Soft Tissue Healing Flashcards
DEFINE SPRAIN
Sprain is a tear or stretch of a ligament
Functions of ligaments
Fibrous band of connective tissue that connects bone to bone
Stabilises and supports joints in the body, eg TALOCRURAL joint
Soft tissue injury categories
GRADE 1/ Mild ligament sprain = parallel collagen fibres with small tears along.
GRADE 2/ moderate ligament sprain = large but incomplete tear- not through whole cross section of ligament
GRADE 3/ severe ligament sprain= Complete tear through whole cross section of ligament
Define STRAIN
Injury to a muscle or tendon- overlengthening or over contracting a muscle causing tear of collagen
Internal and external strain
Internal - strain caused by over stretching or over lengthening muscles in body
External- eg damage to muscles or tendons from being kicked
Basic muscle structure
Myofibrils make up muscle fibres
Muscle fibres collaborate into a fascicle
Perimysium surrounds fascicles
Outer muscle surrounded by epimysium
Epimysium separates muscle from other tissues and allows muscle to glide freely over structures
Grade 1 soft tissue injury
Ligament, tendon or muscle overstretched with only micro tears. Localised pain and tenderness No visible bruising Minimal swelling Minimal loss of function
Ligament = no ligament laxity (looseness) Muscle= no loss of muscle strength and ROM only down by a max. Of 10 degrees
Grade 2 soft tissue injury
Partial / incomplete tear of ligament, tendon or muscle (some of cross section).
Immediate onset of cardinal signs - warmth, redness, swelling, pain and loss of function
Poorly localised pain
Moderate swelling
Bruising visible
Impairment and painful ROM
Muscle = decrease in strength and pain on contraction Ligament = joint may be unstable
Grade 3 soft tissue injury
A complete rupture of tendon, ligament or muscle.
Sprain = the ligament has totally torn and joint is unstable
Strain= muscle or tendon, inability to contract muscle and separation evident sometimes
Grade 3 = immediate acute pain , all cardinal signs and pop or crack
Later on= symptoms may be less than a grade 2
May require immobilisation or surgery.
Limitations to grade one two three system
Symptoms don’t always correlate to the given chart
Not always accurate diagnosis or length of time until recovery
Brutus athletics muscle injury
A= myofascial injury B= musculotendinous C= intratendinous injury
0= pain is referred, no tissue damage in MRI 1= small injury (less than 10% tissue damage) 2= larger tear of muscle (10-50%) 3= more than 50% torn 4= complete tear of the muscle through full cross section
Positives and negatives of that system
Positives - more accurate information and imagery
Negatives - NHS can’t fund that many MRI scans
MRI within 24 hours not possible in NHS
Factors that cause soft tissue damage
I I I I
Injury - physical, electrical, thermal, radiational and chemical
Infection- virus , bacteria , fungi and Protozoa . Can transfer from one part of body to soft tissue and damage it
Infarction- part of tissue cut off from blood supply eg, MI
Immune reactions- foreign protein hypersensitivity allergies
Auto immune diseases like RA , ankylosing spondylitis and MS.
Attacks healthy tissue and damages it!
Types of body tissue
PARENCYHMAL TISSUE
STOMAL / INTERSTITIAL TISSUE
Parenchymal tissue
Functional cells of organs
Eg, neuronal tissue in brain, cardiac myocyte in heart, epithelial tissue in skin and hepatocyte cells in liver
STOMAL / interstitial tissue
Connective tissue parts of organs
This connective tissue contains cell types like fibroblasts, blood vessels, nerves and nerve endings
3 types of tissue healing
RRR
Resolution- rapid healing of mild injury. Epithelial cells slough and regenerate as required.
Regeneration - specialised tissue replaced by proliferation of surrounding undamaged cells eg, injured tissues repaired with parenchyma
Repair (replacement) - lost tissue replaced with granulation tissue (matures to scar tissue)
What types of cell are there for regeneration ?
LSF - kasabian
LABILE CELLS- constantly turn over and regenerate. Eg, skin cells
STABLE CELLS- can divide and regenerate but stops growing once growth stops. It is supportive framework if damage occurs as can regenerate if needed. Eg, liver tissue
FIXED / PERMANENT CELLS- non dividing cells No mitosis So they can’t regenerate if injured Tissue repair leaves a scar Eg, nerve , muscle and cardiac cells
TISSUE REGENERATION
Injury in parenchymal tissue with labile or stable cells can regenerate.
