02 Soft Tissue by Zahoor Ahmad

Dr.
Zahoor Ahmad (DPT,OMPT) Riphah

International University
Soft Tissue Injuries
& Dr. Zahoor Ahmad
Managements DPT, OMPT
Lecture: University of Lahore
Dr.Zahoor Ahmad (DPT,OMPT) Riphah
Trauma:
• Macrotrauma :Sudden episode of overload injury to a

tissue.
• Dislocation/subluxation:
• Sprain
• Strain
• Contusion
• Microtrauma: Results from repeated, abnormal stresses
applied to a tissue….
–Stress fracture:
–Tendonitis:
–Tendonosis:
Zahoor Ahmad OMPT, DPT (Riphah International University)
Examples
 Sprain :
 Severe stretch, or tear of soft tissues (capsule, ligament,
tendon or muscle).
 Specifically used to refer ligamentous injury.
 First- (mild),
 Second- (moderate)
 Third- (severe) degree

STRAIN
 Overuse of soft tissue.

 Less severe than a sprain.
 Occurs from slight trauma or unusual repeated trauma of
a minor degree.
 This term is frequently used to refer specifically to some
degree of disruption of the musculotendinous unit.

DISLOCATION
• Displacement of a part, usually the bony partners in a

joint resulting in loss of the anatomical relationship
• Leading to soft tissue damage, inflammation, pain, and
muscle spasm.
SUBLUXATION:
• An incomplete or partial dislocation of the bony
partners in a joint
• Often involves secondary trauma to
surrounding soft tissue.
Muscle/tendon rupture
or tear:
• With partial rupture or tear, pain is experienced

in the region of the breach when the muscle is ;
1. Stretched
2. When it contracts against resistance.
• With complete rupture or tear , the muscle does
not pull against the injury, so stretching or
contraction of the muscle does not cause pain.

Tendinous lesions
/tendinopathy:
(1):Tenosynovitis :Inflammation of the synovial membrane

covering a tendon.
(2):Tendinitis Inflammation of a tendon; there may be resulting
scarring or calcium deposits.
(3)Tenovaginitis: Inflammation with thickening of a tendon sheath.
(4)Tendinosis :Degeneration of the tendon due to repetitive micro
trauma.
Synovitis:
Inflammation of a synovial membrane; an excess
of normal synovial fluid in a joint caused
by trauma or disease.
Hemarthrosis: Bleeding into a joint, usually due to
severe trauma.
Bursitis: Inflammation of a bursa.
Contusion: Bruising from a direct blow, resulting in

capillary rupture, bleeding, edema, and an inflammatory
response.

Clinical Conditions Resulting
from Trauma or Pathology
Dysfunction :Loss of normal function of a tissue or

region. may be caused by adaptive shortening of the soft
tissues, adhesions, muscle weakness,
Joint dysfunction Mechanical loss of normal joint play in
synovial joints; commonly causes loss of function and
pain.
trauma, Immobilization, Disuse, Aging, Serious pathological condition.
Contracture Adaptive shortening of skin, fascia,
muscle, or a joint capsule that prevents normal
mobility or flexibility
Contt……
Adhesions
Abnormal adherence of collagen fibers to surrounding
structures, which restricts normal elasticity and gliding of the
structures.
 During immobilization
 After trauma
 Complication of surgery
Reflex muscle guarding

• Prolonged contraction of a muscle in response to a painful
stimulus(in or underlying tissue) .Contracting muscles
functionally splints the injured tissues against movements .
Further guarding ceases when stimulus is removed.
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.
Spasm may also be a response of muscle to,

Cold
Prolonged periods of immobilization
Emotional tension
Direct trauma to muscle
CONTT………
Muscle weakness:
A decrease in the strength of muscle contraction.
• May be the result of a systemic
lesion,
• Local lesion of a nerve of the CNS
PNS.
• May be the result of a direct insult to
the muscle
• Inactivity
Severity of Tissue Injury
 Grade 1 (First-degree).
 Mild pain at the time of injury or within the first 24 hours.
 Mild swelling, local tenderness, and pain occur when the
tissue is stressed.
 Grade 2 (Second-degree).
 Moderate pain that requires stopping the activity.
 Stress and palpation of the tissue greatly increase the pain.
 When the injury is to ligaments, some of the fibers are torn,
resulting in some increased joint mobility.
 Grade 3 (Third-degree).
 Near-complete or complete tear of the tissue (tendon or
ligament) with severe pain. Stress to the tissue is usually
painless;
 palpation may reveal the defect.
A torn ligament results in instability of the joint.
Incidence
• Over 14 million ED visits

annually
• Wounds accounts for
12% of all ED visits
• Skin first line of defense,
therefore, prone to
injury

