Soft tissue and post op Flashcards
physiology of CT repair
affected by age, lifestyle, and systemic factors
microstructure of CTs
- fibers (collagen, elastin)
- ground substance (glycosaminoglycans)
- cellular substances (fibroblasts, fibrocytes)
function of CTs depends on portions of intracellular and extracellular components
response to loading
- Tensile loads-primarily resisted by collagen fibers
- if tissue is elongated beyond 4%, plastic changes begin to occur (x-links begin to fail)
- yield point is where increase in strain occurs w/o increase in stress
- cyclic loading produces microstructural damage that accumulates with each cycling loading cycle
- failure from cyclic loading=fatigue failure
viscoelastic properties
creep and relaxation allow CTs to adapt and function in a variety of loading conditions without being damaged
creep
tissue lengthens in response to a constant load
relaxation
amount of force necessary to maintain new length decreases
phases of healing
- needed to formulate a plan of care
- allows for matching the loading capability to intervention
- understanding provides the tools to treat a variety of injury and surgical conditions
characteristics phase 1 healing- inflammatory response
3-5 days
- palpable pain, tenderness, swelling
- release of chemical substances (protaglandins, bradykinin)
treatment of phase 1 healing
- decrease pain and inflammation
- maintain mobility and strength of adjacent joints and soft tissues if possible
characteristics of phase 2 healing- repair and regeneration
- up to 8 weeks
- new collagen forming (primarily type 3)
- edema is resolved during this phase
- bone-callus phase
treatment of phase 2 healing
- focus on normal tissue relationships, optimal loading
- changes become habitual in this stage!
- ROM exercises and joint mobilization, WBing
- end of this stage-mobility and strength base should be established
- bone-limited activity allowed
characteristics of phase 3 healing- remodeling and maturation
- deposition of type 1 collagen (end of phase 2)
- decreased synthetic activity and extracellularity
treatment of phase 3 healing
- tension/resistance becomes more important in orientation of collagen
- normal loading is necessary for bone remodeling - Wolff’s law
restoration of normal tissue relationships
after CT injury, relationship and integrity of tissues are altered
possible interventions:
- active muscle contractions
- passive joint motion
- mobilization
- stretching
- begin preventative interventions as early as healing process allows!
optimal loading
**chose tx procedures that don’t disrupt the healing process
requires:
- choosing a load that doesn’t under or overload the tissue
- considering biomechanical effects of daily activities
- understanding of mechanism of injured tissue loading
- individual factors- age, tissue quality, nutrition, fitness
signs of overload
1: increased pain that doesn’t resolve within the next 12 hours
2: pain that is increased over the previous session or comes on earlier in the exercise session
3: increased swelling, warmth or redness in the injury area
4: decreased ability to use the part
specific adaptations to imposed demands (SAID)
- includes QUANTITY and TYPE of activity
- extension of Wolff’s low
- guides exercise rx parameters
- stage of healing and optimal loading parameters closely reflect the specific demands on the pt’s functional tasks
prevention of complications
GOAL: minimize effects of immobilization while an injury is healing
- e-stim or isometric contractions
- AROM at joints above and below injury sites
- WB exercises when feasible to load articular cartilage and prevent degradation
Sprain
acute injury to a ligament or joint capsule without dislocation
-may resolve with short term immobilization, controlled activity and rehab exercises
sprain classification
grade I: mild, ligament is stretched, no discontinuity
grade II: moderate, some fibers stretched/torn, some joint laxity
grade III: severe, complete ligament disruption with resultant laxity
sprain examination and evaluation
-observation to assess ecchymosis and edema
-observe functional ROM, AROM and PROM
-assess joint integrity and mobility
laxity-manual/instrument
instability- apprehension/instability
-palpation to identify primary and secondary injuries- surrounding joints and soft tissues
strain
musculotendinous injury
=acute injury to the muscle or tendon from an abrupt or excessive muscle contraction
-usually a result of a quick overload to the muscle-tendon unit whereby the tension generated > tissue’s capacity
strain classification
1: mild
2: moderate
3: severe
based on clinical examination- pain, edema, loss of motion, tenderness
contributing factors to strain
poor flexibility
poor warm up exercise
insufficient strength or endurance
poor coordination
strain exam and eval
- thorough history
- palpation- ms/tendon junction, muscle belly
- reproduce clinically through active or resisted contraction- ms may need to be put on stretch
- localized swelling and warmth may be observed
application of treatment principles for phase I healing
Principle: optimal loading; prevent secondary complications
Loading zone: balance of rest and loading
Modalities: cryotherapy w/ compression/elevation
Exercise intervention: Isometric contractions
application of treatment principles for phase II healing
Principle: restore normal tissue relationships; prevent complications
Loading zone: loading is important- orientation of collagen fibers
Modalities: Joint mobs; stretching; massage; postural education
Exercise intervention: contraction of lengthened ms in shortened range
application of treatment principles for phase III healing
Principle: fine tune; convert baseline strength and mobility into functional movement patterns
Loading zone: graded, progressive exercise is necessary to maintain improvements
Modalities: pt maintenance program; postural education, stretching; strengthening, etc
Exercise intervention: more whole body patterns and functional activity
Tendinitis and tendon injuries
- failure occurs due to micro- or macrotrauma
- outcomes are lengthy BUT predictable
- categories/classifications have evolved
classification of tendon injuries
1: macrotrauma:
2: microtrauma:
3: tendinosis
