Chapter 11
Soft Tissue Injury and
Postoperative Treatment
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Physiology of Connective
Tissue Repair
Ligaments
Tendon
Cartilage
Respond to injury
predictably
Some repair variability
between tissues (e.g.,
bone)
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Microstructure of Connective Tissues
Fibers (collagen, elastin)
Ground substance (glycosaminoglycans)
Cellular substances (fibroblasts, fibrocytes)
Function of connective tissues depends on
portions of intracellular and extracellular
components.
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Collagen Distribution of Joint Tissues
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Response to Loading
 Tensile loads – primarily resisted by collagen fibers.
 If tissue is elongated beyond 4%, plastic changes
begin to occur (X-links begin to fail).
 Yield point is where increase in strain occurs w/o an
increase in stress.
 Cyclic loading produces microstructural damage that
accumulates with each loading cycle.
 Failure from cyclic loading = fatigue failure.
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Stress-Strain Curve Showing Elastic Limit
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Stress-Strain Curve of Cortical Bone
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Viscoelastic Properties
Creep
Tissue lengthens in
response to a
constant load.
Relaxation
Amount of force
necessary to maintain
new length
decreases.
Creep and relaxation
allow connective
tissues to adapt and
function in a variety of
loading conditions
without being
damaged.
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Phases of Healing
Needed to formulate a plan of care.
Allows for matching the loading capability to
intervention.
Understanding provides the tools to treat a
variety of injury and surgical conditions.
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Phase I – Inflammatory Response
Characteristics
 3–5 days
 Palpable pain,
tenderness, swelling
 Release of chemical
substances
(prostaglandins,
bradykinin)
Treatment
 Decrease pain and
inflammation
 Maintain mobility and
strength of adjacent joints
and soft tissues if
possible
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Repair and Regeneration (Phase II)
Characteristics
Treatment
 Up to 8 weeks
 New collagen forming (primarily
type III)
 Edema is resolved during this
phase
 Bone – Callus phase
 Focus on normal tissue
relationships, optimal loading
 Changes become habitual in
this stage
 ROM exercises and joint
mobilization
 End of this stage – Mobility
and strength base should be
established
 Bone – Limited activity
allowed
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Remodeling and Maturation (Phase III)
Characteristics
Treatment
 Deposition of type I
collagen (end of phase II)
 Decreased synthetic
activity and
extracellularity
 Tension/resistance
becomes more important
in orientation of collagen
 Normal loading is
necessary for bone
remodeling
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Stage of Ligament Healing
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Restoration of Normal Tissue
Relationships
After connective tissue injury, relationship and
integrity of tissues are altered.
Possible Interventions:
 Active muscle contractions
 Passive joint motion
 Mobilization
 Stretching
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Optimal Loading
Choose treatment procedures that don’t disrupt
the healing process.
Requires:
1. Choosing a load that doesn’t under- or overload the
tissue.
2. Considering biomechanical effects of daily activities.
3. Understanding of mechanism of injured tissue loading.
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Optimal Loading
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Signs of Overload
1.
2.
3.
4.
Increased pain that does not resolve within the
next 12 hours.
Pain that is increased over the previous
session or comes on earlier in the exercise
session.
Increased swelling, warmth, or redness in the
injury area.
Decreased ability to use the part.
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Specific Adaptations to Imposed
Demands (SAID)
Includes quantity and type of activity.
Extension of Wolff’s law.
Guides exercise prescription parameters.
Stage of healing and optimal loading
parameters closely reflect the specific
demands on the patient’s functional
tasks.
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Prevention of Complications
Goal – Minimize effects of immobilization
while an injury is healing.
 Electrical stimulation or isometric contractions.
 AROM at joints above and below injury sites.
 Weight-bearing exercises when feasible to
load articular cartilage and prevent
degradation.
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Management of Impairments Associated
with Connective Tissue Dysfunction
Sprain – Acute injury to a ligament or joint
capsule without dislocation.
May resolve with short-term immobilization,
controlled activity, and rehab exercises.
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Sprain Classification
1. Grade I – Mild, ligament is stretched, no
discontinuity.
2. Grade II – Moderate, some fibers
stretched/torn, some joint laxity.
3. Grade III – Severe, complete ligament
disruption with resultant laxity.
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Examination and Evaluation
Observation to assess ecchymosis and edema.
Observe functional ROM, AROM, and PROM.
Assess joint integrity and mobility.
Palpation to identify primary and secondary
injuries.
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Strain: Musculotendinous Injury
Strain – An acute injury to the muscle or tendon
from an abrupt or excessive muscle contraction.
Usually a result of a quick overload to the muscle–
tendon unit whereby the tension generated >
tissue’s capacity.
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Strain Classification
1. Mild
2. Moderate
3. Severe
Based on clinical examination – Pain, edema, loss of motion,
tenderness.
Contributing factors – Poor flexibility, poor warm-up exercise,
insufficient strength or endurance, poor coordination.
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Examination and Evaluation
Thorough history.
Reproduce clinically through active or resisted
contraction.
Muscle may need to be put on stretch during
active or resisted contraction.
Localized swelling and warmth may be
observed.