Mechanism of Injury
Special Considerations
• Tissue Injury Common - blunt & penetrating
• Injury Environment - dirt, debris, ditch water
• Occupational Injury - chemical exposure
• Foreign Body Risk - ex motorcycle road rash
• Bite Injuries - highly infectious
• Pressure Injection Injuries- surgical emergency
• Compression injuries - high risk for necrosis
Soft Tissue Layers

Soft Tissue Functions
Skin Barrier
Thermal regulation
Homeostasis
Subcutaneous Adipose - thermal regulation & shock absorption

Tissue Wound Healing
Muscles Mobility
Highly Vascular
High metabolism
Nerves Afferent = sensation

Efferent = action
Blood Vessels Nutrient & gas exchange
Wound Healing – By Intention
Primary Clean wound with limited tissue loss

Intention Wounds edges easily approximated
Classic surgical wound closure
Using suture, staples, adhesive tape
Secondary Large tissue loss / heavy contamination
Intention Wound cleaned & left open to granulate
Surgeon may pack & place drain
Wound care……daily promotes granulation
Tertiary Also called: Delayed primary closure
Intention Often used with heavy bacteria counts
Wound is cleaned, debrided, left open
Typically 4-5 days-then surgical closure

Causes of soft tissue Healing
Age Aging skin associated with :

• Slower cellular activity
•↓ Elastin fibers
•↓ Dermal thickness
Perfusion Decreased perfusion noted in trauma:

• Vasoconstriction
• Shock states
• Excessive catecholamine release
• Hypothermia

Temperature Hypothermia
•Vasoconstriction → impaired healing
•Leukocyte activity inhibited
•Associated with ↑ wound infections
Smoking Peripheral vasoconstriction

↓ tissue oxygenation
↑ platelet aggregation
↑ blood viscosity
↓ collagen deposition
Significantly impairs wound healing

Initial Assessment
Soft Tissue Injuries
• Rarely life-threatening
alone
• Always start with
ABCDEs
• Do not be distracted
by the wound or
injury before
addressing the
ABCDEs

Controlling External Bleeding
• Direct pressure
• Elevate the wound
• Pressure points
• Tourniquets

Assessment
• Medical history
• Time of injury
• Allergy history
– Antibiotics
– Local anesthetics
• Tetanus history
• Occupation
• Hand dominance
Patient Symptoms
Paresthesia Neurovascular
Loss of Sensation Injury
Underlying Fracture
Severe Foreign Body
Pain Compartment Syndrome
Necrotizing Fasciitis

Physical Examination
 Hemostasis
 Local anesthesia
 Size/Depth
 Location
 Circulation
 Nerve function
 Motor function
 Injury to underlying
structures
Time of Injury to Closure
• Wound infection risk

increases with increased
time from injury to
repair
– 6-8 hours acceptable

Injury Location Significance
Face/neck:
– Greater blood flow
(lower infection risk)
Lower extremities
– Less blood flow
(infection prone)
Wounds involving
tendons, joints, bone
– Infection prone
Topical Anesthetic For Wounds
• LET (gold standard) • Ideal for lacerations:

– Lidocaine 4% – Small & superficial
– Epinephrine 0.1% – Scalp and face
– Tetracaine 0.5% • Advantages:
• Solution or Gel – No pain of injection
– Saturated gauze on wound – No tissue swelling
– 15-30 minutes – Minimize bleeding
– Safe

Initial Debridement
• Removing devitalized tissue

• Pressure irrigation preferred
• Mechanical debridement if
necessary
• Caution if extent of tissue
devitalization unknown:
– Wait and see approach

Foreign Body
• Retained foreign body

– Inflammation/Infection
– Delayed wound healing
– Loss of function
• X-ray /CT helpful
• Most difficult to identify
– Small glass
– Plastic
– Wood
Closed Injuries (skin intact)
• Contusion • Hematoma
– Epidermis intact – Blood collection under
skin
– Swelling and pain
– Larger tissue damage

Abrasion Contusion Hematoma

Laceration
• Vary in depth:
• Superficial
• Deep tissue
• Vary in appearance:
• Linear (regular)
• Stellate (irregular)
• Assess
– Underlying damage
– Contamination
– Foreign bodies
Avulsion
• Tearing, stretching
mechanism
• Full thickness loss of
tissue; wound edges
cannot be approximated
• Assess degree of injury,
underlying damage

Dressings
Type Advantages / Considerations
Transparent -transmits moisture vapor; semipermeable to gases
-no absorption capability
-provides protection from friction
-aids in autolytic debridement
Hydrocolloid -impermeable to gases and water vapor

-provides moist environment
-excessive granulation and maceration can occur
Hydrogel -water in a gel form

