EHR315 - Week 2
Dr Stephen Bird
Understanding the Healing
Process
• Primary Injury
• Inflammatory Response
• Role of Mobility
• Injuries to Various Tissues
• Musculoskeletal Structures
• Managing the Healing Process
Reading: Chapter 2
Quiz 2: Functional anatomy
The Healing Process
Programs based on healing process framework
1
di
1. Bl
Bleeding
(Inflammatory)
No definitive
beginning or
end
3. Maturation(remodeling)
2. Fibroblasticrepair
(Proliferation)
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EHR315 - Week 2
Dr Stephen Bird
The Primary Injury
• Acute or chronic
1. Macrotraumatic injuries
Look away if you don’t like pain
• Acute
A t trauma;
t
immediate
i
di t pain/disability
i /di bilit
• Fractures, dislocations, sprains, strains
2. Microtraumatic injuries
• Overuse injuries, repetitive overload, incorrect mechanics
• Tendinitis, tenosynovitis bursitis
• Secondary injury
–
Inflammatory or hypoxia response
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EHR315 - Week 2
Dr Stephen Bird
1. Inflammatory Response Phase
Injury = altered cellular metabolism = chemical mediators
• Macroscopic characteristics
1.
2.
3.
4.
Swelling
Tenderness
Redness
Increased temperature
• Initial response is critical in healing process
–
Leukocytes, phagocytic cells and exudate delivered to tissue
–
Protective response, localization and removal of injury by-products
Stages of Inflammation
• Vasoconstriction
• 5-10min post-injury
p
lasts 24-48 hours
• Initial response
• Histamine: causes vasodilation cell permeability
• Leukotrienes: causes margination
• Cytokines: attract leukocytes to site of InF
• Plug
Pl obstructs
b
llocall llymphatic
h i fl
fluid
id d
drainage
i
• Results in localization of the injury
• Begins 12hrs post-inj; complete within 48hrs
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EHR315 - Week 2
Dr Stephen Bird
Vascular
Reaction
Chemical
mediators
Clot
Cl t
Formation
2. Fibroblastic-Repair Phase
Proliferative/regenerative activity leads to scar formation
– referred to as fibroplasia
– begins within 2 hrs,
hrs can last _________________
• Signs associated with InF response subside
 Granulation tissue
• Breakdown of the fibrin clot
• Consists of fibroblasts, collagen and capillaries
 Collagen
g deposited
p
randomlyy _________________
• Results in  scar tensile strength
Persistent InF response promotes extended fibroplasia
resulting in increased scarring
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EHR315 - Week 2
Dr Stephen Bird
Collagen
Major structural protein
– Forms strong structures that hold connective tissue together
– Enables tissue to resist mechanical forces/ deformation
• Collagen fibrils: ___________ elements of connective tissue
– Mechanical/physical properties allow collagen to respond to loading /
deformation
• Elasticity, visco-elasticity, plasticity, creep response, hysteresis
– Limitations exceed, injury results
3. Maturation-Remodeling Phase
Realignment of _________________
– Continued breakdown and synthesis of collagen
– Increased stress/strain results in increased collagen realignment
• ___ wks firm, strong, contracted, nonvascular, scar present
– Fibroplasia - can last 4-6 wks
• Maturation long-term process
– may require several years to complete
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EHR315 - Week 2
Dr Stephen Bird
Role of Progressive Mobility
• Wolff’s law: soft tissue respond to physical demands
placed upon them, causing tissue to remodel along line
of tensile force
– Controlled mobilisation superior to immobilisation for scar
formation, revascularisation & muscle regeneration
1. InF Response Phase
2. Repair Phase
3. Remodeling Phase
Factors that Impede Healing
• Extent of Injury
• Atrophy
• Edema
• Corticosteroids
• Hemorrhage
• Muscle Spasm
• Poor vascular supply
• Infection
• Separation of tissue
• Age
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EHR315 - Week 2
Dr Stephen Bird
Injuries to Ligament
Sprains: damage to a ligament
• Ligaments
g
 Inelastic band of tissue, provides joint stability
 Controls bone position during joint motion
Grades o
of Ligamentt Sprains
 Provides proprioceptive input
Grade I tear
minor stretching, tearing of the ligaments; no joint instability
G d II tear
Grade
t
(minor)
( i )
major tearing, separation of the ligament; moderate to severe joint
instability; moderate to severe pain
Grade II tear (major)
major tearing, separation of the ligament; moderate to severe joint
i t bilit moderate
instability;
d t tto severe pain
i
Grade III
complete tear, gross joint instability; injury may involve multiple joint
structures
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EHR315 - Week 2
Dr Stephen Bird
Ligament Healing
Same course of repair as with other vascular tissues
– Extra-articularly ligament sprains bleeding in subcutaneous space
– Intra-articular ligament sprains bleeding within the capsule
Vascular
• vascular proliferation, fibroblastic activity and clot formation
• during the initial _________________________
Collagen Granulation tissue
• bridge torn ends of ligaments via scar tissue formation
• scar maturation and collagen tensile strength increase
Factors Affecting Healing
1. Surgically repaired extra-articular ligaments
– Heal with less scarring
– Stronger than un-repaired
un repaired ligaments
2. Non-surgically repaired ligaments
– Heal via fibrous scarring = ligament lengthening /  joint instability
3. Intra-articular ligament damage
– synovial fluid presence, diluting hematoma, disrupting clot/healing
4. Ligament healing/immobilization: decreased tensile strength
– Muscle strength training can enhance joint stability
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EHR315 - Week 2
Dr Stephen Bird
Injuries to
Musculotendinous Structures
• Skeletal muscle exhibits 4 traits (page 31)
–
–
–
–
.
