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631: Clinical Management of the Musculoskeletal System I > Tissue Behavior, Injury, Healing, and Treatment > Flashcards

Tissue Behavior, Injury, Healing, and Treatment Flashcards

1
Q

What is stress used to describe?

A

The type of force applied

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2
Q

Stress is ____ related to the magnitude of force and _____ related to the unit area

A

directly

inversely

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3
Q

What is strain?

A

the change in length of a material due to an imposed load divided by the original length

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4
Q

What are the 2 types of strain?

A
  • Linear

- Shear

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5
Q

Linear strain causes what?

A

a change in the length of a structure

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6
Q

Shear strain causes what?

A

a change in the angular relationships within a structure

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7
Q

What is responsible for influencing the mechanical properties of the tissue?

A

the concentration of proteoglycans in solution

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8
Q

What are the 4 regions of the load-deformation (stress-strain) curve?

A
  • Toe
  • Elastic
  • Plastic
  • Failure
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9
Q

Describe the toe region on the stress-strain curve

A

This is the region in which the “slack” is taken up

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10
Q

Describe the elastic deformation region on the stress-strain curve

A

This region represents the linear geometric deformation that occurs in the structure with increasingly load

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11
Q

In the elastic region, the stiffer the tissue, the _____ the slope

A

steeper

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12
Q

What occurs in the plastic deformation region on the stress-strain curve?

A

Progressive failure and microscopic tearing of the collagen fibers in the tissue results with an increasing level of stress

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13
Q

When tissue reaches the plastic deformation region permanent changes in the tissue result from what?

A

From the breaking of bonds and their subsequent inability to contribute to the recovery of the tissue

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14
Q

Biological tissues are anisotropic, what does this mean?

A

they can demonstrate differing mechanical behavior as a function of test direction

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15
Q

What are the 6 protective mechanisms that tissues possess?

A
  • Crimp
  • Viscoelasticity
  • Creep
  • Stress Relaxation
  • Plastic Deformation
  • Stress Response
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16
Q

What is crimp?

A

A protective mechanism of tissues in which the fibers line up in the direction of an applied force as they uncramp

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17
Q

In what types of tissues is crimp seen?

A

ligaments, tendons, and joint capsules

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18
Q

What is viscoelasticity?

A

the ability to stretch or shorten over time, and return to its original shape when a force is removed

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19
Q

What is creep?

A

the gradual rearrangement of collagen fibers, proteoglycans, and water that occurs because of a constantly applied force after the initial lengthening caused by crimp has ceased

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20
Q

Can tissues return to their original length once creep occurs?

A

They have difficulty

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21
Q

Describe the phenomenon of stress relaxation

A

Stress in a deformed structure decreases with time, while the deformation is held constant

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22
Q

Why does stress decrease in a structure with time, while the deformation is held constant?

A

Microfailures/microfractures result which decreases the stress on the structure

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23
Q

What is plastic deformation?

A

A phenomenon in which tissues remain deformed after the force is removed and they will not return to their pre-stress length

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24
Q

Collagen fibers can sustain _% increase in elongation before microscopic damage occurs

A

3

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25
Q

Due to the stress response improved strength in muscles, tendons, and ligaments due to exercise results from what?

A

An increase in the proteoglycan content and collagen cross-links

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26
Q

The physiological capacity of tissue is dependent on what 5 factors?

A
  • Health of the tissue
  • Age
  • Proteoglycan and collagen content of the tissue
  • Ability of the tissue to undergo adaptive change
  • The speed at which the adaptive change occurs
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27
Q

Intrinsic vs. Extrinsic factors for microtraumatic injuries

A
  • Intrinsic factors are physical characteristics that predispose an individual to microtrauma (muscle imbalance)
  • Extrinsic are external conditions under which the activity is performed (training errors)
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28
Q

What are the 3 phases of healing and how long do they last?

A
  • acute: 7-10 days
  • subacute: 5-10 days
  • chronic: 26-34 days
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29
Q

What are the 3 stages of tissue healing?

A

1) Coagulation and Inflammation Stage
2) Migratory and Proliferative Stage
3) Remodeling Stage

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30
Q

What occurs during the coagulation and inflammation stage?

A
  • blood and lymph enter the wound

- there is insufficient blood flow to the area due to the capillary blood flow being disrupted

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31
Q

During the coagulation and inflammation stage is there vasoconstriction or vasodilation? Explain

A

There is first vasoconstriction for 5-10 minutes which prompts a period of vasodilation and the release of blood elements, such as platelets

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32
Q

What is the function of platelets during the coagulation and inflammation stage?

