PARE Soft Tissue Injury, Repair, and Management CHAPTER © Sort Tissue Lesions 295 Examples of Soft Tissue Lesions Musculoskeletal Disorders. 295 Clinical Conditions Resulting from Trauma or Pathology 296 Severity of Tissue Injury 27 Irritability of Tissue: Stages of Inflammation and Repair 297 © Manacewent Dunne THe Acute Stace 298 Tissue ResponseInflammation 298 Management Guidelines-Protection Phase 298 © Manacevenr Dunne THE Susacute Stage 300 Tissue Response—Repair and Healing 300 ‘© Mavacement Dunne THE CHzoNic Stace 302 Tissue Response—Maturation and Remodeling 202 Management Guidelines—Return to Function Phase 203, (© Cumutative Traunta—CuRonie RECURRING Pan 305 Tissue Response—Chronic Inflammation 305 Etiology of Cheonic Inflammation Leading to Prolonged or Recurting Pain 305 Contributing Factors 305 “Management Guidelines—Chronie Management Guidelines—Controlled Motion Phase 300 Tie proper use of therapeutic exercise in the management ‘of musculoskeletal disorders depends on determining the impairments, functional limitations, or disabilities. In many cases itis possible to identify the musculoskeletal structure involved and its stage of inflammation or recovery. Exami- nation of the involved region isan important prerequisite for identifying the anatomical structure or structures that fare causing the impairments and limiting function and also for determining whether the tissue is inthe acute, subacute, or chronic stage of recovery. This chapter and subsequent chapters in this book have been written with the assumption that the reader has a background in exami- nation, evaluation, and program planning to be able to assess impairments and develop functional goals. Utilizing the principles presented in this chapter, the reader should be able to design therapeutic exercise programs that meet the goals and choose techniques for intervention that are at Inflammation 208 ‘© Inoerenoenr Leannina Actives 307 ‘an appropriate intensity for the stage of healing of connec- tive tissue disorders. Subsequent chapters in this section deal with specific joint, soft tissue, bony, and nerve lesions as well as common surgical interventions, @ Sort Tissue Lesions Examples of Soft Tissue Lesions— Musculoskeletal Disorders Strain: Overstretching, overexertion, overuse of soft tissue. Tends to be less severe than a sprain. Occurs from slight trauma or unaccustomed repeated trauma ‘ofa minor degree.® This term is frequently used to refer specifically to some degree of disruption of the ‘musculotendinous unit!” 295Severe stress, stretch, or tear of soft tissues, such as joint capsule, ligament, tendon, or muscle. This term is frequently used to refer specifically to injury of a ligament and is graded as first- (mild), second- (moder- ate), or third- (severe) degree sprain," ‘© Dislocation: Displacement of a part, usually the bony partners in a joint resulting in loss of the anatomical relationship and leading to soft tissue damage, inflam- ‘mation, pain, and muscle spasm. ‘© Subluxation: An incomplete or partial dislocation of the bbony partners in a joint that often involves secondary trauma to surrounding sof tissue. ‘© Muscle/tendon rupture or tear: Ifa rupture or tear is partial, pain is experienced in the region of the breach when the muscle is stretched or when it contracts against resistance. Ifa rupture or tear is complete, the ‘muscle does not pull against the injury, so stretching fr contraction of the muscle does not cause pain ® ‘© Tendinous lesions/tendinopathy: Tenosynovitis is inflammation of the synovial membrane covering a ten- don. Tendinitis is inflammation of a tendon; there may be resulting scarring or caleium deposits. Tenovaginitis is inflammation with thickening of a tendon sheath Tendinosis is degeneration of the tendon due to repetitive ‘microtrauma. ‘© Synovitis: Inflammation of a synovial membrane; an ‘excess of normal synovial fluid in a joint or tendon sheath caused by trauma or disease. © Hemarthrosis: Bleeding into a joint, usually due to severe trauma, ‘© Ganglion: Ballooning of the wall ofa joint capsule or tendon sheath. Ganglia may arise after trauma, and they sometimes occur with rheumatoid arthritis. ‘© Bursitis: Inflammation of a bursa © Contusion: Bruising from a direct blow, resulting in capillary rupture, bleeding, edema, and an inflammatory response, © Overuse syndromes, cumulative trauma disorders, repetitive strain injury: Repeated, submaximal over- load and/or frictional wear to a muscle or tendon result- ing in inflammation and pain Clinical Conditions Resulting from Trauma or Pathology In many conditions involving soft tissue, the primary pathology is difficult to define or the tissue has healed with limitations, resulting in secondary loss of function. The following are examples of clinical manifestations resulting from a variety of causes, including those listed under the previous section ‘© Dysfunetion: Loss of normal function of a tissue or region, The dysfunction may be caused by adaptive short- ening of the soft tissues, adhesions, muscle weakness, or any condition resulting in loss of normal mobility. ‘© Joint dysfunction: Mechanical loss of normal joint play in synovial joints; commonly causes loss of function and pain. Precipitating factors may be trauma, immobiliza- tion, disuse, aging, or a serious pathological condition.