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Application of Treatment Principles
Phase I
Phase II
Phase III
Principle
Optimal loading
Prevent secondary
complications
Restore normal
tissue relationships
Prevent
complications
Fine Tune.
Convert baseline
strength and mobility
into functional
movement patterns
Loading Zone
Balance of rest and
loading
Loading is
important–
orientation of
collagen fibers
Graded, progressive
exercise is necessary
to maintain
improvements
Modalities
Cryotherapy with
compression/
elevation
Joint mobilization
Stretching,
massage, postural
education
Patient maintenance
program.
Postural education,
stretching,
strengthening, etc.
Exercise
Intervention
Isometric
contractions
Contraction of
lengthened muscle
in shortened range
More whole body
patterns and
functional activity
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Tendinitis and Tendon Injuries
Failure occurs due to micro- or macrotrauma.
Outcomes are lengthy BUT predictable.
Categories/classifications have evolved.
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Classification of Tendon Injuries
1. Macrotrauma – Commonly occur at
musculotendinous junction.
2. Microtrauma – Paratendinitis (inflamation of
outer layer of tendon).
3. Tendinosis – Degeneration without
inflammatory response.
4. Tendinitis – Symptomatic degeneration of
tendon with vascular disruption and an
inflammatory response.
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Examination and Evaluation
History and subjective symptoms are of primary
importance.
ROM, muscle performance, posture, joint
integrity, mobility tests.
Observe structural or postural abnormality.
Document nodules, palpable defects, crepitus.
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Treatment Principles and Procedures
Treatment based on specific tendon injury.
Restoring length, strength: fundamental.
If inflammation is present – consider cold
packs, electrotherapeutic modalities.
Stretching (low load) if muscle length is
inadequate.
 Appropriate rehabilitation activities (w/
appropriate modifications).
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Management of Cartilage Injury
Classification of Cartilage Injuries
Mechanical
Nonmechanical – Infection, inflammatory
conditions, prolonged joint immobilization
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Examination and Evaluation
Cause of damage
Area of damage
Classification/health
of cartilage
General health
Lifestyle factors
Body weight
Joint alignment
ROM
Muscle performance
Joint integrity
Mobility
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Treatment Principles
Primary goal – Restoration of motion
Freedom of motion
Equitable load distribution
Stability
Increased muscle performance
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Management of Impairments
Associated with Localized Inflammation
Contusion
Results from a blow and can occur in any area
of the body.
Blood vessels below skin become damaged.
Accumulation in deeper tissues (hematoma)
may develop.
If untreated, may progress to myositis
ossifications.
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Examination and Evaluation
History of a “blow” provides best information.
Size, location, and direction lend a window into
location and extent of soft tissue injuries.
Palpation, joint mobility, muscle performance,
flexibility, and function tests help guide treatment
procedures.
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Treatment Principles
 Simple contusions resolve in a timely manner.
 Use measures of pain, muscle length, muscle
performance to guide aggressiveness of treatment.
 ROM must be restored as quickly as possible.
 Use ice to control swelling and local inflammation.
 Restore muscle performance.
 Submaximal isometrics may be initiated in early stages.
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Management of Impairments
Associated with Fractures
Fracture – Break in the
continuity of the bone.
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Classification of Fractures
1. Open fractures – Breaking the skin’s surface.
2. Closed fractures – Does not break through the
skin.
3. Nondisplaced – All sides of fracture remain in
anatomic alignment.
4. Displaced – The ends of the bones are not in
anatomic alignment.
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Types of Fractures
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Application of Treatment Principles
Consider associated soft tissues.
Healing of fracture is primary.
Rehabilitation of soft tissue may be more
challenging.
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Fracture Intervention
 Treatment focuses on recovery of initial trauma,
rehabilitating tissues that were immobilized.
 Initially, gentle joint mobilization, stretching.
 Decrease loading when indicated (e.g., stress fracture).
 Gentle strengthening (isometrics, etc.).
 NMES, SEMG – Feedback for atrophy.
 As impairments improve, incorporate activities to
alleviate remaining functional limitations.
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Soft Tissue Procedures
Ligament
reconstruction
Tendon surgery
Debridement
Synovectomy
Decompression
Soft tissue
stabilization and
realignment
Meniscal and labral
repairs
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Bony Procedures
Debridement/abrasion chondroplasty
Osteochondral autograft transplantation
(OAT)
Autologous chondrocyte implantation
Open reduction and internal fixation
Fusion
Osteotomy
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Summary
 Composition and structure of connective tissues provide
information regarding mechanical properties and
function.
 Unique viscoelastic characteristics are the result of fluid
and solid constituent materials.
 When connective tissues are loaded, the stress or
change per unit length gives information about the
tissue’s ability to withstand loads.
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Summary (cont.)
 Stages of healing & knowledge of injury give clinician
guidelines for intervention throughout care.
 Restoration of tissue relationships, SAID principle,
prevention of secondary complications – Guide
treatment.
 Acute soft tissue injuries necessitate early
intervention to avoid secondary complications.
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Summary (cont.)
 Management of tendon injuries and prognosis
varies according to injury classification.
 Interventions used in treatment of bony or
surgical procedures should have foundations
in basic science and require an understanding
in anatomy and kinesiology of the area.
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