Tissue Response to Injury
Cardinal Signs of Inflammation
Redness Heat
Swelling Pain
Caused by
dilation of
arterioles/
increased
blood flow
Caused by
accumulation
of blood &
damaged tissue
cells
Increased
chemical
activity &
increased
blood flow to
skin surface
Loss of
Function
Direct injury
Increased
of nerve
pain/ swelling
fibers,
pressure of
hematoma on n.
endings
Chemical
irritants –
bradykinin,
histamine,
prostaglandin
Three Phases of Healing
Phase I: Acute Inflammatory Phase
Phase II: Proliferation/Fibroblastic/
Repair/Regeneration Phase
Phase III: Remodeling/ Maturation
Phase
Phase I: Acute Inflammatory Phase
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Begins almost right away, lasts
approx. 2-4 days
Goal
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Protect,
Localize,
Decrease injurious agents,
Prepare for healing and repair
Acute Inflammatory Response

Vascular changes
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Vasoconstriction – immediately; decreased blood flow to area
(approx. 5-10 mins.); platelet plug formed; blood coagulation;
produces local anemia
Vasodilation – increased blood flow; increased hydrostatic
pressure in blood vessels ( capillary permeability, plasma
proteins leak out; proteins attract H2O - edema)
Cellular Changes – chemical reactions start immediately
Protein presence – proteins are the building blocks.
Neutralizes/destroys offending agents, restricts
tissue damage to the smallest possible tissue &
prepares area for healing
Phase II: Proliferation Phase
“Repair/Regeneration”
 Phase will extend from 48 hours to 3-6
weeks
 Phase removes debris & temporary
repair – SCAR FORMATION
(fibroplasia)
Dependent on levels of: debris removal,
skin cell production, production of
fibroblasts

Phase II: Proliferation Phase

Repaired through 3 phases
 Resolution - dead cells & cellular debris are
removed (tissue left with original structure
& function in tact)
 fibroblast
(tissue cells) formation
 tissue remodeling
Phase II: Proliferation Phase

Regeneration – damaged tissue is replaced
by cells of the same type (structure
retains some or all of its original structure
& function)


synthesis of collagen (fencing)
Repair – original tissue is replaced with
scar tissue (original structure & function
is lost)

tissue alignment
Phase III: Remodeling Phase
 Usually begins @ week 3
 Purpose is to increase strength of
repaired/replaced tissues

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
First 3-6 weeks involves laying down of
collagen and strengthening of fibers
3 months to 2 years allowed for enhanced
scar tissue strength
Balance must be maintained between
synthesis & lysis

Build up (synthesis) and break down (lysis)
Phase III: Remodeling Phase

Take into consideration
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forces applied,
immobilization time frames relative to
tissue
healing time
Scars fade & eventually return to near
normal color
Modifying Soft-Tissue Healing
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Varying issues exist for all soft tissues
relative to healing (cartilage, muscle,
nerves)
Blood supply and nutrients is necessary
for all healing
Healing in older athletes or those with
poor diets may take longer
Certain organic disorders (blood
conditions) may slow or inhibit the healing
process
Factors That Impede Healing
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Extent of
injury
Edema
Hemorrhage
Poor Vascular
Supply
Muscle Spasm

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Atrophy
Infection
Health, Age,
and Nutrition
Types of Tissues and their Healing
Cartilage
 Limited capacity to heal
 Little or no direct blood supply
 Articular cartilage that fails to clot
heals very slowly
Ligaments/ Tendons
 Long full healing process (12 months)
 Decent blood supply
 Requires a lot of collagen being laid down
Skeletal Muscle Healing
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Initial bleeding followed by laying down a ground
substance
Healing could last 6-8 weeks depending on
muscle injured
Importance of Controlling Swelling
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Initial injury management an swelling control
is critical
Swelling can result in increased pressure to
the injured area, causing pain and altered
neuromuscular function
Swelling slows the healing process and normal
function is not regained until swelling is
eliminated
To limit swelling use the RICE principle
Importance of Controlling Swelling

Protection & Ice

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Protect the injury
from further damage
Splint, wrap,
immobilize the
injured site
If the lower
extremity is involved,
crutches should be
supplied
Importance of Controlling Swelling

Restricted Activity (Rest)
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Healing immediately begins after injury
Without rest, external stresses are still placed
on the injured area, interfering with the healing
process- prolonging recovery
Controlled mobility is superior to immobilization
24-48 hours of rest should be applied prior to
active rehabilitation – depends on severity
Rest applies to the injured body part –
cardiovascular fitness, strengthening and
flexibility should be maintained
Importance of Controlling Swelling

Compression
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Single most important factor in swelling control
Mechanically reduces space available for swelling
accumulation
Using an elastic wrap, firm, evenly applied pressure
can be achieved
Compression should be maintained continuously for
72 hours – depends on severity
With chronic inflammatory conditions compression
should be applied until the swelling is almost
entirely gone
Importance of Controlling Swelling

Elevation
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Used to eliminate the effects of gravity on blood
pooling
Assists venous and lymphatic drainage of blood and
other fluids from the injured area
Elevation should occur as often as possible during
the first 72 hours of the acute injury – depends on
severity
Grades of Sprains/Strains
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Grade I – some pain, minimal loss of
function, no abnormal function, & mild
point tenderness
Grade II – pain, moderate loss of
function, swelling & instability
Grade III – extremely painful,
inevitable loss of function, swelling
Managing the Healing Process
through Rehabilitation

Pre-surgical Phase:
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If surgery can be delayed, exercise may
help to improve outcome
Maintaining or improving ROM, strength,
cardiovascular fitness, neuromuscular
control may enhance the athlete’s ability
to perform rehab after surgery
Rehab Phases
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Phase 1 – Acute
Inflammatory Phase
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Phase 2 – Proliferation
Phase
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Phase 3 - Remodeling
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Inflammation
Mobility
Proprioception
Resistance
Endurance
Sport Specific
Managing the Healing Process
through Rehabilitation

Phase I: Acute Inflammatory Phase

Initial swelling management & pain control are
crucial
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PRICE
If you are too aggressive in the 1st 48 hours the
inflammatory process may not have time to accomplish
what it needs to
By days 3-4 some mobility exercises should
be performed along with gradual increase of
weight bearing status
Use of NSAIDs
Managing the Healing Process
through Rehabilitation
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Phase II: Fibroblastic Phase:
As inflammatory phase begins to subside &
pain decreases with PROM, add
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Cardiorespiratory fitness
Restore full ROM
Restore or increase strength
Re-establish neuromuscular control
Continued use of modalities for pain control
Managing the Healing Process
through Rehabilitation
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Phase III: Remodeling Phase:
Longest phase with the ultimate goal of
returning to activity
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Regain sports-specific skills
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Continued collagen realignment
Pain continues to decrease
Dynamic functional activities
Sports-directed strengthening activities
Plyometric strengthening
Functional testing

Determine specific skill weakness
Pain Management
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Reduce pain!
Control acute pain!
Protect the patient from further injury while
encouraging progressive exercise
Minimize further tissue damage
Encourage psychological interaction (positive
thinking, etc.)
Medications
Communication with athlete
Use of modalities to reduce pain