Week 3 - Soft Tissue

Question 1

What are the acute soft Tissue injury faces?

Answer 1

– Bleeding: as clot formation increases, swelling potential is reduced
– Inflammatory: critical period 2h - 6 days; first 72 hours vital poor management may lead to some optimal outcomes
– Proliferative: new tissue, Increased vascularisation / angiogenesis
– Maturation: scar formation, remodelling, alignment - repaired as best as the body can

Phases are not sequential, each phase can overlap into the next

Question 2

What happens during phase 1 initial bleed?

Answer 2

– Hemostasis: platelet plug coagulation, fibrin reinforcement
– platelet-derived growth factor (PDGF): promotes tissue healing

Question 3

What happens during stage two: inflammatory stage?

Answer 3

Pathologic process = dynamic cascade of psychologic and Hyster logic reactions in blood vessels and adjacent tissues
– White blood cells, neutrophil, macrophage, lymphocyte, enter the affected area (These work for immune infiltration, debris clearance and pathogen killing)

Question 4

What happens during stage three: proliferation phase?

Answer 4

– Angiogenesis: an increase in vascularisation
– fibroblast collagen deposition: create provisional matrix (granulation tissue) composed mainly of collagen type 3 (not as good as type one, but intermittent phase collagen)
- Shortly after injury, resident Tendons cells adjacent to the injury site undergo apoptosis
- ECM - protoglycans, glycosaminoglycans, elastin, fibronectin
- progressive fibroblast apoptosis

Question 5

What happens during stage four: maturation phase?

Answer 5

– Remodelling: scar tissue remains disorganised compared to native tissue (tendon, ligament etc)
– dramatic decrease in both vascularity and cellularity
– adult tendons lack inherent ability to fully regenerate damaged tissue – fibrovascular scar generated during initial healing phase is never fully replaced

Question 6

What are the signs and symptoms of inflammation?

Answer 6

– Pain (Latin dolor)
- swelling (Latin tumor)
- redness (Latin rubor)
- heat (Latin calor)
- loss of function (Latin funtio lasea)

Question 7

Where does the redness and warmth come from in soft tissue damage?

Answer 7

– Bleeding, RBC damage/coagulation
– vasodilation
– chemical reactions (histamine, substance P, increased blood supply)

Question 8

Where does Pain come from in soft tissue damage?

Answer 8

– Trauma: tissue damage/neural
– swelling: mechanical pressure on nerve endings
– cell hypoxia: altered tissue/neural metabolism
– chemical reactions: heat/pH alterations

Question 9

Where does the acute swelling (oedema) come from in soft tissue injury?

Answer 9

– Variable bleeding: capillaries/really arterial
– increased vascular/cell membrane permeability: serotonin, leukotrienes, histamine, prostaglandin, albumin (interstitial tissue plasma)
– Osmotic gradient: extracellular protein draws fluid into extracellular space and increases oedema
– lymphatic stasis: blocked by thick exudate

Question 10

What are the three clinical aspects of soft tissue injury that we are interested in?

Answer 10

– Pain: physical and psychological aspects (chronic)
– swelling: extensive and fluctuating
– dysfunction: activity limitation and deconditioning

Question 11

How do we as clinicians manage soft tissue injury?

Answer 11

– Protect from further injury, new fibrin bonds
– control (reduced) inflammatory exudate, pain, metabolic demands of tissue, local tissue temperature
– promote collagen fibre growth and realignment
– maintain CV/MSK fitness

Question 12

What is the acute management of soft tissue injury?

Answer 12

– PRICE: protect, rest, ice, compression, elevation
– Exclude: severe pain, immediate/profuse swelling, deformity, extreme loss of function, unusual/false motion, noises at injury site

Question 13

What does it mean to avoid HARM?

Answer 13

H = heat: will increase local metabolism, vasodilation
A = alcohol: may mask pain, vasodilation
R = running: disrupt repair processes, secondary bleeds
M = massage: in acute phases disrupt repair processes, secondary bleeds

Question 14

What is POLICE?

Answer 14

P = protection of injury
OL = optimal loading
I = ice
C = compression
E = elevation

Question 15

What is the “protect” aspect of POLICE?

Answer 15

• protect/prevent further injury
• reduce pain
• brief period of complete immobilisation
  - muscle strain 2 days
  - grade 2, 3 ligament sprain - up to 10 days
• non / minimal weight bearing

Clinical objectives
- balance immobilisation for anatomical alignment of injured structures with mobilisation to reduce atrophy effects

Question 16

What is the “optimal loading” aspect of POLICE

Answer 16

Early loading
- clinical exercise interventions
- there are long term negative effects of immobilisation
- clinical challenge: determine optimal loading for each individual/tissue/pathological presentation
- muscle: improve capillarization & fibre regeneration
- lateral ankle sprain: improve swelling, patient satisfaction & return to play

Question 17

What is the “ICE” component of POLICE?

Answer 17

Inexpensive and widely used
– crushed ice bag: skin at 15°C, deeper tissues at 20 to 25°C
– applied every 20 minutes for the first 48 to 72 hours
– decrease pain via local analgesia
– decrease muscle spasm
– reduce motor/sensory nerve conduction

Clinical questions
- decrease local metabolism (secondary tissue hypoxia)
- effects on inflammatory process (WBC activity)
- vasoconstriction (decrease oedema / metabolism)
- proprioception (cold temps cools nerves, ice between activity can increase risk of injury, cold temps also cools muscle activity - timing of application)

Precautions and checks
- skin health/circulatory diseases (diabetes, peripheral vascular disease, chronic corticosteroid use)
- extreme pain reaction with application
- prior / cold adverse reactions (blue/white (cold) extremities, Raynaud’s phenomenon)
- don’t apply to open wounds
- don’t reapply until sensation/ temp returns (around 20 mins)
- use mouse cloth to avoid frostbite/skin burn

Question 18

What is the compression component of POLICE?

Answer 18

– Increase pressure gradients in Venus and lymphatic systems (facilitate drainage) to counteract oedema
– apply distal to proximal, 50% overlapping, light to moderate pressure

Precautions and checks
- check for diminished circulation
- consider removing Compression while elevating limb
– contraindication in acute compartment syndrome

Question 19

What is the elevation component of POLICE?

Answer 19

– Elevate above heart: decrease hydrostatic pressure – reduce accumulation of interstitial fluid
– lower limb above level of pelvis
– combine with ice

Precautions and checks
- Rebound phenomenon: dependent limb position after elevation
– consider removing compression whilst elevating limb
– contraindication: acute compartment syndrome
– acutely effective in reducing Oedema