Therex Lecture 1 Flashcards
Soft Tissue Healing
What are examples of soft tissue lesions?
Examples of soft tissue lesions are:
- strain
- sprain
- dislocation
- subluxation
- muscle/tendon rupture or tear
- tendinopathy/tendinous lesions
- synovitis
- hemarthrosis
- ganglion
- bursitis
- contusions
- overuse syndromes/cumulative trauma disorders/repetitive strain injury
What are strains?
Strains are some degree of disruption of musculotendinous unit. It occurs from slight trauma or unaccustomed repeated trauma of a minor degree
What are sprains?
Sprains are severe stress, stretch, or tear of soft tissues such as joint capsule, ligament, tendon, or muscle; used to refer to injury to the ligament
What are dislocations?
Dislocations are displacement of boney part in a joint. It results in loss of anatomical relationship and leads to soft tissue damage, inflammation, pain, and muscle spasm
What are subluxations?
Subluxations are incomplete or partial dislocation of boney partners in joint. They are often involves secondary trauma to surrounding soft tissue
What are muscle/tendon rupture or tears?
Muscle/tendon rupture or tears depend on whether it is partial or not.
If it is a partial rupture/tear then pain is experienced in region of breach when the muscle is stretched or when it contracts against resistance
If it is a complete rupture/tear then muscle does not pull against injury so stretching or contraction of muscle does not cause pain
What are the types of tendinopathy/tendinous lesions?
The types of tendinopathy/tendinous lesions are:
- tendinopathy (general term for chronic tendon pathology)
- tenosynovitis (inflammation of synovial membrane covering tendon)
- tendinitis (inflammation of tendon => may result in scarring or calcium deposits)
- tenovaginitis (inflammation with thickening of tendon sheath)
- tendonosis (degeneration of tendon due to repetitive microtrauma)
What are synovitis, hemarthrosis, ganglion, bursitis, and contusions?
Synovitis - inflammation of synovial membrane
Hemarthrosis - bleeding in joint spaces
Ganglion - abnormal benign swelling on tendon sheath
Bursitis - inflammation of bursa
Contusions - bruise/blood capillaries rupturing
What are the categories of tissue injury severity?
The categories of tissue injury severity are:
- Grade 1: Mild pain at the time of injury or within the first 24 hrs; mild swelling, local tenderness, and pain occur when the tissue is stressed (e.g. stressed)
- Grade 2: Moderate pain that requires stopping the activity; stress and palpation of tissue greatly increase pain; when injury is to ligaments, some fibers are torn, resulting in some increased joint mobility (e.g. tear)
- Near-complete or complete tear or avulsion of tissue (tendon or ligament) with severe pain; stress to the tissue is usually painless; palpation may reveal defect; torn ligament results in instability of joint(e.g. rupture)
What information is needed from the subjective history in regards to soft tissue healing?
The information needed from subjective history in regards to soft tissue healing are:
- functional limitations
- structure and degree of injury
- classification schemes (grades)
- therapeutic effect
What are the primary musculoskeletal injuries?
The primary musculoskeletal injuries are:
- Strain (muscle)
- Sprain (ligament)
- Contusion (soft tissue)
- Subluxation (joint)
- Fractures (bone)
What are the secondary musculoskeletal injuries?
The secondary musculoskeletal injuries are:
- Hypoxic (e.g. vascular damage and blockage)
- Enzymatic (e.g. lysosomal post-injury muscle atrophy
What are the physiologic stages of healing?
The physiologic stages of healing are:
- Acute: First 4-7 days following an injury
- Sub-Acute: >7 Days to 3 Months
- Chronic: >3 Months
**The time frames above aren’t universal, it varies from one type of tissue to another (e.g. bone and muscle) and mechanism of injury (e.g. contusion and surgery), which can cause some confusion
What are the physiological presentations of the acute stage of tissue healing?
The physiologic presentations of the acute stage/inflammatory phase of tissue healing (4-6 days following an injury) are:
- vascular changes
- exudation of cells and chemicals
- clot formation
- phagocytosis, neutralization of irritants
- early fibroblastic activity (collagen and fiber production)
What are the clinical signs of the acute stage of tissue healing?
The clinical signs of the acute stage/inflammatory phase of tissue healing (4-6 days following an injury) are:
- pain with resting/aching (due to altered chemical state)
- pain with AROM (and open end-feel with PROM and OP)
- pain with Objective Testing (local stress to involved tissue due to MMT or palpation; red, warm, swollen; more exaggerated response to pain)
- compensatory movement patterns and loss of function (due to muscle guarding and muscle inhibition)
- pain before tissue resistance
What are the physical therapy goals and interventions for a patient in the acute stage of tissue healing?
