Unit 2/ Chapter 10:
Tissue Response to Injury
The Healing Process
 Essential for athletic trainer to possess knowledge of healing process
 If you interfere with the process, _____________________ it down
 Cannot speed up the process but one can impede it
Three Phases of Healing Process
1. Inflammatory Response
2. Fibroblastic Repair Phase
3. Maturation- Remodeling Phase
 Healing is a continuum
Draw Healing Process
Phase I: Inflammatory Response Phase
 Once tissue is injured- the process of healing begins __________________________
 Starts ____________________ release
Cardinal Signs of Inflammation
 Rubor (____________________)
 Tumor (____________________)
 Color (_____________________)
 Dolor (____________________)
 Functio laesa (_______________________________)
Chemical Mediators
 Histamine (from injured cells)
o Causes _____________________________ and changes cell permeability leading
to swelling
 Leukotrienes
o Impact margination (adherence along cell walls)
o Increase permeability locally for fluid and protein passage (diapedesis)
 Cytokines
o Regulators of leukocytes and attract phagocytes (ingests foreign particles)
Goal
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
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______________________
Localize
Decrease injurious agents
Prepare for healing and repair
QUESTION
What are the 5 cardinal signs of inflammation?
______________________________________________________________________________
What are the 3 chemical mediators in Phase I: Inflammatory Phase?
______________________________________________________________________________
What are the goals during the inflammatory phase?
______________________________________________________________________________
New Vocab Word
 Vasodilation
o Increase diameter of blood vessel
 Vasoconstriction
o Decrease in diameter of a blood vessel
Vascular Response
 Vasoconstriction initially and coagulation occur to seal blood vessels then chemical
mediators are released
 Followed by __________________________________________ minutes later
 Causes
o Initial increases blood flow (transitory)
o Swelling
o WBC’s able to adhere to walls
o Initial effusion of blood and plasma lasts 24-36 hours
QUESTIONS
What happens to the vascular system during the Inflammatory Phase?
______________________________________________________________________________
What happens chemically during the Inflammatory Phase?
______________________________________________________________________________
______________________________________________________________________________
Function of Platelets
 Do not normally adhere to the vascular wall
 Injury exposes collagen fibers to _______________________ matrix
 Platelets adhere and form a plug
Clot Formation
 Clots obstruct lymphatic fluid drainage and aid in______________________ injury
 Clot formation begins approx. _____________ post injury and complete within 48 hour
 Leukocytes phagocytize most of debris setting stage for Phase II: Fibroblastic Repair
Phase
Chronic Inflammation
 Acute inflammatory response ___________________________________ injuring agent
 As inflammation persists necrosis (tissue death) and fibrosis prolong healing process
 Shift from acute to chronic is unknown
o Associated with overuse, overload, cumulative microtrauma
Phase II: Fibroblastic Repair Phase
New Vocab Word
 Fibroplasia
o Period of scar formation
Phase II: Fibroblastic Repair Phase
 Fibroplasia begins
 Pain and tenderness ______________________________
 Scar tissue is deposited in a random fashion
Phase III: Maturation & Remodeling
 ____________________________ process, may require several years to complete
 Realignment of collagen relative to applied tensile forces
 Continued breakdown and synthesis of collagen = increased strength (SAID)
 Tissue will gradually assume __________________________________
Progressive Controlled Mobility
 Initially must maintain some immobilization in order to allow for initial healing during
Inflammation Phase
 Repair Phase- Controlled activity towards __________________________________
o Wolff’s Law- SAID principle
 Remodeling Phase- _____________________________________________ exercises
should be incorporated
o Facilitates remodeling and realignment
 Must be aware of pain and other clinical signs – may be too much too soon
Factors That Impede Healing
Extent of injury: (Acute vs.