.
.
.
• Muscle size and architecture often contribute
to type
yp and magnitude
g
of motion
– (gross vs. fine, powerful vs. coordinated)
Mechanics of Muscular Contraction
Review the following:
1.
2.
3.
4.
.
.
.
.
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EHR315 - Week 2
Dr Stephen Bird
Muscle Strains
Strains occur when the musculotendinous unit is:
1. Overstretched
2 Forced
2.
F
d tto contract
t t against
i t too
t greatt
a resistance…. (_________________)
• Damage occurs
–
–
–
–
Muscle
Tendon
.
Tendon-bone interface
Muscle S
Strain Class
sifications
Armfield, D. R., Kim, D. H.-M., Towers, J. D., Bradley, J. P., &
Robertson, D. D. (2006). Sports-related muscle injury in the
lower extremity. Clinics in Sports Medicine, 25(4), 803-842.
Grade I tear
• some fibers have been stretched or actually torn
• resulting in tenderness and pain on active ROM
• movement painful but full range present
Grade II tear (minor)
• number of fibers have been torn and active contraction is painful,
• usually a depression or divot is palpable
• some swelling and discoloration result
Grade III
• Complete rupture of muscle or musculotendinous junction
• significant impairment,
• initially a great deal of pain that diminishes due to nerve damage
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Dr Stephen Bird
Muscle Healing: 4 stages
EHR315 - Week 2
• lead to
phagocytosis
• produce gel-like
matrix leading
to fibrosis and
scarring
1
2
Hemorrhaging
and edema
Fibroblasts
and ground
substance
4
3
Collagen
undergoes
maturation
Myoblastic
cell infiltrate
the region
• active
contractions
critical to apply
tensile stress
• promotes
myofibril
regeneration
Lengthy recovery for each grade, Patience is a must
Tendinitis
Describes multiple pathological tendon conditions
– Tendon InF, with no involvement of paratenon
• Paratenonitis
– InF of tendon outer layer
– Friction injury
• Tendinosis
– Degenerative tendon changes no clinical/histological signs of InF
• Chronic tendinitis significant tendon degeneration
– Most common: _______________________________
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EHR315 - Week 2
Dr Stephen Bird
Tendon Healing
Time frame dependant on severity of injury
Wk 0-2
Wks
02
• healing tendon adheres to the surrounding tissue
Wks 3-4
• tendon separates (varying degrees) from tissues
Wks 5+
• tensile strength increases
Managing the Healing Process
Through Rehabilitation
Pre-Surgical Phase
• If surgery can be delayed, ExTh may help to improve outcome
• Maintaining/increasing strength, ROM, CV fitness, NM control enhance athlete’s
ability to perform rehabilitation after surgery
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EHR315 - Week 2
Dr Stephen Bird
Phase I – Acute Injury Phase
Initial swelling management / pain control crucial
 ______________________________
 Loading too aggressive first 48hr InF process may not accomplish what it
needs to....
to
 Immobilization for 24-48hrs????
• Day 3-4 engage in mobility ex
 gradually bear weight if lower extremity injury
 Use of NSAID’s (table 2.1 p.41)
Järvinen, T. A. H., Järvinen, T. L. N., Kääriäinen, M., Äärimaa, V., Vaittinen,
S., Kalimo, H., et al. (2007). Muscle injuries: optimising recovery. Best
Practice and Research Clinical Rheumatology, 21(2), 317-331.
Phase II – Repair Phase
As InF subside =  pain  passive ROM ex added
 CV fitness
 Restore ROM
 Regain / increase strength
 Re-establish NM control
• Continued modality use for pain modulation and ______________________
 Cryotherapy ?
 Electrical stimulation (TENS)?
•
Transcutaneous Electrical Nerve Stimulation
Hubbard, T.J., & Denegar, C.R. (2004). Does cryotherapy
improve outcomes with soft tissue injury? Journal of
Athletic Training, 39(3), 278-279.
Machado, A., et al. (2012). The effects of transcutaneous
electrical nerve stimulation on tissue repair: A literature
review. Plastic Surgery, 20(4), 237 – 240.
Finberg, M., et al.. (2013). Effects of electro-stimulation
therapy on recovery from acute team sport activity. Int J
Sports Physiol Perf, 8(3), 293-299.
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EHR315 - Week 2
Dr Stephen Bird
Phase III – Remodeling Phase
Longest phase; ultimate goal R2S/R2A
 Continued collagen realignment
 Pain continues to decrease with activity
• Regain sports-specific skills
 Dynamic functional activities
 Sports-directed strengthening activities
 Plyometric strengthening
• Functional testing
 Determine specific skill weakness
Werner, G. (2010). Strength and conditioning
techniques in the rehabilitation of sports injury.
Clinics in Sports Medicine, 29(1), 177-191. p183
Phase III – Remodeling Phase (continued)
• Heating modalities
 Ultrasound, diathermy
 Increase circulation in deeper tissue
• Manual therapy
 Massage: reduce guarding, spasm, pain
 Techniques include Hoffa massage Friction massage, Rolfing Acupressure,
Connective tissue massage, Myofascial release
Enhanced lymphatic flow will deliver essential nutrients and increase
breakdown/removal of waste.
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EHR315 - Week 2
Dr Stephen Bird
Summary: Key Points
1. Healing process
– Inflammation
– Fibroblastic-repair
– Maturation-remodeling
2. Tissue response to injury: _____________________________
– How does injury effect the mechanics of muscular contraction?
3. Expedite recovery of function
– ROM,
ROM strength
strength, cardiorespiratory fitness,
fitness NM control
4. Prevent recurrence of injury the phased-approach to rehab
– Phase I:
– Phase II:
– Phase III:
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