-facilitates autolysis and removal of devitalized tissue
-hydrates dry wound beds
-may require daily changes
Dressings
Foam -highly absorbent, used in moderate to heavy exudate
-permeable to gases and water vapor
-can be used on infected wounds if changed daily
-available with ionic silver
Calcium alginate -absorbent, non-adherent, biodegradable
-forms a soluble alginate gel when in contact with wound
drainage promoting moist wound bed
-available in various sizes
-requires a secondary dressing
Hydrofiber -forms a gel when interacts with wound fluid
-maintains a moist environment
-should not beInternational
used onUniversity
dry wound or heavy bleeding
Dressings
Collagen -highly absorptive, hydrophilic (contains bovine)
-can be used on granulating or necrotic wounds
-changed every 7 days (daily if infected)
Composite -a combination of materials make up a single dressing
-may adhere to wound bed: remove with caution
-may be used on infected wounds
-may facilitate autolytic debridement
Contact -low adherence material of woven net

Layer -acts as a protective layer between wound and secondary
dressing
-used with ointments or other topical agents
-not recommended for(DPT,OMPT)
Dr.Zahoor Ahmad dry wounds
Riphah or third-degree burns
Dressings
Gauze • can be used as packing, primary or secondary
dressing
• does not provide moist wound environment
• may traumatize wound bed upon removal
• requires frequent changes
Antimicrobial • provides antimicrobial effect against bacteria

• available in a variety of forms (transparent, foam,
fillers)
• some may remain in place for 7 days
• does not replace need for systemic antibiotics

Injury Impact on Nutrition
– Energy Expenditure
– Protein & Amino Acid

Requirements
– Metabolic Demand

Essential Nutrients for Wound Healing
• Calories
• Carbohydrates
• Protein
• Fats
• Vitamin A
• Vitamin C
• Zinc
• Water

Zahoor Ahmad OMPT, DPT (Riphah
International University)
Table 20.1

INFLAMMATION
4-6 MAX.
DAYS PROTECTION
ACUTE
STAGE
ACUTE STAGE:
• Impairments
• Inflammation, pain, edema, muscle
guarding
• ROM painful and decreased,
1. Irritation of free nerve endings
2. Increased tissue tension from edema
3. Guarding body's own way of protecting
the body
• Impaired movement
• Decreased use of associated areas
PT Management
(Protection Phase)
Educate the patient

 Clear picture
• Inform the patient about the expected duration of symptoms
• what he or she can do during this stage,
• precautions or contraindications,
• Patients need reassurance that the acute symptoms are usually short-lived,
and they need to learn what is safe to do during this stage of healing
 Protection of the Injured Tissue
• To reduce pain and promote healing,
• Protection is necessary during the first 24 to 48 hours.
• Usually provided by rest (splint, tape, cast), cold (ice), compression, and
elevation.
• Assistive devices for ambulation may be required.
CONTT……..
Prevention of ill Effects of Immobility

• Complete immobilization can lead to;
1. Adherence of the developing fibrils to surrounding
tissue,
2. Weakening of connective tissue,
3. Changes in articular cartilage.

Contt…..
Specific Interventions
P- ROM EXERCISES ; for
1. maintaining mobility in joints, ligaments, tendons, and muscles
2. improving fluid dynamics
3. maintaining nutrition in the joints.
• Initially, the range is probably very small. Any motion gained
from the PROM techniques is because of decreased pain, swelling,
and muscle guarding.
Contraindications:
(1)Stretching
(2)A-ROM Zahoor Ahmad OMPT, DPT (Riphah
Contt……….
Muscle setting.
• Intermittently and at a very low intensity so as not to
cause pain or joint compression
• The pumping action of the contracting muscle assists the
circulation and, therefore, fluid dynamics.
• Always done with the muscle in the shortened position.
• If tolerated, the intermittent setting techniques are
performed in several positions.

CONTT….
Low-dosage joint mobilization techniques.

Grade I or II
• Distraction and glide techniques have the benefit of
 Improving fluid dynamics in the joint to maintain cartilage health.
 Inhibit the perception of pain.
• Beneficial with joint pathologies and any other connective tissue injury that
affects joint motion.
Interventions for Associated Areas
• Range of motion. Actively OR passively,
• Muscle performance..
• Functional activities.

Refresh what you heard
• PRICE : Controls signs of inflammation

Precautions
• proper dosage of rest and movement
• Signs of too much movement
• Signs of too early movement
Contra indications
• Stretching
• Active movements but not always
• Resistance exercises at the site of the inflamed tissue
REPAIR
&
HEALING
CONTROLLED
10-17 DAYS MOTION
PHASE
SUB-
ACUTE
IMPAIRMENTS
 Pain when end of available ROM is reached

 Decreasing soft tissue edema
 Decreasing joint effusion (if joints are involved)
 Developing soft tissue, muscle, and/or joint
contractures
 Developing muscle weakness from reduced
usage
 Decreased functional use of the part and
associated areas
PT Management
(Controlled Motion Phase)
Educate the patient

Promote healing of injured tissues.
 Assistive devices,
 Splints
Restore soft tissues, muscle and joint mobility.
 Joint Mobilization tech.