** © Contractures: Adaptive shortening of skin, fascia, mus- le, or a joint capsule that prevents normal mobility or flexibility ofthat structure © Adhesions: Abnormal adherence of collagen fibers to surrounding structures during immobilization, after trauma, or as a complication of surgery, which restricts normal elasticity and gliding of the structures involved. © Reflex musele guarding: Prolonged contraction of a muscle in response to a painful stimulus. The primary pain-causing lesion may be in nearby or underlying tis- sue, oF it may be a referred pain source. When not referred, the contracting muscle functionally splints the injured tissue against movement. Guarding ceases when ‘the painful stimulus is relieved © Intrinsic muscle spasm: Prolonged contraction of a muscle in response to the local circulatory and metabolic changes that occur when a muscle is in a continued state ‘of contraction, Pain isa result of the altered circulatory ‘and metabolic environment, so the muscle contraction ‘becomes self-perpetuating regardless of whether the primary lesion that caused the initial guarding is still inrtable (Fig. 10.1). Spasm may also be a response of muscle to viral infection, cold, prolonged periods of immobilization, emotional tension, or direct trauma to muscle. © Muscle weakness: A decrease in the strength of muscle contraction. Muscle weakness may be the result ofa sys= temic, chemical, or local lesion of a nerve of the central ‘or peripheral nervous system or the myoneural junction. Itmay also be the result ofa direct insult to the muscle ‘or simply due to inactivity. ‘© Myofascial compartment syndromes: Increased inter- stitial pressure in a closed, nonexpanding, myofascial ‘compartment that compromises the function of the blood vessels, muscles, and nerves. It results in ischemia and. inreversible muscle loss if there is no intervention.* ‘Causes include, but are not limited to, fractures, repeti- tive trauma, erish injuries, skeletal traction, and restrie- tive clothing, wraps, or casts FIGURE 10.1 Sef perpensating cyl of muse spasm,CHAPTER 10. Soft Tissue Injury, Repay and Management 287 TABLE 1 ‘Acute Stage: Inflammatory Reaction ‘Subacute Stage: Repair and Healing CChronie Stage: Maturation and Remodeling Characteristics Vascular changes Exudation of cells and chemicals Clot formation Phagocytosis, neutralization of iritants Early broblastic activity Clinical signs Inflammation Pain before tissue resistance Collagen formation Granulation tissue resistance Physical therapy intervention PROTECTION PHASE Control effects of inflammation Modalities Selective resvimmobilization Promote early healing and prevent deleterious effects of rest Passive movement, massage, ‘and muscle setting with caution Removal of noxious stimuli Growth of capillary beds into area Decreasing inflammation Pain synchronous with tissue CONTROLLED-MOTION PHASE Promote healing; develop mobile Nondestructive active, resistive, ‘open-and closed-chain stabiliza- tion, and muscular endurance exercises, carefully progressed in intensity and range Maturation of connective tissue ‘Contracture of scar tissue Remodeling of scar Collagen aligns to stress Very fragile, easily injured tissue ‘Absence of inflammation Pain after tissue resistance RETURN-TO-FUNCTION PHASE Increase strength and alignment of scar; develop functional independence Progressive stretching, strength- ening, endurance training, functional exercises, and specificity dls Severity of Tissue Injury (© Grade 1 (first-degree). Mild pain atthe time of injury or within the frst 24 hours. Mild swelling, local tenderness, and pain occur when the tissue is stressed. "5!* © Grade 2 (second-degree). Moderate pain that requires stopping the activity. Stress and palpation of the tissue greatly increase the pain. When the injury isto liga- ments, some of the fibers are tom, resulting in some increased joint mobility." © Grade 3 (third-degree). Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with severe pain, Stress to the tissue is usually painless; palpation may reveal the defect. A tom ligament results in instabil- ity of the joint." Irritability of Tissue: Stages of Inflammation and Repair ‘After any insult to connective tissue, whether itis from mechanical injury (including surgery) or chemical irtant, the vascular and cellular response is similar (Table 10.1). Tissue instability, or sensitivity, i the result ofthese responses and is usually divided into three stages of inflammation and repair with the following clinical sigas and symptoms, ‘Acute Stage (Inflammatory Reaction) During the acute stage, the signs of inflammation are pres- cent; they are swelling, redness, heat, pain at rest, and loss, ‘of function. When testing the range of motion (ROM), ‘movement is painful, and the patient usually guards ‘against the motion before completion of the range is possible (Fig. 10.2). The pain and impaired movement are from the altered chemical state that irritates the nerve endings, increased tissue tension due to edema or joint effusion, and muscle guarding, which is the body's way of immobilizing a painful area. This stage usually lasts 4 t0 6 days unless the insult is perpetuated. Subacute Stage (Repair and Healing) During the subacute stage, the signs of inflammation pro- gressively decrease and eventually are absent. When testing ROM, the patient may experience pain synchronous with encountering tissue resistance at the end of the available ROM (Fig. 10.2B). Pain occurs only when the newly developing tissue is stressed beyond its tolerance or when tight tissue is stressed. Muscles may test weak, and func tion is limited as a result of the weakened tissue. This stage usually lasts 10 to 17 days (14 to 21 days after the onset of | injury) but may last up to 6 weeks in some tissues with limited circulation, such as tendons." Chronic Stage (Maturation and Remodeling) There are no signs of inflammation during the chronic stage. There may be contractures or adhesions that limit range, and there may be muscle weakness limiting normal function, Connective tissue continues to strengthen and remodel during this stage. A stretch pain may be felt when testing tight structures at the end of their available range (Fig, 10.2C). Function may be limited by muscle weak- ness, poor endurance, or poor neuromuscular contro.