SOFT TISSUE INJURY,

REPAIR, AND
MANAGEMENT
WRC Z , PTRP
 Soft Tissue Lesions
• Strain
• d/t overstretching,
overexertion, overuse of
soft tissue
• Less severe than a sprain
• Refer to some degree of
disruption of the
musculotendinous unit
Soft Tissue Lesions
Sprain
• Severe stress, stretch or tear of soft tissues
like joint capsule, ligament tendon or muscle
• Commonly used in ligamental injury and
graded as mild, moderate and severe
Soft Tissue Lesions
• Subluxation
• An incomplete or partial dislocation of the bony
partners in a joint that often involves secondary
trauma to surrounding soft tissue.
Soft Tissue Lesions

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,
inflammation, pain, and muscle
spasm.
Soft Tissue Lesions

• Muscle or Tendon
Rupture
• Partial tear – pain is felt on
the area of the breach when
muscle is stretched or
contracts against resistance
• Complete tear – the muscle
doesn’t pull against injury,
thus stretching or muscle
contraction won’t cause pain
 Soft Tissue Lesions

Tendon Lesions or Tendinopathy

• Tendinopathy– is the general term that
refers to tendon injury affected by
mechanical loading
• Tendinitis- inflammation of a tendon;
there may be resulting scarring or
calcium deposits
• Tenovaginitis – inflammation with
thickening of the tendon sheaths
• Tendinosis – degeneration of tendon
due to repetitive microtrauma
• Tenosynovitis- inflammation of the
synovial membrane covering a tendon.
Soft Tissue Lesions
• 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
Soft Tissue Lesions
• Ganglion
• Ballooning of the
wall of a joint
capsule or tendon
sheath
• May arise after a
trauma or with RA
• Bursitis
• Inflammation of
bursa
Soft Tissue Lesions
• Contusion
• Bruising from direct blow,
capillary rupture, edema,
bleeding

• Overuse Syndromes
• Repetitive submaximal
overload
• Frictional wear and tear or
muscle and tendon resulting
in inflammation
 Clinical Conditions from Trauma or
Pathology
• Dysfunction
• Loss of normal function, LOM
• d/t adaptive shortening, adhesions,
weakness resulting to LOM

• Joint Dysfunction
• Mechanical loss of joint play in synovial
joints
• Common cause of LOF and pain
• d/t trauma, immobilization, disuse,
aging, pathology
 Clinical Conditions from Trauma or
Pathology
• Contractures
• Shortening or tightening of skin,
fascia, muscle or joint capsule
which prevents normal mobility or
flexibility