A

They secrete macrophages and fibroblasts which form a clot to prevent bleeding and infection, clean dead tissue, and nourish white cells.

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33
Q

The coagulation and inflammation stage is characterized by what 5 things?

A
  • swelling
  • redness
  • heat
  • impairment of function
  • pain at rest or with AROM, or when a stress is applied to the tissue
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34
Q

The inflammation present during the coagulation and inflammation stage attracts what 2 WBC types?

A

neutrophils and monocytes

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35
Q

What are neutrophils?

A

WBCs that are filled with phagocytes which bind to and kill harmful bacteria and dead cells

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36
Q

What are monocytes?

A

WBCs that migrate into tissues and develop into macrophages which phagocytose harmful bacteria and dead cells

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37
Q

Edema during the and inflammation stage is due to what?

A

An increase in the permeability of the venules, plasma proteins, and leukocytes which leak into the site of injury causing edema

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38
Q

New stroma begins to invade the wound space approximately _ days after injury

A

4

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39
Q

The migratory and proliferative stage includes what 4 things?

A
  • Capillary growth
  • Granulation tissue formation
  • Collagen synthesis
  • Increased macrophage and mast cell activity
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40
Q

Which stage of tissue healing is responsible for the development of wound tensile strength?

A

Migratory and Proliferative Stage

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41
Q

The proliferation of collagen results from the action of what type of cells?

A

fibroblasts

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42
Q

Describe the process a wound takes to close

A
  • Fibrinogen is produce first, followed by fibrin, which forms a wound matrix and walls off the wound.
  • This matrix functions as a glue to hold the wound together and helps it resist infection
  • Due to lack of tensile strength this matrix is replaced by a collagen matrix which facilitates angiogenesis
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43
Q

What happens once the collagen matrix is formed?

A

The fibroblasts stop producing collagen and the granulation tissue is replaced by an acellular scar, marking the end of the proliferation stage

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44
Q

The process of developing an acellular scar can take anywhere from - days up to __ weeks

A

5-10 days

10 weeks

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45
Q

The remodeling phase involves what?

A

A conversion of the initial healing tissue to scar tissue

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46
Q

How long can the remodeling phase last?

A

Up to 1 year

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47
Q

After the fibroblasts deposit granulation tissue what happens?

A

The fibroblasts are transformed into myofibroblasts, which congregate at the wound margins and start pulling the edges inward, reducing the size of the wound

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48
Q

What collagen types are responsible for wound contraction and visible scar formation?

A

collagen types I and III

49
Q

The production of the new epidermis is toughened by what protein?

A

keratin

50
Q

What causes hypertrophic scars to form?

A

Imbalances in collagen synthesis & degradation

51
Q

What does scar contraction result from?

A

cross-linking of the collagen fibers

*important that adhesions do not form between the collagen and surrounding tissues

52
Q

3 factors that can impact tissue and examples of each

A
  • Intrinsic: extent of injury, edema, separation of tissue, and scarring
  • Extrinsic: medications, temperature, modalities, and exercise
  • Systemic: age, obesity, malnutrition, and infection
53
Q

What are the 3 important factors that can impact muscle performance?

A
  • Age
  • Temperature
  • Immobilization
54
Q

What are the 2 primary causes of muscle injury?

A

excessive strain and contusion

55
Q

What are 4 contributors to muscle strain?

A
  • Inadequate flexibility and/or strength
  • Dyssynergistic muscle contraction
  • Insufficient warm-up
  • Inadequate rehab from previous injury
56
Q

A muscle contusion typically results in what?

A

a hematoma

57
Q

Describe the 3 degrees of muscle strains

A
  • 1st degree: There is minimal structural damage, minimal hemorrhage, and early resolution
  • 2nd degree: There is a partial tear of the muscle, considered a large spectrum injury, and there is significant early los of function
    3rd degree: There is a complete muscle tear which may require aspiration and/or surgery
58
Q

What are the 3 phases in the healing process of an injured muscle?

A
  • Destruction phase
  • Repair phase
  • Remodeling phase
59
Q

Guiding principles that should guide the PT when rehabbing a muscle injury

A
  • prevention is easier than treatment
  • intervention depends on the stage of healing
  • controlled mobility and activity are best
  • medications and modalities are important
  • use pain as a guiding factor
60
Q

Is the toe region smaller in ligaments or tendons and why?

