Lecture 1-intro Flashcards
Ligaments and tendons
- composed of dense, organised connective tissue
- 78% water, 20% collagen and 2 % GAGs
- collagen forms 70% of dry weight
- extreme tensile strength with great resistance to pulling forces with minimal elongation
What are the phases of connective tissue healing?
- Reaction phase
-lasts up to 72hrs
Vasodilation, oedema, stimulation of pain fibres - Regeneration phase
- lasts from 48hrs to 6 weeks
- elimination of debris, revascularization, fibroblast proliferation
- reduces pain and inflammation - Remodelling phase
- lasts from 3 weeks to 12 months
- contraction and slow maturation of collagen for increase in tensile strength
- increase ROM, strength and proprioception
-
What are the classifications of connection tissue ligament trauma / injury?
First degree (mild) - microscopic stretching or minimal tearing ( classic strain) - painful but minimal loss of integrity - full recovery 10 days - 2 weeks Second degree (moderate) - moderate tearing - some loss of structural integrity -2-3 weeks of activity modification and rehab with up to 3 months full recovery Third degree (severe) - complete tear - up to 6 months for full recovery
What is the grading used for a connective tissue injury?
Grade 1: pain following activity
Grade 2: pain during activity
Grade 3: pain interferes with activity
Grade 4: continuing pain even between activities
Grade 5: pain interferes with activity and daily living
What are the aims of treatment in muscle injury?
- minimise further damage
- reduce pain and spasm
- control haemorrhage and oedema
- promote healing
- reduce scaring formation
- regain strength
- regain flexibility
What are the classifications of a muscle injury?
- Exercise induced muscle injury
- Muscle strain
- Contusion
- Avulsion
Exercise induced muscle injury
• Also referred to as post-exercise soreness
• Manifests 24 – 48 hours following unaccustomed or intense
exercise
• Excessive eccentric loading magnifies the response
• Pain is related to damage of muscle cells and associated inflammation
• Can result in acute compartment syndrome, usually in LL
• Significant bacterial or viral infection, particularly if associated with fever or myalgia may result in inflammatory myopathy with associated rhabdomyolysis (muscle breakdown).
• Can result in secondary renal damage due to myoglobinuira.
Muscle Strain
In turn classified as:
1. First degree (mild)
2. Second degree / partial tear (moderate)
3. Third degree / complete tear (severe)
• Presentation: Trauma, significant loss of ROM and function, tense and painful swelling
• Tears of muscle belly heal more rapidly than the musculotendinous junction
• Better prognosis associated with mild-moderate strains and minimal bleeding
• Poorer prognosis associated with re-tear, severe strain esp. located in a compartment with excessive bleeding
Muscle strain- risk of complication
Degree of injury correlates with long-term disability as well as risk of complications such as:
*Myositis ossificans uProlific scarring
*Slow resolution
*Risk of re-injury
As the degree of the muscle strain increase (grade I to III) there is :
Increase Pain and spasm
Increase Swelling and bruising
Increase Defect
Increase Loss of ROM and Function
Increase Recovery time
Contusions
Contusion
• Common in contact sports
• Mild contusion – more haematoma than with a
comparable strain
• Moderate to severe – hard to distinguish from tears (moderate – severe strains)
Severe contusions may predispose
Contusions may either be?