 Agonist contration
 Hold-relex
 Passive………………Positional ……..….Mechanical
CONTT…….
Develop muscle endurance, and strength.

 Active ROM Exercises.
 Multiple-angle isometric Exercises
 Dynamic Resistive Exercises (with mini. load & maxi.repetitions.)
Maintain integrity and function of associated areas.
 low-intensity functional activities that do not Inc,symptoms
 Walk with assistive devices ……….PWB
 Precautions; Some discomfort may occur as the activity level increases,
but it should not last longer than a couple of hours.
 Signs of too much motion or activity;
 resting pain,
 fatigue,
 increased weakness, SIGNS OF CHRONIC INFLAMMATION
 spasm.
MATURATION
&
REMODELING
3W… RETURN TO
POST FUNCTIONAL
TRAUMA PHASE
CHRONIC
STAGE
IMPAIRMENTS
• Soft tissue and/or joint contractures and adhesions that limit

normal ROM or joint play
• Decreased muscle performance: weakness, poor endurance,
• Decreased functional usage of the involved part
• Inability to function normally in an expected activity

PT Management
(Return to Function Phase)
• Educate the patient.

• Increase soft tissue, muscle and/or joint mobility.
 Stretching techniques specific to tight tissue:•

 joint …………………… III mobilization
 Ligaments, tendons and soft tissue adhesions …………….cross-fiber
massage.
 Muscles ,………………HOLD-RELEX, passive stretch, massage,
• Improve muscle performance.
• Improve cardiovascular endurance.
• Progress functional activities.
Signs of Excessive Stress with
Exercise or Activities
• Exercise or activity soreness that does not decrease after hours and is not
resolved after 24 hours
• Progressively increased feelings of stiffness and decreased ROM over several

exercise sessions
• Swelling, redness, and warmth in the healing tissue
• Progressive weakness over several exercise sessions
• Decreased functional usage of the involved part
• if the above signs and symptoms occur, exercise, or stretching maneuvers are
too stressful and should be modified or reduced in intensity.


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02 Soft Tissue by Zahoor Ahmad

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Dr.

Zahoor Ahmad (DPT,OMPT) Riphah

• Macrotrauma :Sudden episode of overload injury to a

Zahoor Ahmad OMPT, DPT (Riphah International University)

 Overuse of soft tissue.

Zahoor Ahmad OMPT, DPT (Riphah International University)

• Displacement of a part, usually the bony partners in a

• With partial rupture or tear, pain is experienced

Zahoor Ahmad OMPT, DPT (Riphah International University)

(1):Tenosynovitis :Inflammation of the synovial membrane

Bursitis: Inflammation of a bursa.

Contusion: Bruising from a direct blow, resulting in

Zahoor Ahmad OMPT, DPT (Riphah International University)

Dysfunction :Loss of normal function of a tissue or

Reflex muscle guarding

 Prolonged contraction of a muscle in response to the local

Spasm may also be a response of muscle to,

• Over 14 million ED visits

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Subcutaneous Adipose - thermal regulation & shock absorption

Nerves Afferent = sensation

Primary Clean wound with limited tissue loss

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Age Aging skin associated with :

Perfusion Decreased perfusion noted in trauma:

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Smoking Peripheral vasoconstriction

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

• Wound infection risk

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

• LET (gold standard) • Ideal for lacerations:

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

• Removing devitalized tissue

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

• Retained foreign body

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Hydrocolloid -impermeable to gases and water vapor

Hydrogel -water in a gel form

Contact -low adherence material of woven net

Antimicrobial • provides antimicrobial effect against bacteria

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

– Protein & Amino Acid

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Dr.Zahoor Ahmad (DPT,OMPT) Riphah

Zahoor Ahmad OMPT, DPT (Riphah International University)

Educate the patient

Prevention of ill Effects of Immobility

Zahoor Ahmad OMPT, DPT (Riphah

Zahoor Ahmad OMPT, DPT (Riphah International University)

Low-dosage joint mobilization techniques.

Zahoor Ahmad OMPT, DPT (Riphah International University)

• PRICE : Controls signs of inflammation

 Pain when end of available ROM is reached

Educate the patient

Restore soft tissues, muscle and joint mobility.

 Joint Mobilization tech.

Develop muscle endurance, and strength.