A

In tendons because they have more parallel collagen fibers and less realignment occurs during initial loading

61
Q

How do most tendon injuries occur?

A

From sudden overload, repetitive loading or rapid unloading

62
Q

Tendon injuries are classified as either ____ or ____.

A

acute or chronic

63
Q

Acute tendon injuries include what types of pathologies?

A
  • tendon ruptures
  • partial tendon tears
  • tendinitis
64
Q

What is tendinitis?

A

Microscopic tearing and inflammation of the tendon tissue, commonly resulting from tissue fatigue rather than direct trauma

65
Q

What are the 5 grades of tendinitis from least severe to most? Describe each

A
  • Grade I – includes pain after activity, but does not interfere with performance
  • Grade II – there is minimal pain with activity and localized tenderness
  • Grade III – pain interferes with activity, but usually disappears between sessions
  • Grade IV – pain does not disappear between sessions and seriously interferes with activity
  • Grade V – pain interferes with ADLs, symptoms often chronic and there is altered muscle function
66
Q

What are the 3 chronic tendon injuries?

A
  • Paratenonitis
  • Tenosynovitis
  • Tendinosis
67
Q

What is Paratenonitis?

A

an inflammation of the outermost layer of the tendon

68
Q

What is Tenosynovitis?

A

a pathology in which the outermost layer of a tendon and the tendon sheath are inflamed

69
Q

What is tendinosis?

A

An intratendinous degenerative lesion without an inflammatory component

70
Q

What are the 3 phases in the healing process of an injured tendon?

A
  • Inflammation
  • Repair
  • Remodeling
71
Q

What is the most important thing to enforce during the treatment of a tendon?

A

Judicious application of force must be used to encourage the new collagen fibrils to align in the direction of the force application

72
Q

What is the major difference between the treatment of tendinitis and tendinosis?

A

Controlling inflammation is the focus of tendinitis, whereas loading based rehab is the focus of tendinosis

73
Q

During the rehabilitation of a tendon you should do ____ repetition, ____ load exercises

A

high rep

low load

74
Q

Damage to a ligament results in what?

A

A loss of normal kinematic relationships between the connected bones

75
Q

With external loads, the ligaments that are ____ at the time of impact will most-likely be injured

A

taut

76
Q

3 Characteristics of Ligament Injuries

A
  • history of trauma
  • point tenderness
  • joint effusion
77
Q

How can you tell the differences between grade II and III ligament injuries?

A

With grade III injuries there is significant joint gapping with the application of the stress test

78
Q

Do intra- or extra-articular ligaments heal slower and why?

A

intra-articular ligaments do not heal as well secondary to decreased blood supply and synovial fluid

79
Q

What are the 4 phases in the healing process of an injured ligament?

A
  • Hemorrhagic
  • Inflammatory
  • Proliferation
  • Remodeling and Maturation
80
Q

Ligament repair can take up to how many years to repair?

A

3 years

81
Q

What are 2 important rehab considerations to keep in mind when treating ligament injuries?

A
  • Force must be applied to the ligament to help develop strength in the force direction
  • Immobilization should be minimized
82
Q

What are the 3 distinct areas or zones present with joint mobility?

A
  • Neutral Zone: crimp is taken up
  • Elastic Zone: from crimp into PROM
  • Plastic Zone: deformation of tissue
83
Q

Define joint hypomobilty

A

movement of the joint is less than that considered normal or when compared to the uninvolved side

84
Q

Define joint hypermobility

A

movement of the joint is more than that considered normal or when compared to the uninvolved side

85
Q

Joint hypermobility can be generalized or localized. Localized hypermobility usually occurs because of what?

A

neighboring stiffness

commonly found in adjacent spinal levels

86
Q

Define an unstable joint

A

This is a potential or real pathologic state of the joint that involves a disruption of the osseous and ligamentous structures of that joint as the result of some applied external force

Results in pain, weakness, and transitory deformity

87
Q

What are the 3 types of clinical joint instability?

A
  • Translational
  • Anatomical
  • Functional
88
Q

Describe translational joint instability

A

refers to a loss of control of the small, arthrokinematic joint movements that occur when the patient attempts to stabilize the joint during movement

89
Q

Describe anatomical joint instability

A

refers to excessive physiological movement in the joint which leads to abnormal patterns of coupled and translational movements

90
Q

Describe functional joint instability

A

occurs when the severity of the instability adversely affects a patient’s function

91
Q

What are 2 important factors to keep in mind when treating a joint injury?

