGEMENT DURING

THE SUBACUTE STAGE Protected weight-bearing exercises.

P R E C A U T I O N : Eccentric and heavy-resistanceexercises (such as PRE) may cause added trauma to muscleand are not used in the early subacute stage after muscle

injury when the weak tensile quality of the healing tissuecould be jeopardized. For nonmuscular injuries, eccentricexercises may not reinjure the part, but the resistanceshould be limited to a low intensity at this stage to avoiddelayed-onset muscle soreness. (This is in contrast to usingeccentric exercises to facilitate and strengthen weak

muscles when there has been no injury to take advantageof greater tension development with less energy ineccentric contractions,


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MANAGEMENT DURING

THE SUBACUTE STAGE Initiation and Progression of Stretching

Warm the tissues.

Inhibition techniques Stretching techniques

Massage

Use of the new range


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MANAGEMENT DURING

THE CHRONIC STAGE

Maturation of Tissue The primary differences in the state of the healing

tissue between the late subacute and chronic

stages are the improvement in quality (orientationand tensile strength) of the collagen and thereduction of the wound size during the chronicstages. The quantity of collagen stabilizes; andthere is a balance between synthesis anddegradation. Depending on the size of thestructure or degree of injury or pathology, healing,with progressively increasing tensile quality in theinjured tissue, may continue for 12 to 18 months.


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Remodeling of Tissue Because of the way immature collagen molecules are

held together (hydrogen bonding) and adhere tosurrounding tissue, they can be easily remodeled with

gentle and persistent treatment. This is possible for upto 10 weeks. If not properly stressed, the fibers adhereto surrounding tissue and form a restricting scar. Asthe structure of collagen changes to covalent bondingand thickens, it becomes stronger and resistant to

remodeling. At 14 weeks, the scar tissue isunresponsive to remodeling. Consequently, an old scarhas a poor response to stretch. Treatment under theseconditions requires either adaptive lengthening in thetissue surrounding the scar or surgical release


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Management Guidelines

Return to Function Phase

Considerations for Progression of Exercises

Signs of Excessive Stress with Exercise or Activities Exercise or activity soreness that does not decrease after 4

hours and is not resolved after 24 hours Exercise or activity pain that comes on earlier or is

increased over the previous session

Progressively increased feelings of stiffness and

ROM over several exercise sessions Swelling, redness, and warmth in the healing tissue

Progressive weakness over several exercise sessions

Decreased functional usage of the involved part


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Progression of Exercises for Muscle

Performance: Developing Neuromuscular

Control, Strength, and Endurance If the patient is not using some of the muscles

because of inhibition, weakness, or dominance ofsubstitute patterns, isolate the desired muscle actionor use unidirectional motions to develop awareness

of muscle activity and control of the movement. Progress exercises from isolated, unidirectional,

simple movements to complex patterns andmultidirectional movements requiring coordinationwith all muscles functioning for the desired activity.

Progress strengthening exercises to simulate specificdemands including both weight-bearing and non-weight-bearing (closed and open chain) and botheccentric and concentric contractions


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Progression of Exercises for Muscle

Performance: Developing Neuromuscular

Control, Strength, and Endurance Progress trunk stabilization, postural control, and balance

exercises as well as coordinate with extremity motions foreffective total body movement patterns.

Teach safe body mechanics and have the patient practice

activities that replicate his or her work environment. Often overlooked but of importance in preventing injury

associated with fatigue is developing muscular endurancein the prime mover muscles and stabilizing muscles as wellas cardiovascular endurance

Return to High-Demand Activities are progressed further to more intense exercises including

plyometrics, agility training, and skill development


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MANAGEMENT GUIDELINESAcute Stage/Protection Phase

Impairments:

Inflammation, pain, edema, muscle spasm

Impaired movementJoint effusion (if the joint is injured or if there is arthritis)

Decreased use of associated areasPlan of Care Intervention (up to 1 week postinjury)

1. Educate the patient.2. Control pain, edema, spasm.3. Maintain soft tissue and

joint integrity and mobility.4. Reduce joint swelling ifsymptoms are present.5. Maintain integrity andfunction of associatedarease.

Precautions: The proper dosage of rest andmovement must be used during the inflammatorystage. Signs of too muchmovement are increased pain or increasedinflammation.Contraindications: Stretching and resistance

exercises should not be performed at the site of theinflamed tissue.

