Tissue Injury and Repair

Question 1

Compression Injury

Answer 1

Soft tissue contusions

Disrupt mm fiber and intramuscular bleed results

Question 2

Tension Forces

Answer 2

Strain, Sprain
Ligament and tendon disruptions
Muscle tears

Question 3

Fatigue or stress failure

Answer 3

Microtrauma

Repetitive submaximal stress

Question 4

Grade 1

Answer 4

Mild pain and swelling

Localized tenderness, and pain with tissue stress

Question 5

Grade 2

Answer 5

moderate pain, may have significant swelling, stress greatly increases pain

Question 6

Grade 3

Answer 6

moderate to sever pain, tissue stress usually does not increase pain; if joint stabilizing tissue may have laxity

Question 7

Ultimate goal of treatment

Answer 7

The formation of a strong, mobile, scar at the site of the lesion so that there is complete and painless restoration of function

Question 8

Points to keep in mind with reaching goal in treatment - blood supply

Answer 8

Allow for healing and inflammation
If on prolonged steroir for RA
Body parts with less blood supply (ligaments vs muscle)

Question 9

Points to keep in mind with achieving goal - normal forces

Answer 9

Having the tissue undergo its normal forces

Question 10

Points to keep in mind with reaching goal - existing pathologies

Answer 10

would influence mediators involved in inflammation as well as blood supply

Question 11

Things to keep in mind with reaching goal

Answer 11

Blood supply
Normal forces
Existing pathologies

Question 12

Phases of Injury

Answer 12

1. Hemostasis
2. Inflammatory phase
3. Proliferative (Granulation phase)
4. Remodeling (Maturation) Phase

Question 13

Primary injury effects

Answer 13

Blood into tissue

Cellular death and necrosis

Question 14

Injury Effects - Blood into Tissue

Answer 14

Tissue Degeneration
Clotting mechanism initiated
Clots plug damaged vessels and lymphatics

Question 15

Injury Effects - Cellular death and necrosis

Answer 15

Release of lysosomes

Increased cellular debris

Question 16

Hemostasis Phase - Evaluation

Answer 16

Time of insult (about 15 min)
Pain is low - they just hurt themselves
Minimal swelling
Little mm. guarding 
This is best chance you have at figuring out what tissues might be injured

Question 17

Hemostasis Phase - Goals

Answer 17

Life/limb threatening conditions
Control bleeding
Stabilize the area

Question 18

Inflammatory Phase - Acute

Answer 18

15 minutes to 4/6 days
Hemodynamic effects going on:
Dilation of blood vessels
Increased vascular permeability
Increased pain

Question 19

Cardinal Signs of Inflammation

Answer 19

Heat
Redness
Pain
Swelling
Loss of function

Question 20

Secondary Hypoxic Injury

Answer 20

Decreased fluid return

Interstitial space distension

Question 21

Secondary Hypoxic Injury - Dec Fluid Return

Answer 21

Lymphatics are plugged
Fluid is actively being moved into the area
Osmotic pressure increases

Question 22

Secondary Hypoxic Injury - Interstitial Space Distension

Answer 22

Increase distance btw cells and nutrient source

Low PO2 levels

Question 23

Why does early activity worsen the situation

Answer 23

Supply and demand issue

Less nutrients and when we ask it to work, even less

Question 24

Margination of Cells

Answer 24

Neutrophils followed by macrophages
Chemotaxis
Platelets - fibrinogen –> fibrin clot formation
Fibrin clot = scaffold for other cell types

Question 25

Clot Dissolution

Answer 25

Signals the end of inflammatory phase Fibrinolytic system causes degradation of fibrin clot Lyphatics open Edema begins to resolve

Question 26

Goal - Inflammatory Phase - Protective Phase

Answer 26

1. Limit early bleeding 2. Dec. inflammatory exudate 3. Reduce pain and mm. guarding 4. Promote phagocytosis 5. Stabalize part as needed 6. Dec. dysfunctional movements 7. Promote general body fitness

Question 27

Treatments Options

Answer 27

1. RICE/MICE 2. Compression, Ice 3. Stabilization 4. Isometric muscle sets 5. Motion to adjacent areas 6. Modalities (E-Stim) 7. Medications 8. Patient Education

Question 28

Treatment Options - RICE vs. MICE

Answer 28

Rest, Ice, Compression, Elevation Motion, Ice, Compression, Elecation Need to be careful with MICE - want passive normal forces but not too much

Question 29

Tx options - Compression and ICe

Answer 29

Ice = reduce blood flow to the area and will dec. chemotaxin factors and dec. inflammation

Question 30

Proliferative Phase (Reconstructive/Subacute)

Answer 30

2-3 days to 21-28 days Fibroblasts are primary mediator Granulation starts First part = neovasculatization (new blood vessels)

Question 31

Fibroblast Activity

Answer 31

Attracted via platelet and macrophage chemotaxis Produce Collagen matrix - Type 3 collagen - Elastin - Reticulin - Ground substances (GAGS and Proteoglycans)

Question 32

GAGS and Proteoglycans

Answer 32

Helps stablize tissue Hydration of tissue Aid in developing cross links

Question 33

Collagen Production

Answer 33

``` A variety of collagen types Protein molecule with triple helix structure - tropocollagen is precursor Group of 5 to form a microfibril Intramolecular crosslinks Intermolecular crosslinks Collagen organization ```

Question 34

Most common collagen type

Answer 34

Type I - 80% of collagen in our body

Question 35

First collagen type that is laid down

Answer 35

Type III - will eventually be replaced by Type I

Question 36

Wound Contraction

Answer 36

Some fibroblasts change to myofibroblasts | Some continue to produce collagen

Question 37

Strength factors in wound contraction

Answer 37

Crosslinks developed | GAGs

Question 38

End of Proliferation Phase

Answer 38

21-28 days Can tolerate bidirectional motion Scar starts to chrink secondary to the myofibroblast contractile ability Signals end of fibroblastic phase

Question 39

Management Goal - Controlled Motion

Answer 39

Develop a managable scar Amount of scarring is inversely related to return of function Wound ends must remain approximated

Question 40

Treatment

Answer 40

Movement within efected area Control of inflammation and pain Protected weight bearing Gentle stretching - tissue specific Easy to stress new tissue and surrounding tissue Multi-angle isometric, AROM, endurance exercises

Question 41

Remodeling Phase - Consolidation Phase

Answer 41

``` Consolidation stage (3-8 weeks) # of fibroblasts dec Dec development of new vascular networks Collagen fibers continue to replace (50% turnover in first 3 weeks) Type 3 collagen is being replaced by type 1 ```

Question 42

Remodeling Phase - Maturation Stage

Answer 42

2-18 months Cell activity continues to decrease but remains higher than surrounding tissue 85% of collagen is replaced by 5 months Stops responding to conservative treatment at 14 week mark

Question 43

Physiological Characteristics

Answer 43

Collagen synthesis/lysis balance occurs during maturation phase Although scar is shrinking, strength is increasing Balance is oxygen deoendent Fibers will orient themselves based on demand