Chronic)
Edema (swelling)
Hemorrhage (bleeding)
Poor Vascular Supply
Separation of Tissue (smooth vs.
jagged edge)
Muscle Spasm
Corticosteroids
Keloids and Hypertrophic Scars
Infection
Humidity, Climate, Oxygen
Tension
Health, Age, and Nutrition
Atrophy (decrease muscle size)
Questions
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Soft- Tissue Healing
 Cell Structure & Function:
o Each cell contains a _____________________surrounded by cytoplasm
o Nucleus contains DNA
4 Types of Soft Tissues
1. ___________________________ tissue
o Skin, vessel & organ linings
2. ___________________________ tissue
o Tendons, ligaments, cartilage, fat, blood, and bone
3. ___________________________ tissue
o Skeletal, smooth, cardiac muscle
4. ___________________________ tissue
o Brain, spinal cord & nerves
New Vocab Word
 Atrophy
o A decrease in size of the tissue due to cell death and resorption or decreased cell
proliferation
 Hypertrophy
o An increase in the size of a tissue without necessarily increasing the number of
cells
Tissue Adaptation
 Metaplasia- conversion of a tissue to a form not normal for that tissue
 Dysplasia- abnormal development of tissue
 Hyperplasia- excessive proliferation of a normal cell
 Atrophy
 Hypertrophy
Cartilage Healing
 ________________capacity to heal
 Little or no direct blood supply to cartilage alone
 If involves subchondral bone (______________________ blood supply) - healing
proceeds normally
 Approx. 2 months
Ligament Healing
 Follows same course of other vascular tissue
 Failure usually too Producing enough scar tissue
o Reconnect the ligament to the appropriate location
 Full healing can require up to ________ months
Factors Affecting Ligament Healing
 Surgical repaired ligaments have ____________________ scar formation with increased
strength
 Nonsurgical repair usually lengthened by scarring and thus increased instability
 Increased immobility leads to decreased strength
 Muscles need to be strengthened around the joint
Skeletal Muscle Healing
 Collagen will mature and orient along lines of tension (Wolff’s Law)
 Healing could last __________ weeks depending on muscle injured
Tendon Healing
 Requires dense fibrous union of separated ends
 Abundance of collagen is required for good tensile strength
o Too much = fibrosis (scar tissue)
 Tissue not strong enough until weeks 4-5
Nerve Healing
 Nerve cell _______________________ regenerate after injury
 Regeneration can take place within a nerve fiber
 Proximity of injury to nerve cell makes regeneration more difficult
 Rate of healing occurs at ______________ per day
 Injured central nervous system nerves do not heal as well as peripheral nerves
New Vocab Word
 NSAIDs
o Nonsteriodal antiinflammatory drugs
Modifying Soft-Tissue Healing
 Blood supply and nutrients
 Healing in older patients or those with ___________________ may take longer
 Certain organic disorders (blood conditions) may slow or inhibit the healing process
Management Concepts
 NSAIDs
 ______________________________ Modalitieso Heat- Vasodilation
o Cold- Vasoconstriction
o Others- Pain
 Exercise Rehabilitation- Early controlled mobilization may enhance healing
Question
What are the types of soft tissue and how long does each take to heal?
______________________________________________________________________________
______________________________________________________________________________
What are some management concepts?
______________________________________________________________________________
______________________________________________________________________________
Bone Healing
 Follows the 3 phases of soft tissue healing
 The tensile ___________________ the most important facture
o Contend with numerous forces
Hematoma Formation
 Blood vessels in bone and periosteum is damaged
 Results in _____________________________________________________
Cellular Proliferation & Callus Formation
 Within ________________, fibroblast lay down a fibrous collagen network
 Starts to form a soft callus
Ossification
 Osteoblasts begin to proliferate and enter the callus
 Callus crystalizes into bone
Remodeling
 Osteoclasts appear to reabsorb bone fragments and debris
 Same process of osteoblast and osteoclasts growth process
 Once cast remove bones need to ____________________ to develop (Wolff’s Law)
 Time required is dependent on various factors
o Severity and site of fracture
o Age and extent of trauma
 Time will range from _______________ weeks
Acute Fracture Management
 Must be appropriately immobilized, until X-rays reveal the presence of a
____________________________
 Fractures can limit participation for weeks or months
New Vocab Word
 Avascular Necrosis
o A portion of the bone degenerates due to a poor blood supply
Conditions that Interfere with Healing
 Avascular Necrosis
 Poor _________________________- poor casting allows for movement
o May result in deformity
 ___________________- Seen more in open (step & staph)
 Soft tissue between severed bone
Healing of Stress Fractures
 Osteoclastic activity is not in balance with osteoblastic activity = Bone becomes more
susceptible to fractures
 Need to achieve balance to heal
o ________________________ activity
o Elimination of factors causing excess stress
Question
What are the 4 Conditions that may interfere with fracture healing?
