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Prepared by: Maria Christina M.

Gutierrez, PTRP

SOFT TISSUE INJURY, REPAIR, AND MANAGEMENT

SOFT TISSUE LESIONS


Examples of Soft Tissue Lesions

Musculoskeletal Disorders
Sprain vs. Strain Dislocation vs Subluxation Synovitis, Bursitis, Tendinitis, Tenosynovitis,

Tenovaginitis and tendinosis Hemarthrosis Muscle/tendon rupture/lesion Ganglion Contusion Overuse Syndromes

Clinical Conditions Resulting from Trauma or Pathology


Joint Dysfunction Contracture Adhesion Reflex Muscle Guarding Intrinsic Muscle Spasm Muscle Weakness Myofascial compartment syndromes

Severity of Tissue Injury


Grade 1 (first-degree). Mild pain at the time of injury or

within the first 24 hours. Mild swelling, local tenderness, and pain occur when the tissue is stressed. Grade 2 (second-degree). Moderate pain that requires stopping the activity. Stress and palpation of the tissue greatly increase the pain. When the injury is to ligaments, some of the fibers are torn, resulting in some increased joint mobility. Grade 3 (third-degree). Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with severe pain. Stress to the tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint.

Irritability of Tissue: Stages of Inflammation and Repair


Acute Stage (Inflammatory Reaction) During the

acute stage, the signs of inflammation are present; they are swelling, redness, heat, pain at rest, and loss of function. When testing the range of motion (ROM), movement is painful, and the patient usually guards against the motion before completion of the range is possible . The pain and impaired movement are from the altered chemical state that irritates the nerve endings, increased tissue tension due to edema or joint effusion, and muscle guarding, which is the bodys way of immobilizing a painful area. This stage usually lasts 4 to 6 days unless the insult is perpetuated

Irritability of Tissue: Stages of Inflammation and Repair


Subacute Stage (Repair and Healing) During the

subacute stage, the signs of inflammation progressively decrease and eventually are absent. When testing ROM, the patient may experience pain synchronous with encountering tissue resistance at the end of the available ROM . Pain occurs only when the newly developing tissue is stressed beyond its tolerance or when tight tissue is stressed. Muscles may test weak, and function is limited as a result of the weakened tissue. This stage usually lasts 10 to 17 days (14 to 21 days after the onset of injury) but may last up to 6 weeks in some tissues with limited circulation, such as tendons.

Irritability of Tissue: Stages of Inflammation and Repair


Chronic Stage (Maturation and Remodeling) There are no signs of inflammation during the

chronic stage. There may be contractures or adhesions that limit range, and there may be muscle weakness limiting normal function. Connective tissue continues to strengthen and remodel during this stage. A stretch pain may be felt when testing tight structures at the end of their available range . Function may be limited by muscle weakness, poor endurance, or poor neuromuscular control. This stage may last 6 months to 1 year depending on the tissue involved and amount of tissue damage.

Irritability of Tissue: Stages of Inflammation and Repair


Chronic Inflammation (Overuse Syndrome)

An overuse syndrome is a state of prolonged inflammation.There are symptoms of increased pain, swelling, and muscle guarding that last more than several hours after activity. There are also increased feelings of stiffness after rest, loss of ROM 24 hours after activity, and progressively greater stiffness of the tissue as long as the irritation persists. Chronic Pain Syndrome Chronic pain syndrome is a state that persists longer than 6 months. It includes pain that cannot be linked to a source of irritation or inflammation and functional limitations and disability that include physical, emotional, and psychosocial parameters.

Characteristics and Clinical Signs of the Stages of Inflammation, Repair, and Maturation of Tissue
Acute Stage: Inflammatory Reaction
Characteristics Vascular changes Exudation of cells and chemicals Clot formation Phagocytosis, neutralization of irritants Early fibroblastic activity Clinical signs Inflammation Pain before tissue resistance

Subacute Stage:Repair and Healing

Chronic Stage:Maturation and Remodeling


Maturation of connective tissue Contracture of scar tissue Remodeling of scar Collagen aligns to stress

Removal of noxious stimuli Growth of capillary beds into area Collagen formation Granulation tissue Very fragile, easily injured tissue

Absence of inflammation Decreasing inflammation Pain after tissue Pain synchronous with resistance tissue resistance

MANAGEMENT DURING THE ACUTE STAGE


Management GuidelinesProtection Phase
The therapists role during the protection phase of

intervention is to control the effects of the inflammation, facilitate wound healing, and maintain normal function in unaffected tissues and body regions Patient Education Protection of the Injured Tissue Prevention of Adverse Effects of Immobility
Tissue-specific movement Intensity General movement

MANAGEMENT DURING THE ACUTE STAGE


P R E C A U T I O N : If the movement

increases pain or inflammation, it is either of too great a dosage or it should not be done. Extreme care must be used with movement at this stage.
Passive range of motion.
Low-dosage joint mobilization techniques Muscle setting

Massage

MANAGEMENT DURING THE SUBACUTE STAGE


Management Guidelines Controlled Motion Phase The therapists role during this stage is critical. The patient

feels much better because the pain is no longer constant, and active movement can begin. It is easy to begin too much movement too soon or be tempted to approach intervention cautiously and not progress rapidly enough. Understanding the healing process and tissue response to stresses underlies the critical decisions that are made throughout this phase of intervention. The key is to initiate and progress nondestructive exercises and activities (i.e., exercises and activities that are within the tolerance of the healing tissues, which can then respond without reinjury or inflammation).

MANAGEMENT DURING THE SUBACUTE STAGE


Patient Education Management of Pain and Inflammation

Monitor activities and exercises

P R E C A U T I O N : The new tissue being developed is fragile and easily interrupted. The patient often feels good and returns to normal activity too soon, causing exacerbation of symptoms. Exercises progressed too vigorously or functional activities begun too early can be injurious to the fragile, newly developing tissue and therefore may delay recovery by perpetuating the inflammatory response. However, if movement is not progressed, the new tissue adheres to surrounding structures and eventually becomes a source of pain and limited tissue mobility. Initiation of Active Exercises Multiple-angle, submaximal isometric exercises Active range of motion exercises Muscular endurance
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MANAGEMENT DURING THE SUBACUTE STAGE


Protected weight-bearing exercises. P R E C A U T I O N : Eccentric and heavy-resistance

exercises (such as PRE) may cause added trauma to muscle and are not used in the early subacute stage after muscle injury when the weak tensile quality of the healing tissue could be jeopardized. For nonmuscular injuries, eccentric exercises may not reinjure the part, but the resistance should be limited to a low intensity at this stage to avoid delayed-onset muscle soreness. (This is in contrast to using eccentric exercises to facilitate and strengthen weak muscles when there has been no injury to take advantage of greater tension development with less energy in eccentric contractions,

MANAGEMENT DURING THE SUBACUTE STAGE


Initiation and Progression of Stretching Warm the tissues. Inhibition techniques Stretching techniques Massage Use of the new range

MANAGEMENT DURING THE CHRONIC STAGE


Maturation of Tissue
The primary differences in the state of the healing

tissue between the late subacute and chronic stages are the improvement in quality (orientation and tensile strength) of the collagen and the reduction of the wound size during the chronic stages. The quantity of collagen stabilizes; and there is a balance between synthesis and degradation. Depending on the size of the structure or degree of injury or pathology, healing, with progressively increasing tensile quality in the injured tissue, may continue for 12 to 18 months.

Remodeling of Tissue
Because of the way immature collagen molecules are

held together (hydrogen bonding) and adhere to surrounding tissue, they can be easily remodeled with gentle and persistent treatment. This is possible for up to 10 weeks. If not properly stressed, the fibers adhere to surrounding tissue and form a restricting scar. As the structure of collagen changes to covalent bonding and thickens, it becomes stronger and resistant to remodeling. At 14 weeks, the scar tissue is unresponsive to remodeling. Consequently, an old scar has a poor response to stretch. Treatment under these conditions requires either adaptive lengthening in the tissue surrounding the scar or surgical release

Management Guidelines Return to Function Phase


Considerations for Progression of Exercises Signs of Excessive Stress with Exercise or Activities
Exercise or activity soreness that does not decrease after 4

hours and is not resolved after 24 hours

Exercise or activity pain that comes on earlier or is

increased over the previous session Progressively increased feelings of stiffness and ROM over several exercise sessions Swelling, redness, and warmth in the healing tissue Progressive weakness over several exercise sessions Decreased functional usage of the involved part

Progression of Exercises for Muscle Performance: Developing Neuromuscular Control, Strength, and Endurance
If the patient is not using some of the muscles

because of inhibition, weakness, or dominance of substitute patterns, isolate the desired muscle action or use unidirectional motions to develop awareness of muscle activity and control of the movement. Progress exercises from isolated, unidirectional, simple movements to complex patterns and multidirectional movements requiring coordination with all muscles functioning for the desired activity. Progress strengthening exercises to simulate specific demands including both weight-bearing and nonweight-bearing (closed and open chain) and both eccentric and concentric contractions

Progression of Exercises for Muscle Performance: Developing Neuromuscular Control, Strength, and Endurance
Progress trunk stabilization, postural control, and balance

exercises as well as coordinate with extremity motions for effective total body movement patterns. Teach safe body mechanics and have the patient practice activities that replicate his or her work environment. Often overlooked but of importance in preventing injury associated with fatigue is developing muscular endurance in the prime mover muscles and stabilizing muscles as well as cardiovascular endurance Return to High-Demand Activities
are progressed further to more intense exercises including

