EHR315 - Week 2 Dr Stephen Bird

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Understanding the Healing Understanding the Healing ProcessProcess• Primary Injury

• Inflammatory Response

• Role of Mobility

• Injuries to Various Tissues

• Musculoskeletal StructuresMusculoskeletal Structures

• Managing the Healing Process

Reading: Chapter 2

Quiz 2: Functional anatomy

The Healing ProcessPrograms based on healing process framework

1 Bl di

No definitive beginning or

end

1. Bleeding (Inflammatory)

2. Fibroblastic-repair

(Proliferation)

3. Maturation-(remodeling)

EHR315 - Week 2 Dr Stephen Bird

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The Primary Injury• Acute or chronic

1. Macrotraumatic injuriesA t t i di t i /di bilit

Look away if you don’t like pain

• Acute trauma; immediate pain/disability

• Fractures, dislocations, sprains, strains

2. Microtraumatic injuries• Overuse injuries, repetitive overload, incorrect mechanics

• Tendinitis, tenosynovitis bursitis

• Secondary injurySecondary injury– Inflammatory or hypoxia response

EHR315 - Week 2 Dr Stephen Bird

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1. Inflammatory Response PhaseInjury = altered cellular metabolism = chemical mediators

• Macroscopic characteristicsMacroscopic characteristics

1. Swelling2. Tenderness3. Redness4. Increased temperature

• Initial response is critical in healing process

– Leukocytes, phagocytic cells and exudate delivered to tissue

– Protective response, localization and removal of injury by-products

Stages of Inflammation

• Vasoconstriction• 5-10min post-injury• Initial response lasts 24-48 hoursp

• Histamine: causes vasodilation cell permeability• Leukotrienes: causes margination• Cytokines: attract leukocytes to site of InF

Pl b l l l h i fl id d i• Plug obstructs local lymphatic fluid drainage• Results in localization of the injury• Begins 12hrs post-inj; complete within 48hrs

EHR315 - Week 2 Dr Stephen Bird

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Vascular Reaction

Chemical mediators

Cl tClot Formation

2. Fibroblastic-Repair Phase

Proliferative/regenerative activity leads to scar formation– referred to as fibroplasia

begins within 2 hrs can last– begins within 2 hrs, can last _________________

• Signs associated with InF response subside

Granulation tissue• Breakdown of the fibrin clot

• Consists of fibroblasts, collagen and capillaries

Collagen deposited randomlyg p y _________________• Results in scar tensile strength

Persistent InF response promotes extended fibroplasiaresulting in increased scarring

EHR315 - Week 2 Dr Stephen Bird

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CollagenMajor structural protein

– Forms strong structures that hold connective tissue together

Enables tissue to resist mechanical forces/ deformation– Enables tissue to resist mechanical forces/ deformation

• Collagen fibrils: ___________ elements of connective tissue

– Mechanical/physical properties allow collagen to respond to loading /deformation

• Elasticity, visco-elasticity, plasticity, creep response, hysteresis

– Limitations exceed, injury results

3. Maturation-Remodeling Phase

Realignment of _________________– Continued breakdown and synthesis of collagen

Increased stress/strain results in increased collagen realignment– Increased stress/strain results in increased collagen realignment

• ___ wks firm, strong, contracted, nonvascular, scar present– Fibroplasia - can last 4-6 wks

• Maturation long-term process– may require several years to complete

EHR315 - Week 2 Dr Stephen Bird

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Role of Progressive Mobility• Wolff’s law: soft tissue respond to physical demands

placed upon them, causing tissue to remodel along lineof tensile forceof tensile force– Controlled mobilisation superior to immobilisation for scar

formation, revascularisation & muscle regeneration

1. InF Response Phase

2. Repair Phase

3. Remodeling Phase

• Extent of Injury

• Edema

• Atrophy

• Corticosteroids

Factors that Impede Healing

• Hemorrhage

• Poor vascular supply

• Separation of tissue

• Muscle Spasm

• Infection

• Age

EHR315 - Week 2 Dr Stephen Bird

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Injuries to Ligament

Sprains: damage to a ligament

• Ligamentsg

Inelastic band of tissue, provides joint stability

Controls bone position during joint motion

Provides proprioceptive input

t S

pra

ins

G d II t ( i )

Grade I tear

minor stretching, tearing of the ligaments; no joint instability

of

Lig

amen

t

Grade II tear (major) major tearing, separation of the ligament; moderate to severe joint

i t bilit d t t i

Grade II tear (minor)major tearing, separation of the ligament; moderate to severe joint

instability; moderate to severe pain

Gra

des

o

Grade IIIcomplete tear, gross joint instability; injury may involve multiple joint

structures

instability; moderate to severe pain

EHR315 - Week 2 Dr Stephen Bird

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Ligament HealingSame course of repair as with other vascular tissues

– Extra-articularly ligament sprains bleeding in subcutaneous space

– Intra-articular ligament sprains bleeding within the capsule

Vascular

• vascular proliferation, fibroblastic activity and clot formation• during the initial _________________________

Collagen Granulation tissue

• bridge torn ends of ligaments via scar tissue formation• scar maturation and collagen tensile strength increase

Factors Affecting Healing1. Surgically repaired extra-articular ligaments

– Heal with less scarring Stronger than un repaired ligaments– Stronger than un-repaired ligaments

2. Non-surgically repaired ligaments

– Heal via fibrous scarring = ligament lengthening / joint instability

3. Intra-articular ligament damage

– synovial fluid presence, diluting hematoma, disrupting clot/healing

4. Ligament healing/immobilization: decreased tensile strength

– Muscle strength training can enhance joint stability

EHR315 - Week 2 Dr Stephen Bird

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Injuries to Musculotendinous Structures

• Skeletal muscle exhibits 4 traits (page 31)

– .