1. Inform patient of anticipated recovery time andhow to protect the part while maintainingappropriate functional activities.2. Cold, compression, elevation, massage (48

hours).Immobilize the part (rest, splint, tape, cast).Avoid positions of stress to the part.Gentle (grade I) joint oscillations with joint in pain-free position.3. Appropriate dosage of passive movementswithin limit of pain, specific to structure

involved.Appropriate dosage of intermittent muscle setting orelectrical stimulation.4. May require medical intervention if swelling israpid (blood).Provide protection (splint, cast).5. Active-assistive, free, resistive, and/or modifiedaerobic exercises, depending on proximity

to associated areas and effect on the primary lesion.Adaptive or assistive devices as needed to protect the


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MANAGEMENT GUIDELINESSubacute Stage/Controlled Motion Phase

Impairments:

Pain when end of available ROM is reached, Decreasing soft tissue edema

Decreasing joint effusion (if joints are involved), Developing softtissue, muscle, and/or joint contractures, Developing muscle weakness

from reduced usage, Decreased functional use of the part and associated

areasPlan of Care Intervention (up to 3 weeks postinjury)

1. Educate the patient.2. Promote healing of injuredtissues.

3. Restore soft tissue, muscle,and/or joint mobility.

1. Inform patient of anticipated healing time andimportance of following guidelines.Teach home exercises and encourage functionalactivities consistent with plan;

monitor and modify as patient progresses.2. Monitor response of tissue to exerciseprogression; decrease intensity if inflammationincreases.Protect healing tissue with assistive devices, splints,tape, or wrap; progressivelyincrease amount of time the joint is free to move

each day and decrease use ofassistive device as strength in supporting musclesincreases.3. Progress from passive to active-assistive toactive ROM within limits of pain.Gradually increase mobility of scar, specific tostructure involved.Progressively increase mobility of related structures if

they are tight; use techniquesspecific to tight structure.


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MANAGEMENT GUIDELINESSubacute

Stage/Controlled Motion Phase

Plan of Care Intervention (up to 3 weekspostinjury)

4. Develop neuromuscular control,muscle endurance, and strength

in involved and related muscles.5. Maintain integrity and functionof associated areas.

Precautions: The signs ofinflammation or joint swelling normally

decrease early in this stage. Somediscomfort willoccur as the activity level is progressed,but it should not last longer than acouple of hours. Signs of too muchmotion or

activity are resting pain, fatigue,increased weakness, and spasm.

4. Initially, progress multiple-angleisometric exercises within patients

tolerance;begin cautiously with mild resistance.Initiate AROM and protected weightbearing and stabilization exercises.As ROM, joint play, and healingimprove, progress isotonic exercises

withincreased repetitions.Emphasize control and propermechanics.Progress resistance later in this stage.5. Apply progressive strengthening

and stabilizing exercises, monitoringeffect on


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MANAGEMENT GUIDELINESChronic Stage/Return to Function Phase

Impairments:

Soft tissue and/or joint contractures and adhesions that limit normal ROM or

joint play

Decreased muscle performance: weakness, poor endurance, poor neuromuscularcontrol

Decreased functional usage of the involved part

Inability to function normally in an expected activity

Plan of Care Interventions (3 weeks postinjury)

1. Educate the patient.2. Increase soft tissue, muscleand/or joint mobility.3. Improve neuromuscular control,

strength, muscle endurance.

1. Instruct patient in safe progressions of exercises and

stretching.Monitor understanding and compliance.Teach ways to avoid reinjuring the part.Teach safe body mechanics.Provide ergonomic counseling.

2. Stretching techniques specific to tight tissue: Joint and selected ligaments (joint mobilization). Ligaments, tendons and soft tissue adhesions (cross-fibermassage). Muscles (neuromuscular inhibition, passive stretch, massage,and flexibilityexercises).3. Progress exercises: Submaximal to maximal resistance. Specificity of exercise using resisted concentric andeccentric, weightbearing and non-weight-bearing. Single plane to multiplane motions. Simple to complex motions, emphasizing movements thatsimulatefunctional activities. Controlled proximal stability, superimpose distal motion.

Safe biomechanics. Increase time at slow speed; progress complexity and time;progress speed


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MANAGEMENT GUIDELINESChronic Stage/Return to

Function Phase

Plan of Care Interventions (3 weeks postinjury)

4. Improve cardiovascular endurance.5. Progress functional activities.

Precautions: There should be no signsof inflammation. Some discomfortwill occur as the activity level isprogressed,but it should not last longer than a

couple of hours. Signs that activitiesare progressing too quickly or with toogreat adosage are joint swelling, pain thatlasts longer than 4 hours or thatrequires medication for relief, a

decrease in strength, or fatiguing morel

4. Progress aerobic exercises usingsafe activities.5. Continue using supportive and/or

assistive devices until the ROM isfunctionalwith joint play, and strength insupporting muscles is adequate.Progress functional training withsimulated activities from protected and

controlledto unprotected and variable.Continue progressive strengtheningexercises and advanced trainingactivitiesuntil the muscles are strong enough

and able to respond to the requiredf l

Soft Tissue Injury, Repair,

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