Injury to fixed cells has a tissue repair process
In parenchymal, cells:
Growth factors release from damaged cells and tissues
Platelet derived growth factor and cytokines to increase mitotic divisions
Injured tissue replaced with parenchymal cells
Little evidence of injury after repair
TISSUE REPAIR STEPS
BIPR
Bleeding phase = 6-8 hrs
Inflammation= 2-3 weeks
Proliferation= days to months
Remodelling= weeks to months
Some overlap
Bleeding phase
Occurs immediately after injury
Relatively short lived
Vascular tissue like muscle bleeds for longer
Other tissues ligaments and tendons for example, bleed less in volume and duration
On average = 4-6 hours bleeding , but some people bleed longer
Inflammatory phase
VCPL Vascular phase- changes in blood flow and exudation of protein rich exudate Cellular phase - leucocyte emigration Phagocytosis Lymphatic drainage
Starts after 2 hrs, worsen in 2-3 days and continues for 2-3 weeks
Damage cells release histamine, bradykinin and prostaglandins which cause blood vessels to dilate. Fluid from blood leaks out into limb causing oedema
Leucocyte emigration- chemicals encourage WBCs to the area. Neutrophils fight bacterial infection and macrophages use phagocytosis.
Lymphatic drainage- carries excess fluid and products of inflammation back to bloodstream to be removed from body
Proliferation phase
24-48 hrs after injury
Fibroblasts, macrophages and blood vessels proliferate to form granulation tissue
Angiogenesis causes new blood vessels to form in tissue
Capillary network is leaky
WBC and plasma protein leak into tissue
Fibroblasts secrete weak type three collagen and that reaches peak at 5-7 days then lasts many weeks
Granulation tissue matures:
Lymphatic development
Nerve fibre in growth
Mast cell division
Remodelling / maturation phase
Begins at 3 weeks + can last 2 years
Continuous remodelling of scar tissue by:
Type 1 collagen secreted by fibroblasts
Lysis by many collagenase enzymes
Physical stress should be done in this phase.
Too much stress re injures
No stress won’t repair it.
Primary intention healing
Wound edges joined by stitches , Steri strips and skin glue
Eg, paper cut or surgical wound
Skin surfaces approximated
Less tissue loss
Wound healing quick and easy
Less scar formation
Secondary intention healing
Larger wounds where you can’t approximate skin surfaces
Loss of tissue at the wound
Edges can’t be brought together
Eg, pressure ulcer
More scar formation
Open wound = great risk of infection
Longer repair and healing time
Tertiary intention
Keeping wound open to aid healing process
Factors affecting wound healing
Nature of injury Site of injury - cell types Temperature NSAIDS and corticosteroids delay healing Prolonged use antibiotics Movement - immobilised or needs movement Malnutrition impacts collagen synthesis from fibroblasts Age - wounds heal slower as older Blood flow and o2 supply Infection Wound separation Foreign bodies Adhesion to bones and tissues
Complications of tissue repair
Acronym- I Understand Daves Kind Aunty
INFECTION- microorganisms can invade open wound
ULCERATION- crater like lesions of skin or mucus membranes
DEHISCENCE- deficient scar formation and the wound separates
KELOID DEVELOPMENT - excessive collagen production and hypertrophic scars
ADHESIONS- between cavities and tissues has fibrous connections causing pain on contraction
POLICE STANDS FOR
Protection
Optimal loading
Ice compression
Elevation
ICE PRICE AND RICE
Ice, compression and elevation
Rest, ice, compression and elevation
Protect, rest, ice, compression and elevation
PEACE AND LOVE
Protection- don’t do activities that cause pain
Elevation - higher than the heart
Avoid anti inflammatories- they slow the repair process
Compression- elastic bandage or tape to reduce swelling
Education - avoid unnecessary passive treatments or investigations
Load- you know when is safe to increase load
Optimism - be confident and positive
Vascularisation - choose painless cardio to increase blood flow to injured tissue
Exercise- active approach to restore mobility, strength and proprioception
Why progressive overloading?
Restores strength and structure of collagenous tissue, and lots of unloading would change tissue structure and biomechanics and damage them .