- Intermuscular
• Along large intermuscular septa / fascial sheaths (eg. thigh)
• Facilitates gravitational tracking of extravasated blood which minimizes inflammatory response and potential scarring – early resolution! - Intramuscular
• 2-3 times longer to heal than intermuscular
• Haemorrhage more confined and palpable
• Inflammation greater
• Risk of Myositis Ossificans, compartment syndrome and scarring greater to significant scarring
Avulsion
Often commonly occurs in specific anatomic locations: ASIS with Sartorius AIIS with Rectus Femoris Ischial tuberosity with Hamstring Olecranon process with Triceps Patella with Quadriceps tendon
Stages of muscle healing
uInitial inflammation which promotes phagocytosis
uEarly healing: initial focal deposits of collagen represent early scarring and contribute to tissue stiffness (replacement of contractile with non-contractile tissue)
uEarly ROM exercises are essential here to lengthen the immature plastic scar, minimize adhesion formation and assist with collagen orientation
uModalities such as heat and IFC may assist here
uEstablished healing (days 6-14): early, gentle rehabilitation to re-establish strength and ROM, muscle regeneration is facilitated by activity
uCare must be taken here not to re-injure
Common types of fractures
- Stable: broken ends of the bone are aligned (good prognosis for healing)
- Simple (closed): no skin piercing; as opposed to –
- Compound (open): skin is pierced either by bone or trauma to the region, bone may be visible (Concern for development of osteomyelitis)
- Transverse: Horizontal fracture line
- Oblique: Oblique fracture line
- Comminuted: 3 or more fragments; often referred to as “shattered” in lay terms
Childhood fractures
- The zone of hypertrophy (ZOH) is the weakest structural layer in bone, therefore most prone to fracture – and therefore ideally is less likely to have growth implications*
- Fractures in children are classified as Salter-Harris Types I – V (crush injury)
Describe the 5 types of salter-Harris fractures
o uTypes I & II: mostly through ZOH, heal rapidly and are usually ready for full stress by 6-8 weeks. Long- term complications and deformity are minimal.
o uType III: may extend into the joint, leading to problems of joint incongruity
o uType IV: directly cross from metaphysis to epiphysis through the growth plate
o uTypes IV and V may result in growth retardation and/or deformity
Stages of fracture healing
- Inflammation (
Factories influencing fracture healing
Patient age
Circulation
Mechanical factors
Red flags in MSK medicine
uWhat is a RED FLAG?
uCommon (general) red flags in MSK medicine:
uAge >50
uProgressive neurological deficit
uPathological changes in bowel or bladder function
uUMN signs – remember these?
uHistory of cancer
uRecent significant trauma
uLong-term corticosteroid use
uPresence of constitutional symptoms – remember these?
Severity & Character of the Pain
This gives us clues as to which structures are involved too, as well as to what extent!
Remember this?
Visceral pain: eg. hepatitis
uContraction or distention of viscera
uGnawing, cramping or aching
uOften difficult to localize
Parietal pain: eg. appendicitis
uInflammation of viscera which affects parietal peritoneum uMore severe than visceral
uUsually easy to localize
Referred pain: eg. acute cholecystitis
uOriginates at different sites but shares embryological innervation from the same spinal level
uUsually dull, aching pain
uDifficult to differentiate from MSK pain at times!
Differential Diagnoses
Using a universal list: “VINDICATE” uV ascular Infection N eoplasm D egenerative I nflammatory C ongenital A rthritic T raumatic E ndocrine
Active, passive and resisted isometrics
Active:
1. Contractile tissues will be painful with contraction or
stretching
2. Non-contractile tissues will be painful when stretched or ‘pinched’
Passive:
1. Contractile tissues will be painful with stretch
2. Non-contractile tissues will be painful when stretched or ‘pinched’
Resisted isometrics:
1. Contractile tissues will be painful with contraction; stretching not likely to occur due to contraction preventing end-range movement
2. Non-contractile tissues not likely to be stretched or ‘pinched’ due to muscular contraction preventing end- range movement
What is tested during active, passive and resisted isometrics?
Active:
-Contractile & Non-contractile tissues tested, if any pain or limitation
Passive:
-Non-contractile tissues predominantly tested
Resisted isometrics:
-Contractile tissues predominantly tested
Stress fractures
- Usually in response to repetitive stress, often due to accelerated, unaccustomed, intense activity with insufficient recovery period
- Occurs in elderly, osteoporotic, but also healthy young athletes
- Common regions include: femur, tibia, tarsals and metatarsals
- Distinguish from pathological fracture – therefore, if due to osteoporosis can be considered pathological. Other pathological causes include tumors or bone cyst.
Clinically a patient with a stress fracture may present with these different signs:
- Point tenderness of bone
- Soft tissue swelling
- Alteration of gait
- Muscular atrophy
- Full and painless ROM
- Painless resisted active movement of joint
- Hairline radiolucency , periosteal callus
- Palpation of callus with time
- Active:
What is the cycle injury cycle?
Trauma–> inflammation—> pain AND/OR spasm—> healing OR chronicity