macrotrauma
commonly occur at musculotendinous junction
microtrauma
paratendinitis (inflammation of outer layer of tendon)
tendinosis
degeneration w/o inflammatory response
tendinitis
symptomatic degeneration of tendon with vascular disruption and an inflammatory response
exam and eval of tendon injuries
- history and subjective symptoms are of primary importance (acute/chronic, CT/localized inflammation, onset/predisposing factors)
- ROM, muscle performance, posture, joint integrity, mobility tests
- observe structural or postural abnormality
- document nodules, palpable defects, crepitus
treatment principles and procedures for tendon injuries
- tx based on specific tendon injury
- restoring length, strength: fundamental
- stretching (low load) if muscle length is inadequate
- if inflammation is present- consider cold packs, estim, into
- eccentric activities: slow/light -> fast/heavy
- appropriate rehab activities (w/ appropriate modifications)
classification of cartilage injuries
mechanical
non-mechnical: infection, inflammatory conditions, prolonged jt immobilization
exam and eval of cartilage injuries
- cause of damage
- area of damage
- classification/health of cartilage
- general health
- lifestyle factors
- body weight
- joint alignment
- ROM
- ms performance
- joint integrity
- mobility
treatment principles of cartilage injuries
- Primary goal= restoration of motion
- freedom of motion
- equitable load distribution
- stability
- increased muscle performance and normalization of gait
contusion
- results from a blow and can occur in any area of the body
- blood vessels below skin become damaged
- accumulation in deeper tissues (hematoma) may develop
- if untreated, may progress to myositis ossifications
exam and eval of contusions
- history of “blow” provides best info
- size, location, and direction lend a window into location and extent of soft tissue injury
- palpation, joint mobility, ms performance, flexibility, and function tests help guide tx procedures
treatment principles for contusions
- simple contusions resolve in a timely manner
- use & monitor measures of pain, muscle length, muscle performace to guide aggressiveness of treatment
- ROM must be restored as quickly as possible
- use ice to control swelling and local inflammation
- restore muscle performance
- submax isometrics may be initiated in early stages
management of impairments associated with fractures
fracture=break in the continuity of bone
classification of fractures
1: open fractures: breaks through skin surface
2: closed fractures: doesn’t break skin
3: nondisplaced: all sides of fx remain in anatomic alignment
4: displaced: the ends of the bones are not in anatomic alignment
types of fractures
transverse spiral oblique-transverse/butterfly oblique comminuted metaphyseal compression
application of treatment principles for fractures
- consider associated soft tissues
- healing of fx is primary
- rehab of soft tissue may be more challenging
fracture intervention
- tx focuses on recovery of initial trauma, rehabing tissues that were immobilized
- initially-gentle jt mobilization, stretching
- decrease loading when indicated (stress fx)
- gentle strengthening (isometrics)
- NMES, SEMG-feedback for atrophy
- as impairments improve, incorporate activities to alleviate remaining functional limitations
**keep loads w/in optimal zone!
soft tissue procedures
- ligament reconstruction
- tendon surgery
- debridement
- synovectomy
- decompression
- soft tissue stabilization and realignment
- meniscal and labral repairs
bony procedures
- debridement/abrasion chondroplasty
- osteochondral autograft transplantation (OAT) or (mosaicplasty)
- autologous chondrocyte implantation
- open reduction and internal fixation
- fusion
- osteotomy
primary goal of joint arthroplasty
PAIN RELIEF
-generally, any increase in ROM, strength, function is secondary to pain relief
joint arthroplasty is categorized by..
- component design- constrained/unconstrained
- fixation: cement vs biological (cementless)
- materials: metals vs plastics (hybrids)
rehab considerations for joint arthroplasty
- rehab is joint and prosthesis specific
- restore motion, strength, function
- address underlying cause of surgery as well as adjacent joints
total knee arthroplasty (TKA)
unicompartmental (partial) arthroplasty (UKA)
-replaces WB surface secondary to OA, RA, trauma
rehab considerations:
- CPM
- early protected WB w. ADs
- monitor for infection, effusion, DVT post op
- acute-> SNF ->home care -> OP
total shoulder arthroplasty (TSA)
common precautions:
- avoid hyperextension/anterior capsule stretch
- avoid aggressive IR stretch of ER movement
- avoid WB and lifting
total hip arthroplasty (THA)
Cementless: believed to last longer; revisions difficulty
Cemented: immediate stability (>70 y/o)
- loosening via cracked, fragmented cement
- bone resorption around implant
Resurfacing: less risk of dislocation
-younger, active patients (<60 y.o)
THA rehab considerations
Posterior surgical approach:
- no hip flexion beyond 90
- no crossing the legs (hip ADD beyond neutral)
- no hip IR past neutral
Pt education:
- put a pillow between legs if you lie on your side
- sit only on elevated chairs or toilet seats
- don’t bend over from the hips to reach or tie shoes
anterior hip approach:
-positions that involve extreme hip extension and ER will dislocate the hip
summary
- composition and structure of CTs provide info regarding mechanical properties and function
- unique viscoelastic characteristics are the result of fluid and solid constituent materials
- when CTs are loaded, the stress of change per unit length gives info about the tissue’s ability to withstand loads
- stages of healing & knowledge of injury give clinical guidelines for intervention throughout care
- restoration of tissue relationships, SAID principle, prevention of secondary complications-guide treatment
- acute soft tissue injuries necessitate early intervention to avoid secondary complications
- management of tendon injuries and prognosis varies according to injury classification
- interventions used in tx of bony or surgical procedures should have foundations in basic science and require an understanding in anatomy and kinesiology of the area