– .

– .

– .

• Muscle size and architecture often contributeto type and magnitude of motionyp g

– (gross vs. fine, powerful vs. coordinated)

Mechanics of Muscular Contraction

Review the following:

1. .2. .3. .4. .

EHR315 - Week 2 Dr Stephen Bird

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Muscle StrainsStrains occur when the musculotendinous unit is:

1. Overstretched

2 F d t t t i t t t2. Forced to contract against too great a resistance…. (_________________)

• Damage occurs

– Muscle

– Tendon

– ..

– Tendon-bone interface

Armfield, D. R., Kim, D. H.-M., Towers, J. D., Bradley, J. P., & Robertson, D. D. (2006). Sports-related muscle injury in the lower extremity. Clinics in Sports Medicine, 25(4), 803-842.

sifi

cati

on

s

Grade I tear

• some fibers have been stretched or actually torn

• resulting in tenderness and pain on active ROM

• movement painful but full range present

Str

ain

Cla

ss

Grade II tear (minor)

• number of fibers have been torn and active contraction is painful,

• usually a depression or divot is palpable

• some swelling and discoloration result

Mu

scle

S

Grade III

• Complete rupture of muscle or musculotendinous junction

• significant impairment,

• initially a great deal of pain that diminishes due to nerve damage

EHR315 - Week 2 Dr Stephen Bird

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4 st

ages

• produce gel-like matrix leading to fibrosis and scarring

• lead to phagocytosis

1Hemorrhaging

and edema

2Fibroblasts and ground

Hea

ling

: 4 and edema and ground

substance

3Myoblasticcell infiltrate the region

4Collagen

undergoes maturation

Mu

scle

• promotes myofibril regeneration

• active contractions critical to apply tensile stress

the region maturation

Lengthy recovery for each grade, Patience is a must

TendinitisDescribes multiple pathological tendon conditions

– Tendon InF, with no involvement of paratenon

• Paratenonitis

– InF of tendon outer layer

– Friction injury

• Tendinosis

– Degenerative tendon changes no clinical/histological signs of InF

• Chronic tendinitis significant tendon degeneration

– Most common: _______________________________

EHR315 - Week 2 Dr Stephen Bird

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Tendon HealingTime frame dependant on severity of injury

Wk 0 2Wks 0-2

• healing tendon adheres to the surrounding tissue

Wks 3-4

• tendon separates (varying degrees) from tissues

Wks 5+

• tensile strength increases

Managing the Healing Process Through Rehabilitation

Pre-Surgical Phase

• If surgery can be delayed, ExTh may help to improve outcome

• Maintaining/increasing strength, ROM, CV fitness, NM control enhance athlete’s ability to perform rehabilitation after surgery

EHR315 - Week 2 Dr Stephen Bird

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Phase I – Acute Injury Phase

Initial swelling management / pain control crucial

______________________________

Loading too aggressive first 48hr InF process may not accomplish what it needs toneeds to....

Immobilization for 24-48hrs????

• Day 3-4 engage in mobility ex

gradually bear weight if lower extremity injury

Use of NSAID’s (table 2.1 p.41)

Järvinen, T. A. H., Järvinen, T. L. N., Kääriäinen, M., Äärimaa, V., Vaittinen, S., Kalimo, H., et al. (2007). Muscle injuries: optimising recovery. Best Practice and Research Clinical Rheumatology, 21(2), 317-331.

Phase II – Repair Phase

As InF subside = pain passive ROM ex added

CV fitness

Restore ROM

Regain / increase strengthRegain / increase strength

Re-establish NM control

• Continued modality use for pain modulation and ______________________

Cryotherapy ?

Electrical stimulation (TENS)?• Transcutaneous Electrical Nerve Stimulation

Hubbard, T.J., & Denegar, C.R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training, 39(3), 278-279.

Machado, A., et al. (2012). The effects of transcutaneouselectrical nerve stimulation on tissue repair: A literature review. Plastic Surgery, 20(4), 237 – 240.

Finberg, M., et al.. (2013). Effects of electro-stimulation therapy on recovery from acute team sport activity. Int J Sports Physiol Perf, 8(3), 293-299.

EHR315 - Week 2 Dr Stephen Bird

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Phase III – Remodeling Phase

Longest phase; ultimate goal R2S/R2A

Continued collagen realignment

Pain continues to decrease with activity

• Regain sports-specific skills

Dynamic functional activities

Sports-directed strengthening activities

Plyometric strengthening

• Functional testing

Determine specific skill weakness Determine specific skill weakness

Werner, G. (2010). Strength and conditioning techniques in the rehabilitation of sports injury. Clinics in Sports Medicine, 29(1), 177-191. p183

Phase III – Remodeling Phase (continued)

• Heating modalities

Ultrasound, diathermy

Increase circulation in deeper tissue

• Manual therapy

Massage: reduce guarding, spasm, pain

Techniques include Hoffa massage Friction massage, Rolfing Acupressure,Connective tissue massage, Myofascial release

Enhanced lymphatic flow will deliver essential nutrients and increase breakdown/removal of waste.

EHR315 - Week 2 Dr Stephen Bird

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Summary: Key Points1. Healing process

– Inflammation

– Fibroblastic-repair

– Maturation-remodeling

2. Tissue response to injury: _____________________________

– How does injury effect the mechanics of muscular contraction?

3. Expedite recovery of function– ROM strength cardiorespiratory fitness NM control– ROM, strength, cardiorespiratory fitness, NM control

4. Prevent recurrence of injury the phased-approach to rehab– Phase I:

– Phase II:

– Phase III: