Acute Soft Tissue Injuries

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Dylan McDowell
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1 Acute Soft Tissue Injuries Classic Soft-Tissue Injury Response Sequence: v inflammatory phase v proliferative phase v maturation phase Inflammation v pathologic process consisting of dynamic complex of cytologic & histologic reactions that occur in affected blood vessels & adjacent tissues in response to an injury 1

Classic Injury & Healing Phases v inflammatory phase is critical period (2hrs 6 days) v first 72 hours important v poor management may lead to long term adverse sequelae Inflammation, Proliferation

2 Classic Injury & Healing Phases v inflammatory phase is critical period (2hrs 6 days) v first 72 hours important v poor management may lead to long term adverse sequelae Inflammation, Proliferation In & Remodeling Bleeding In Remodeling In Inflammation Proliferation In Hours Days Weeks In Months Classic Acute Management Relative rest Ice Compression Elevation Avoid H.A.R.M v Heat v Alcohol Ø May mask pain v Run v Massage Ø Avoid 24 72hrs 2

3 Classic S&S of Inflammation v Pain v Swelling v Redness v Heat v Dysfunction Classic S&S of Inflammation v Pain v Swelling v Redness v Heat v Dysfunction Redness &Warmth v Chemical release Ø Histamine Ø Substance P v Vasodilation v Increased blood supply v Within several hours 3

v Trauma v Cell hypoxia v Chemical release Ø Bradykinin Ø Prostaglandin Ø Histamine Pain v Pressure on nerve endings Role of CNS in Pain & Injury v Bleeding Ø rarely arterial v Chemical release Ø

4 v Trauma v Cell hypoxia v Chemical release Ø Bradykinin Ø Prostaglandin Ø Histamine Pain v Pressure on nerve endings Role of CNS in Pain & Injury v Bleeding Ø rarely arterial v Chemical release Ø serotonin, leukotrienes, histamine, prostaglandin Swelling Ø cell membrane permeability v Osmotic gradient Ø extra-cellular protein draws fluid into extracellular space and increases oedema v Lymphatic stasis Ø blocked by thick exudate Acute swelling (within 2hrs 4 ds) 4

5 Clinical Aspects of Inflammation v Characterised by Ø fluctuating swelling, functional limitation v Management Ø reduce local tissue temp, pain, inflammatory exudate, metabolic demands of tissue Ø protect from further injury, newly-formed fibrin bonds Ø promote collagen fibre growth & realignment Ø Maintain CV / MSK fitness Classic Soft-Tissue Injury Management Rest, Ice, Compression, Elevation Exclude - severe pain - immediate / profuse swelling - deformity - extreme loss of function - unusual / false motion - noises at injury site Soft-Tissue Injury Management v Principles of acute injury management based largely on expert opinion & laboratory studies v Level 4-5 evidence 5

6 v Protection v Optimal Loading v Ice v Compression v Elevation Many Acronyms v Relative Rest v Elevation v Compression v Ice v Pain Limited Exercise R.E.C.I.P.E Clinical Objectives Relative Rest v protect / prevent further injury reduce pain v balance immobilisation for anatomical alignment of injured structures with mobilisation to reduce atrophy effects 6

7 Relative Rest v brief period of complete immobilization v e.g., muscle 2 days v Grade II, III ligament sprain upto 10 days Relative Rest v Early mobilization (optimal loading): v e.g., lateral ankle sprain improve swelling, patient satisfaction & return to activity v Muscle improve capillarization & muscle fibre regeneration Early Mobilisation vs Immobilization 7

8 Elevation (Rationale) v Elevated above heart v Decrease in hydrostatic pressure v Decrease accumulation of interstitial fluid Elevation (Rationale) v reduce capillary pressure v assist lymphatic drainage prevent accumulation / assists dispersal of inflammatory exudate v reduce tissue pressure / pain (when due to increased pressure) v intra-arterial pressure reduced v elevation alone effective in reducing oedema Elevation: Guidelines / Contraindications v compression removed when limb elevated v caution with acute compartment syndrome v rebound phenomenon (dependent limb position following elevation) 8

9 Compression (Rationale) Increase pressure gradients in venous & lymphatic systems counteracts osmolaritydrive facilitates lymphatic & venous drainage prevent accumulation of oedema / assists in dispersal inhibit seepage, disperse fluid Airaksinen et al ( 90) 1wk & 4wk compression group had less oedema / pain, increased ROM / improved function Compression Guidelines / Contraindications v distal to proximal v applied in spiral fashion v check for diminished circulation v acute compartment syndrome v high pressure (e.g., 80mmHg) counterproductive v snug 15-35mmHg Ice (Rationale) v inexpensive & widely used therapeutic modality v decrease pain v local analgesia when 15 C v decrease metabolism? v Difficult to achieve in practice v decrease 2ndary hypoxia v decrease swelling? v decrease muscle spasm v decrease circulation? 9

10 Ice & Sport Participation v pain reduction after SKIN cooling 10-15deg v reduce motor/sensory nerve conduction v decrease blood flow? v decrease local blood flow? v decrease soft-tissue blood flow? Ice Precautions v skin health / diseases diabetes chronic corticosteroid use Raynaud s phenomenon PVD v prior adverse reactions v cold averse Ø Raynaud s phenomenon Ø blue/white (cold) extremities v pain / excess cold on application Ice Guidelines v not overly cold >5 C (not freezing!) v duration until numb <20minutes / 20 every 2hrs for first hrs v only re-apply sensation / temp normal v remove - excessive pain in first min s (avoid skin burn) v don t apply to fractures, open wounds (infection), dislocations 10

11 Pain Limited Exercise v facilitate lymphatic / venous drainage v assist phagocytosis reduce swelling v increase deep blood supply assist regeneration v facilitate appropriate architecture of collagen bundle functional healing scar tissue Pain Limited Exercise v Therapeutic Exercise v Mechanotherapy v Mechanotransduction v Mechanocoupling v Cell-Cell Communication v Effector Cell Response Pyramid of Recovery Flexibility Strength 11

12 Pyramid of Recovery Proprioception Flexibility Strength Pyramid of Recovery Flexibility Retu rn to Play Motor Re-L earning Endurance Proprioception Strength NSAIDs & Acute Injuries Muscle Ø probably negative effect on muscle healing & hypertrophy Ø can inhibit protein synthesis & reduce satellite cell activation Tendon Bone Ø Reduces tenocyte proliferation & collagen formation Ø Animal studies delay in bone healing Fracture callus (animal model) 12

13 Soft-Tissue Injury & Healing Vascular Response Platelets Fibrin meshwork Capillary dilation Neutrophils Macrophages Lymphocytes Fibroblasts Collagen deposition Angiogenesis Collagen remodeling Scar maturation Inflammatio n Proliferation Maturation Inflammatory Phase v Accumulation of clotting blood, serum fluid & necrotic tissue v Migration of cells to area: Ø Erythrocytes Ø Leukocytes Ø Lymphocytes Ø Monocytes & Macrophages Ø Fibroblasts towards end Cellular Activities Inflam matio n Maturatio n Proliferation A Relative Cell Num bers Neutro phils ( A) Macrophage s (B) Fibroblast s (D) Lymphocytes ( C) Hrs Days Wks Mths Time Post-Injury B C D 13

14 Inflammatory Phase v Vascular Changes Ø Vasodilatation mediated initially by histamine Ø Continued by serotonin, prostaglandin, bradykinin Ø Increased capillary permeability by bradykinin Ø Proliferation of capillary endothelial buds Prepatellar Bursitis Inflammatory Phase v Oedema & increased water content v Collagen Ø Increased content Ø Increased turn over Ø Type 3 > Type I Ø Increased GAG & DNA Olecranon Bursitis Proliferation & Remodeling Phases Proliferation vangiogenesis vfibroblasts: collagen; ECM - glycoprotiens, glycosaminoglycans, proteoglycans, elastin, fibronectin vprogressive fibroblast apoptosis Maturation & Remodeling vtype III collagen degraded replaced by type I collagen vdisorganized fibers rearranged, cross-linked aligned (tension lines) 14

Unit 9 MODALITIES AND REHABILITATION Mobility Worksheet

Unit 9 MODALITIES AND REHABILITATION Mobility Worksheet Name Period The selection of specific treatments is based on a variety of factors list four: What is the protocol for RICE? What are the purposes