Soft Tissue & Healing Flashcards
What are the 2 stages following tissue injury?
(hypothesised by Merrick (2002))
- Primary injury
- Secondary injury
What is the primary injury stage following tissue injury?
direct mechanical damage to cells causing loss of homeostasis and cellular death
- could involve ligaments, tendons, muscle, nerve and connective tissues
- could be via: crush, strain force, contusion, disrupting cell membranes
What is the secondary injury stage following tissue injury?
Physiological response following primary injury, occurring at the periphery of the injury
May occur as:
- hypoxic or ischaemic (decreased blood flow)
- enzymatic mechanisms (destroys lysosomes and cell membrane, causing cells to swell and subsequently die)
What are the 4 phases of tissue healing and repair, and how long do they last?
- Phase 1: Bleeding (0-10 hours)
- Phase 2: Inflammation (0-4 days)
- Phase 3: Tissue proliferation, fibrous repair (1-10+ days post-injury)
- Phase 4: Tissue remodelling (from day 2 - up to 2 years, dependent on injury severity)
0-72 hours post-injury, what are physio interventions in phases 1&2 of tissue healing and repair?
- Reduce pain
- Limit inflammatory exudates
- Reduce newly damaged tissue from further injury
- Protect newly damaged tissue from further injury
- Protect newly-forming tissue from disruption
- Promote new tissue growth and fibre realignment
- Maintain general levels of cardiovascular and musculoskeletal fitness and activity
What is the acute soft injury management principle?
P rotection
E levation
A void anti-inflammatories
C ompression
E ducation
&
L oad
O ptimism
V ascularisation
E xercise
What occurs during phase 3 of tissue healing and repair?
Tissue proliferation and fibrous repair
- ongoing phagocytosis
- angiogenesis (formation of new blood vessels)
- proliferation of fibroblasts
- production of collagen fibres (initially produced in an unordered and random fashion)
- absorption of inflammatory exudate
Angiogenesis
formation of new blood vessels
What are the general physiotherapy aims in the tissue proliferation stage in phase 3 of tissue healing and repair?
- decrease swelling
- decrease pain
- decrease local temp
- prevent further trauma
- protecting new tissue
- increasing range of movement
- maintaining/increasing muscle strength, timing and control
- preventing soft tissue adaptation in non-injured tissues
- improving function
- graded return to exercise and activity (avoid any high SIN - pain severity, irritability and nature)
What are the key processes of phase 4 (remodelling) of tissue healing and repair?
- ongoing fibroblasts activity and collagen production
- deposition of new fibrous tissue
- scar tissue formation
- type 3 collagen fibres being replaced by type 1 collagen fibres
What are the general physiotherapy aims in the remodelling stage in phase 4 of tissue healing and repair?
- Promoting collagen growth and fibre/tissue realignment
- Increasing the ROM - active, passive, accessory
- Increasing muscle strength, control and timing
- Preventing soft tissue adaptation in injured and non-injured tissues
- Maximising function
- Promote movement and mobility of the injured structures/tissues (3-10 days post-injury)
- Prevention of tissue contraction and adhesion formation (3rd week post-injury); therefore end-of-range stretching should commence on 3rd week
What are some factors that influence the clinical reasoning process for the management of a patient’s tissue healing and repair?
- Physiology
- Anatomy
- Environment
- Pathology
- Histology
- Biomechanics
- Sociology
- Kinesiology
- Psychology
- Therapeutic effects of treatment modalities
Enthesis
the site of attachment of tendon to bone
Musculotendinous junction
the point where the tendon forms an attachment to the muscle
Tenocytes
fibroelastic cellular components of tendon that synthesise extracellular matrix and responds to mechanical loads, adapting accordingly
Endotenon
a substance that helps to stabilise and bid the fibrils
Collagen fibre
a group of collagen fibrils bound in a sheath of endotenon
Epitenon
an exterior sheath of connective tissue
Paratenon
fatty tissue between fascia and tendon tissues
Tendinopathy
refers to tendon degeneration that’s characterised by a combination of tendon pain, swelling, and impaired performance
Tendinosis
degeneration of the tendon’s collagen in response to chronic over-use
Tenosynovitis
inflammation of the sheath that surrounds a tendon
Para/peri tendonitis
involvement of the adjacent paratendon (can be alone or in combination with tendinosis)
What happens in Tendinopathy?
- show hypercellularity
- a loss of the tightly bundles collagen fibre appearance
- an increase in proteoglycan content
- neovascularisation
- decreased mechanical integrity
What does Tendinopathy look like?
- accumulation of rounded and enlarge tenocytes
- disorganisation of collagen fibres and loss of architecture
- abundant ground substance with demarcation of collagen bundles
- agglomeration of capillaries
What are issues with management and healing of tendons?
- limited vascularity and slow metabolic rate
- tenocytes have a slow turnaround rate (50-100 days)
- if given inadequate time to repair tenocytes can undergo apoptosis