A
  • First you must ifferentiate between patients with generalized hypermobility vs. localized hypermobility
  • Also be sure to address any neighboring hypomobility
92
Q

How does articular cartilage receive its nutrients?

A

By way of diffusion from the synovial fluid

93
Q

Chondrocytes in loaded joints experience what 3 kinds of forces?

A
  • hydrostatic compressive
  • tensile
  • shear
94
Q

Which force is believed to maintain healthy cartilage the most?

A

hydrostatic compressive

95
Q

Is immobilization healthy for articular cartilage?

A

No, it results in degenerative changes

96
Q

Articular cartilage consists of what 2 phases?

A
  • Fluid phase: water

- Solid phase: ECM

97
Q

5 factors that lead to AC breakdown

A
  • Imbalance between ECM synthesis and degradation
  • Stress deprivation (immobilization)
  • Developmental etiologies leading to abnormal force transmission (genu valgum/varum)
  • Joint surface incongruously and joint instability
  • Disease (rheumatoid arthritis)
98
Q

Describe the 3 types of AC injury

A
  • Type I (superficial): microscopic damage to the chondrocytes and ECM
  • Type II (partial thickness): microscopic disruption of the AC surface
    Type III (full thickness): disruption of the AC with penetration into the subchondral bones, which produces an inflammatory response
99
Q

The body’s ability to repair articular cartilage is dependent upon what?

A

The depth of the lesion. If the injury does not penetrate the subchondral bone, the AC will become necrotic and will not heal

100
Q

How should you treat an articular cartilage injury?

A

Frequent exercise to increase chondrocyte size and strength

101
Q

What are the 3 elements of bone? Which one distinguishes it from other connective tissues?

A
  • organic
  • mineral***
  • fluid
102
Q

Bone is strongest in _____ and weakest in _____.

A

compression

tension

103
Q

Describe the 5 types of bone fractures

A
  • Avulsion: piece of bone is pulled away
  • Transverse: horizontal fracture
  • Oblique: angled fracture
  • Spiral: due to a twisting type motion
  • Comminuted: multiple fragments
104
Q

What is the major difference between bone healing and the healing of other tissues?

A

Repair is by the original tissue, not scar tissue in bones

105
Q

What are the 2 types of fracture healing?

A

1) primary cortical healing

2) secondary callus healing

106
Q

Describe primary cortical healing

A

Involves a direct attempt by the cortex to reestablish itself once it has become interrupted. Bone on one side must unite with bone on the other side

107
Q

Describe secondary callus healing

A

Involves responses in the periosteum and external soft tissues with the subsequent formation of a callus

108
Q

How do the majority of bone fracture heal?

A

by way of secondary callus healing

109
Q

What are the 4 phases of bone healing?

A

1) Hematoma formation
2) Soft callus formation
3) Hard callus formation
4) Remodeling

110
Q

What is angiogenesis?

A

The outgrowth of new capillaries from existing vessels which will eventually lead to osteogenesis

111
Q

According to ____ law bone remodels along lines of stress

A

Wolff’s

112
Q

Do hormones and environment have an impact on osteoblastic and osteoclastic activity?

A

Yes

113
Q

What types of modalities can be used to accomplish a quicker and more complete healing of fractures?

A
  • Pulsed Electromagnetic Fields (PEMF)
  • Ultrasound
  • Direct Current Stimulation
  • Demineralized Bone Matrix (DBM)
114
Q

What are the 3 surgical procedures performed to stabilize fractures?

A
  • Percutaneous pinning
  • External fixation
  • Open reduction and internal fixation (ORIF)
115
Q

What are a few clinical signs of DVT?

A
  • swelling of the LE
  • tenderness
  • feeling of cramping
  • positive Homan’s Sign (pain with DF)
  • vascular prominence
  • elevated temperature
  • tachycardia
  • inflammation
  • discoloration of the extremity
116
Q

What are a few clinical signs of a pulmonary embolus?

A
  • chest pain
  • chest wall tenderness
  • back pain, shoulder pain
  • upper abdominal pain
  • syncope
  • hemoptysis (coughing up blood)
  • shortness of breath
  • painful respiration
  • wheezing
  • any new cardiac arrhythmia
117
Q

What are the 4 Detrimental Effects of Immobilization?

A
  • Cartilage degeneration
  • Decreased mechanical and structural properties of the ligaments
  • Decreased bone density
  • Weakness or atrophy of muscles
118
Q

Disuse atrophy begins within _ hours of the start of bed rest

A

4

631: Clinical Management of the Musculoskeletal System I (19 decks)

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