The physical therapy goals and interventions for a patient in the acute stage of tissue healing are:
- Patient education
- Protect function!
- Prevent adverse effects of immobilization
- Prevent effects of secondary injury
- Passive ROM or single plane isometric contractions per tolerance!
- Light stretching, massage and joint mobilizations.
- Work away from and around the area! (such as working on hip and ankle during knee injury)
In other words, the goal is maximum protection
** It is not beneficial to use anti-inflammatories during the first few days of healing – will disrupt healing
What are the physiological presentations of the sub-acute stage of tissue healing?
The physiologic presentations of the sub-acute stage/proliferation phase of tissue healing (2-3 weeks following an injury) are:
- removal of noxious stimuli (macrophage and mast cell activity)
- growth of capillary beds into area
- collagen formation (fibroblast proliferation w/ collagen synthesis)
- granulation tissue
- very fragile, easily injured tissue
**2-3 weeks for highly vascularized tissue, 6 weeks for less vascularized (>7 days for muscles, >28 days for tendons)
What are the clinical signs of the sub-acute stage of tissue healing?
The clinical signs of the sub-acute stage/proliferative phase of tissue healing (2-3 weeks following an injury) are:
- pain with AAROM/AROM (stress of tissue) but is LESS SEVERE than acute phase
- limited ROM (due to shortening of tissue)
- limited strength (can alter tolerance to ADLs) => early stage can present as guarded movement; later stage can decrease sensitivity to peripheral nociception
- guarding which can lead to atrophy due to disuse of muscle
- less inflammation
What are the physical therapy goals and interventions for a patient in the sub-acute stage of tissue healing?
The physical therapy goals and interventions for a patient in the sub-acute stage of tissue healing are:
- Patient education (key because people start feeling better during this phase)
- Controlled functional training!
- Restore soft tissue, muscle and joint mobility
- Start focusing more on neuromuscular control (but this starts during acute stage)
- Maintain function
- AAROM/AROM => Active Exercise and stretching (be careful!)
- Multiple angle isometrics/sub-max exercise
- Start postural restoration exercises and correct for compensations (contributing factors)
In other words the goal is moderate protection/controlled motion
**Load tissue so it is functional
Ex: rotator cuff strain – 1st stage – avoid ext. int. rot. But do trunk rotations to still maintain function – 2nd stage – same but will add int and ext rot.
What are the physiological presentations of the chronic stage of tissue healing?
The physiologic presentations of the chronic stage/maturation and remodeling phase of tissue healing (>3 months) are:
- 3 weeks to 3 months after injury (scar tissue retraction/shrinking; thicker collagen and reorientation due to stress)
- 3 months to >1 year after injury (improvement in quality and orientation of collagen; increase collagen/scar tissue density)
What are the clinical signs of the chronic stage of tissue healing?
The clinical signs of the chronic stage/maturation and remodeling phase of tissue healing (>3 months) are:
- loss of muscle control and strength secondary to prolonged activity modification
- pain felt at EROM with excessive stress (pain is not as severe as initial stage)
- pain after activity
- no inflammation
- increased tolerance to functional activities (return to previous function without restriction)
**maturation starts happening in sub-acute phase
What are the physical therapy goals and interventions for a patient in the chronic stage of tissue healing?
The physical therapy goals and interventions for a patient in the chronic stage of tissue healing are:
- Patient education
- Increase soft tissue, muscle and joint mobility
- Improve neuromuscular control
- Improve cardiopulmonary endurance
- Return to Function!
- Safe progression of exercise and stretching
- Move into complex patterns, trunk control, body mechanics and injury prevention
- Return to function activities
- Stress tissue as much as they can
In other words the goal is minimum to no protection/return to function
What are the effects of developing abnormalities in soft tissue healing?
The effects of developing abnormalities in soft tissue healing are:
- dysfunction
- contracture
- adhesions
- muscle weakness
- guarding
- spasms
What are the different factors that may prompt poor healing responses?
The different factors that may prompt poor healing responses are:
- Age (aging decreases healing effects)
- Illness
- Hypertrophic scarring (look up more)
- Altered blood supply (e.g. neuropathies, cardiopulmonary diseases)
- Edema (CHF – congestive heart failure)
- Repeated trauma (e.g. biomechanics, re-injury, training errors etc.)
- Weak structural support (e.g. weakness, posture, biomechanics etc.)
- Genetics
** smoking slows healing - due to changes in vasculature in body