• Adhesions
• Abnormal adherence of collagen
fibers to surrounding structures
during immobilization
• As a result of trauma and
complication of surgery
 Clinical Conditions from Trauma or
Pathology
• Reflex muscle guarding
• Prolonged contraction in
response to a painful
stimulus
• Painful causing lesion may be
nearby or underlying tissue
• If not referred pain, the
contracting muscle functions
to splint the injured tissue
against movement
 Clinical Conditions from Trauma or
Pathology
• Intrinsic muscle spasm
• Prolonged contraction in response to local circulatory and metabolic
changes that occur when a muscle is in a continued state of contraction
• Self perpetuating; maybe a response to viral infection, cold, prolonged
immobilization, emotional tension, direct trauma
 Clinical Conditions from Trauma or
Pathology
• Muscle Weakness
• Decrease in the strength of
contraction of muscle
• Systemic, chemical, or local lesion of
a nerve of central or PNS or
myoneural junction
• Direct insult or inactivity
• Myofascial compartment
syndromes:
• Increased interstitial pressure in a
closed, nonexpanding, myofascial
compartment
• results in ischemia and
irreversible muscle loss
• Causes: fractures, repetitive
trauma, crush injuries, skeletal
traction, and restrictive clothing,
wraps, or casts.
 Severity of Tissue Injury
Grade 1 (first degree) Grade 2 (second Grade 3 (third degree)
degree)
Mild pain at the time of Moderate pain that Near-complete or
injury or within the first 24 requires stopping the complete tear or avulsion
hours activities of the tissue (tendon or
ligament) with severe
local tenderness Stress and palpation of pain.
the tissue greatly
pain occur when the increase the pain. Stress to the torn tissue
tissue is stressed is usually painless;
When the injury is to
Mild Swelling ligaments, some of the palpation may reveal the
fibers are torn, resulting defect.
in some increased joint
mobility A torn ligament results in
instability of the joint
 Irritability of Tissue: Stages of
Inflammation and Repair
Acute Stage (Reaction and
Inflammation)
• the signs of inflammation develop
• ROM: movement is painful and the
patient usually guards against the
motion before completion of the
range is possible
• Cause: 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
• lasts 4 to 6 days unless the insult is
perpetuated
 Irritability of Tissue: Stages of
Inflammation and Repair
Subacute Stage (Proliferation,
Repair, and Healing)
• signs of inflammation progressively
decrease and eventually are
absent. ROM: patient may
experience pain synchronous with
encountering tissue resistance at
the end of the available ROM
• Pain: occurs only when the newly
developing tissue is stressed
beyond its tolerance or when tight
tissue is stressed.
• Muscle strength: may test weak,
LOF
• Lasts 10 to 17 days (14 to 21 days
after the onset of injury) but may
last up to 6 weeks
 Irritability of Tissue: Stages of
Inflammation and Repair
Chronic Stage (Maturation and
Remodeling)
• no signs of inflammation during the
chronic stage
• (+) contractures or adhesion(LOM),
muscle weakness (LOF)
• connective tissue continues to
strengthen and remodel in
response to the stresses applied to
it
• Pain: stretch pain may be felt when
testing tight structures at the end of
their available range
• Function: may be limited by muscle
weakness, poor endurance, or poor
neuromuscular control
• 6 months to 1 year
 Irritability of Tissue: Stages of
Inflammation and Repair
Chronic Inflammation
• A state of prolonged inflammation
• occur if injured tissue is continually
stressed beyond its ability to repair
• Symptoms: increased pain,
swelling, and muscle guarding that
last more than several hours after
activity, increased feelings of
stiffness after rest, loss of ROM 24
hours after activity, and
progressively greater stiffness of
the tissue as long as the irritation
persists
 Irritability of Tissue: Stages of
Inflammation and Repair
Chronic Pain Syndrome
• a state that persists longer
than 6 months
• includes pain that cannot be
linked to a source of irritation
or inflammation resulting in
activity limitations and
participation restrictions that
affect many parameters of
function.
Irritability of Tissue: Stages of
Inflammation and Repair
 Stages of Inflammation and Repair
Acute Stage Subacute Stage Chronic Stage
Inflammatory Stage Repair and Healing Maturation and
Remodeling
Feature Vascular changes Removal of noxious Maturation of
stimuli connective tissue
Exudation of cells and
chemicals Growth of capillary Contracture of scar
beds tissue
Clot formation
Collagen formation Remodeling of Scar
Early fibroblastic activity
Granulation tissue Collagen Aligns to
Phagocytosis, Stress
Neutralization of irritants Very fragile and easily
injured
 Stages of Inflammation and Repair
Acute Stage Subacute Stage Chronic Stage
Inflammatory Stage Repair and Healing Maturation and
Remodeling
Clinical Sign Inflammation Decreasing Absence of
inflammation Inflammation
Pain before tissue
resistance Pain synchronous Pain after tissue
with tissue resistance resistance
 Management During the Acute Stage
• Management Guidelines: Maximum Protection (Phase I)
• Patient Education
• Protection of Injured Tissues
• Prevention of Adverse Effects of Immobilization
• Tissue Specific Movement
• Intensity of Movement
• General Movement
• Specific Interventions and Strategies
• PROM. Low dosage joint manipulation/mobilization techniques;muscle
setting; massage
• Interventions for Associated Areas
• ROM, PRE, Functional Activities
 Management During the Subacute Stage
Management Guidelines: Moderate Protection/ Controlled
Motion (Phase II)
• Patient Education
• Encourage return to normal activities that do not exacerbate
symptoms, caution recreational, sports, or work-related
activities
• home exercise program
• Management of Pain and Inflammation
• Criteria for initiating active exercises and stretching:
decreased swelling, pain that is no longer constant, and pain
that is not exacerbated by motion in the available range.
• new exercises: monitor the patient’s response; If symptoms
increase, modify the intensity of exercises.
 Management During the Subacute Stage
Management Guidelines: Moderate Protection/ Controlled
Motion (Phase II)
• Initiation of Active Exercises: Because of the restricted use of the
injured region, there is muscle weakness even in the absence of muscle pathology
• Multiple-angle, submaximal isometric exercises. (healing
muscle) (joint pathology)
• Active ROM (AROM) exercises.
• Muscular endurance exercises.
• Protected weight-bearing exercises.
 Management During the Subacute Stage
Management Guidelines: Moderate Protection/ Controlled
Motion (Phase II)
• Initiation and Progression of Stretching
• Warm the tissues
• Muscle relaxation techniques
• Joint mobilization and manipulation
• stretching techniques
• Massage
• Use of new range
 Management During the Subacute Stage
Management Guidelines: Moderate Protection/ Controlled
Motion (Phase II)
• Initiation and Progression of Stretching
• Warm the tissues
• Muscle relaxation techniques
• Joint mobilization and manipulation
• stretching techniques
• Massage
• Use of new range
• Correction of Contributing Factors
Management During the Chronic Stage
Tissue response: Maturation and Remodeling