plyometrics, agility training, and skill development

MANAGEMENT GUIDELINESAcute Stage/Protection Phase Impairments: Inflammation, pain, edema, muscle spasm Impaired movement Joint effusion (if the joint is injured or if there is arthritis) Decreased use of associated areas Plan of Care Intervention (up to 1 week postinjury)
1. Educate the patient. 2. Control pain, edema, spasm. 3. Maintain soft tissue and joint integrity and mobility. 4. Reduce joint swelling if symptoms are present. 5. Maintain integrity and function of associated arease.
Precautions: The proper dosage of rest and movement must be used during the inflammatory stage. Signs of too much movement are increased pain or increased inflammation. Contraindications: Stretching and resistance exercises should not be performed at the site of the inflamed tissue. 1. Inform patient of anticipated recovery time and how to protect the part while maintaining appropriate functional activities. 2. Cold, compression, elevation, massage (48 hours). Immobilize the part (rest, splint, tape, cast). Avoid positions of stress to the part. Gentle (grade I) joint oscillations with joint in painfree position. 3. Appropriate dosage of passive movements within limit of pain, specific to structure involved. Appropriate dosage of intermittent muscle setting or electrical stimulation. 4. May require medical intervention if swelling is rapid (blood). Provide protection (splint, cast). 5. Active-assistive, free, resistive, and/or modified aerobic exercises, depending on proximity to associated areas and effect on the primary lesion. Adaptive or assistive devices as needed to protect the

MANAGEMENT GUIDELINESSubacute Stage/Controlled Motion Phase Impairments: Pain when end of available ROM is reached, Decreasing soft tissue edema Decreasing joint effusion (if joints are involved), Developing soft tissue, muscle, and/or joint contractures, Developing muscle weakness Intervention of 3 weeks postinjury) from Care Plan of reduced usage, Decreased functional use(up tothe part and associated 1. Inform patient of anticipated healing time and 1.areas the patient. Educate
2. Promote healing of injured tissues. 3. Restore soft tissue, muscle, and/or joint mobility.
importance of following guidelines. Teach home exercises and encourage functional activities consistent with plan; monitor and modify as patient progresses. 2. Monitor response of tissue to exercise progression; decrease intensity if inflammation increases. Protect healing tissue with assistive devices, splints, tape, or wrap; progressively increase amount of time the joint is free to move each day and decrease use of assistive device as strength in supporting muscles increases. 3. Progress from passive to active-assistive to active ROM within limits of pain. Gradually increase mobility of scar, specific to structure involved. Progressively increase mobility of related structures if they are tight; use techniques specific to tight structure.

MANAGEMENT GUIDELINESSubacute Stage/Controlled Motion Phase


Plan of Care
4. Develop neuromuscular control, muscle endurance, and strength in involved and related muscles. 5. Maintain integrity and function of associated areas.

Intervention (up to 3 weeks postinjury)

4. Initially, progress multiple-angle isometric exercises within patients tolerance; begin cautiously with mild resistance. Initiate AROM and protected weight bearing and stabilization exercises. Precautions: The signs of As ROM, joint play, and healing inflammation or joint swelling normally improve, progress isotonic exercises decrease early in this stage. Some with discomfort will increased repetitions. occur as the activity level is progressed, Emphasize control and proper but it should not last longer than a mechanics. couple of hours. Signs of too much Progress resistance later in this stage. motion or 5. Apply progressive strengthening activity are resting pain, fatigue, and stabilizing exercises, monitoring increased weakness, and spasm. effect on

MANAGEMENT GUIDELINESChronic Stage/Return to Function Phase Impairments: Soft tissue and/or joint contractures and adhesions that limit normal ROM or joint play Decreased muscle performance: weakness, poor endurance, poor neuromuscular Plan of Care Interventions (3 weeks postinjury) control Decreased functional usage of the involved part in safe progressions of exercises and 1. Educate the patient. 1. Instruct patient Inability to function normally in an stretching. activity expected 2. Increase soft tissue, muscle

and/or joint mobility. 3. Improve neuromuscular control, strength, muscle endurance.

Monitor understanding and compliance. Teach ways to avoid reinjuring the part. Teach safe body mechanics. Provide ergonomic counseling. 2. Stretching techniques specific to tight tissue: Joint and selected ligaments (joint mobilization). Ligaments, tendons and soft tissue adhesions (cross-fiber massage). Muscles (neuromuscular inhibition, passive stretch, massage, and flexibility exercises). 3. Progress exercises: Submaximal to maximal resistance. Specificity of exercise using resisted concentric and eccentric, weight bearing and non-weight-bearing. Single plane to multiplane motions. Simple to complex motions, emphasizing movements that simulate functional activities. Controlled proximal stability, superimpose distal motion. Safe biomechanics. Increase time at slow speed; progress complexity and time; progress speed

MANAGEMENT GUIDELINESChronic Stage/Return to Function Phase


Plan of Care 4. Improve cardiovascular endurance. 5. Progress functional activities. Interventions (3 weeks postinjury)

4. Progress aerobic exercises using safe activities. 5. Continue using supportive and/or assistive devices until the ROM is Precautions: There should be no signs functional of inflammation. Some discomfort with joint play, and strength in will occur as the activity level is supporting muscles is adequate. progressed, Progress functional training with but it should not last longer than a simulated activities from protected and couple of hours. Signs that activities controlled are progressing too quickly or with too to unprotected and variable. great a Continue progressive strengthening dosage are joint swelling, pain that exercises and advanced training lasts longer than 4 hours or that activities requires medication for relief, a until the muscles are strong enough decrease in strength, or fatiguing more and able to respond to the required easily. functional

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