Phases of Healing
The Inflammatory Response
• Always the same regardless of location and nature of injury
– Physiologic changes
– Anatomic Changes
• Process begins immediately after the injury occurs
• Lasts for 2 - 4 days
• Initial inflammatory response is critical to the entire healing process
The Inflammatory Response
• Cellular injury results
– altered metabolism
– release of materials that initiate the inflammatory response
• Acute Inflammation
• Characteristics
– Chemical changes
– Redness
– Metabolic changes
– Swelling
– Vascular changes
– Tenderness and pain
– Increased temperature
– Loss of function
The Inflammatory Response
• Normal healing can’t take place if inflammatory response
– does not accomplish what it is supposed to
– does not subside
• Use of anti inflammatory medications (NSAIDS) immediately after
injury may prevent the inflammatory process from taking place thus
delaying the healing process
• In most athletic injuries
• Torn vessels allow hemorrhage into the immediate area
• Cells sustain structural damage
• Enzymes from damaged cells cause inflammatory response
• Cell death occurs
• Cells degenerate releasing substances (histamines)
• Histamines cause vascular changes in non disrupted vessels
– Increased permeability of capillaries
– Cells in the vessel wall pull away from each other leaving gaps
– Fluid and blood escape through these gaps into spaces between cells
• Edema or swelling result
Vascular Reaction
• Lasts 5 to 10 minutes
– Decreased blood flow followed by
– Transitory increase of blood flow
– Followed by slowing of flow by stagnation
• Initial effusion lasts 24 - 36 hours
Post Injury Vascular Events
• White blood cells
– tumble along and then adhere to vessel wall
– escape through the vessel wall into the tissue spaces
– outside the vessel they migrate to the injury site
– phagocytosis (process of ingesting or removing irritating materials)
• Cellular debris
• Red blood cells
• Anything else that is in the way of healing
Clot Formation
• Blood platelets adhere to collagen fibers in vessel wall creating a
sticky matrix
• Additional blood products adhere forming a plug or clot
• Plug obstructs further fluid loss
• Begins approximately 12 hours after injury
• Completed within 48 hours
Rehabilitation during the
Inflammatory Response
• Prevent additional injury to the tissues
• Control inflammation
• The amount of exudate* is directly related to the total healing time
• RICE and modalities
– Healing can begin
– Total healing time will be decreased
*material passed through the walls of vessel into adjacent spaces or tissues
during inflammation
Chronic Inflammation
• By product of enzyme release into surrounding inflammatory fluid
• These enzymes attack joint tissues
• Inflammatory response to disease in a joint cavity may be natures way
of removing toxic or foreign materials like bacteria
• In athletic injuries there is no bacteria
• Prolonged continuation of this response may also cause damage to
surrounding joint structures
• Persistent inflammatory response
– Can lead to irreversible tissue damage
– Fibrosis can occur in synovial structures
Phase 2: The Fibroblastic Repair Process
• Begins within first few hours after injury
• The period of scar formation is called fibroplasia
• May last 4 - 6 weeks
• Inflammatory debris has been destroyed or removed
• Clean-up and repair occur simultaneously
• Enough debris must be removed to permit in growth of new tissue
Phase 2 The Repair Process
•
Proliferative and regenerative activity lead to
– Scar formation
– Repair of injured tissue
•
Growth of capillaries into the wound is stimulated by lack of oxygen
•
Promotes increased healing by increasing oxygen delivery
•
Essential for tissue regeneration
•
Formation of granulation tissue occurs (a delicate connective tissue)
Phase 2 The Repair Process
• Scar tissue formation progresses
– Production of collagen fibers
– Deposited in random fashion
– Form a scar
– Scar tissue formation is minimal in this phase
– Day 6 or 7
•
Collagen continues to proliferate
•
Tensile strength of wound increases proportional to rate of collagen
synthesis
Phase 2 The Repair Process
• Signs and symptoms of inflammation begin to subside
– Patient may still have
• Tenderness
• Pain with motions that stress the injured structure
– Complaints of tenderness and pain disappear over time
Rehabilitation during
Phase 2 The Repair Process
• Begins the process of repairing damaged tissues
• Under controlled conditions
– Restore Range of Motion
– Increase Strength
Rehabilitation during Phase 3
•
Involves returning the athlete to activity
– Sport
– Work
– ADL’s
•
Patient learns how to use injured body part to maximum potential
•
Prevention of reinjury