Management Guidelines: No Protection/ Return to

Function (Phase III)
therapist’s role during this phase is to design a
progression of exercises that safely stresses the
maturing connective tissue in terms of both flexibility and
strength so the patient can return to his or her regular
activities and participate in life situations including work,
community mobility, and recreation/sports
Management During the Chronic Stage
Tissue response: Maturation and Remodeling

Management Guidelines: No Protection/ Return to

Function (Phase III)
• Patient Education
• Instruct: safe progressions of resistance and self-stretching
and how to self-monitor
• Establish guidelines for what must be attained to return
safely to recreational, sport, or work-related activities.
• Re-examine and evaluate the patient’s progress and modify
the exercises
• Recommend modifications
Management During the Chronic Stage
Tissue response:
Maturation and
Remodeling

Management Guidelines:
No Protection/ Return to
Function (Phase III)
• Patient Education
Management During the Chronic Stage
Tissue response: Maturation and Remodeling
Management Guidelines: No Protection/ Return to
Function (Phase III)
• Considerations for Progression of Exercises
Free joint play within a useful (or functional) ROM is necessary to avoid joint trauma
Adequate muscle support is necessary to protect the joint (ie weakness-faulty
neuromuscular patterns-poor support or faulty patterns of movement-microtrauma)
The criterion for strength should be a muscle test grade of 4 on a 5-point scale in
lower extremity musculature before discontinuing use of supportive or assistive
devices for ambulation.
• To increase strength when there is a loss of joint play, use multiple-angle isometric
exercises in the available range.
• use resistive dynamic exercises within the available range if joint play is normal
already
• joint dynamics and muscle strength and flexibility should be balanced as the
injured part is progressed to functional exercises.
Management During the Chronic Stage
Tissue response: Maturation and Remodeling

Management Guidelines: No Protection/ Return to

Function (Phase III)
• Progression of Stretching
• progress the intensity and duration of the stretching
maneuvers so long as no signs of increased irritation persist
beyond 24 hours
Management During the Chronic Stage
Tissue response: Maturation and Remodeling
Management Guidelines: No Protection/ Return to
Function (Phase III)
• Progression of Exercises for Muscle Performance:
Developing Neuromuscular Control, Strength, and
Endurance
■ If the patient is not using some of the muscles because of inhibition,
weakness, or dominance of substitute patterns, isolate the desired muscle
action or use unidirectional motions to develop awareness of muscle activity
and control of the movement.
■ Progress exercises from isolated, unidirectional, simple movements to
complex patterns and multidirectional movements requiring coordination with
all muscles functioning for the desired activity.
■ Progress strengthening exercises to simulate specific demands including
both weight-bearing and nonweightbearing (closed- and open-chain) and both
eccentric and concentric contractions.
Management During the Chronic Stage
Tissue response: Maturation and Remodeling
Management Guidelines: No Protection/ Return to
Function (Phase III)
• Progression of Exercises for Muscle Performance:
Developing Neuromuscular Control, Strength, and
Endurance
■ Progress trunk stabilization, postural control, and balance exercises and combine
with extremity motions for effective total body movement patterns.
■ Teach safe body mechanics and have the patient practice activities that replicate
his or her work environment.
■ Often overlooked but of importance in preventing injury associated with fatigue is
developing muscular endurance in the prime mover muscles and stabilizing
muscles as well as cardiopulmonary endurance.
Management During the Chronic Stage
Tissue response: Maturation and Remodeling
Management Guidelines: No Protection/ Return to
Function (Phase III)
• Return to High-Demand Activities
• Patients who must return to activities with greater than normal demand are
progressed further to more intense exercises including plyometrics, agility
training, and skill development.
• Develop exercise drills that simulate the work or sport activities using a
controlled environment with specific, progressive resistance and plyometric
drills
• As the patient demonstrates capabilities, increase the repetitions and speed
of the movement
• Progress by changing the environment and introducing surprise and
uncontrolled events into the activity.
 Stages of Inflammation and Repair
Acute Stage Subacute Stage Chronic Stage
Inflammatory Stage Repair and Healing Maturation and
Remodeling
PT Protection Phase Controlled motion Return to
Intervention Phase Function Phase
Control effects of
inflammation Promote Healing: Increase strength
modalities develop a mobile scar and alignment of
immobilization Nondestructive scar, develop
active, resistive, open- functional indep
Promote early healing closed chain
and prevent effects of stabilization, muscular Progressive
immobilization endurance, stretching,
strengthening,
Progress carefully in endurance training,
intensity and range functional
exercises and
specificity drills
Cumulative Trauma: Chronic Recurring Pain
Refer to act 2