______________________________________________________________________________
______________________________________________________________________________
Pain
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Defined as: “an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.”
Pain is individual and ____________________________
Perception of pain can be modified by past experiences and expectations
Treating pain is to also treat the perception
Types of Pain
 Pain Sources
 Acute vs Chronic
 Referred Pain
o Myofascial Pain
o Sclerotomic, Myotomic & Dermatomic
Pain Sources
 Cutaneous
o ________________________ and burning with fast and slow onset (lacerations,
burns, bumps)
 ________________ somatic
o Originates in tendons, muscles, joints, periosteum and blood vessels
 Visceral
o Begins in _______________ and is diffused at first and may become localized
(appendix)
 Pyschogenic
o Pain is emotional rather than physical
Question
______________________________________________________________________________
______________________________________________________________________________
Acute Vs. Chronic Pain
 Acute- Less than __________ moths
o From tissue damage and a warning to the patient
 Chronic- Over 6 months
Referred Pain
 Pain occurs from actual site of irritation
 Myofascial Pain- caused from active or latent trigger points
 Deep Pain- Follows a ___________________________
o Sclerotome- Bone or fascia
o Myotomes- Muscles
o Dermotomes- Skin
New Vocab Word
 Nociceptors
o Pain receptors
Nociceptors
 Afferent Fibers- from the nociceptors _________________________________
 Efferent Fibers- from the spinal cord __________________________
o Motor Neurons
Facilitators & Inhibitors of Synaptic Transmission
 For information to pass ____________________________ (neurotransmitters)
o A transmitter substances released from one neuron terminal
o Substance enters synaptic cleft
o Attaches to receptor site on next neuron
 Compounds can facilitate or inhibit synaptic activity
Mechanisms of Pain Control: Three Models or Theories
Gate Control Theory
 Sensory information overrides pain information, closing gate
 Pain message never received
 Occurs _______________________ cord level
Why do you rub your head after you bump it?
______________________________________________________________________________
Descending Pathway Pain Control
 AKA- Central Biasing
 From your brain to pain
 _____________________ experiences, emotional influences, sensory perception and
other factors can influence pain reception
Why do placebos work?
Why do you distract a child who fell?
Why does the pain from cut on your hand subside?
______________________________________________________________________________
Release of B- Endorphins
 Noxious stimuli can trigger endorphin release
 Strong analgesic effects
 IE: acupuncture, acupressure, runner’s high
Pain Assessment
 Pain is ________________________ - difficult to evaluate and quantify
 Unidimiensional- pain at this moment or average intensity
 Multidimensional- Quality of pain and effects on mood and function
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Visual Analog Scales
o Mark on scale (linear) pain level
Pain Charts
o Location and level
McGill Pain Questionnaire
o 78 words that describe pain
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Others
o Activty Pain Indicator Profile 64 Questions on functional use
o Numeric Rating Scale Scale of 1-10, 10 being the worst pain ever felt
 Most commonly used in sports medicine
Treating Pain
Modalities
 Must have a ____________________________ use
o Do not ice just because
 Use of gate control theory (hot/ cold, E-stim, massage etc.)
 Use of B-endorphin theory (acupressure, trigger points)
Medications
 Most common are analgesics, anti-inflammatory or both
 Oral or injectable
Psychological Aspects of Pain
 Pain can be subjective and psychological
 Pain is often ____________________________ due to solitude and absence of external
distractions
 Patients, through conditioning, are often able to endure pain and block sensations of
minor injuries