Outlines

1. Example of soft tissue lesions

2. Clinical condition resulting from trauma or pathology

3. Severity of Tissue injury

4. Stages of inflammation & repair.

Strain

Some degree of disruption to the musculotendinous unit.

Due to overstretching overexertion, and overuse of tissue.

Due to trauma (minor or major)

Sprain

Due to severe stress, stretch, or tear in the joint capsule ligament.

They are divided into first mild second moderate and third severe-degree sprains.

Subluxation

An incomplete or partial dislocation often involves secondary trauma to surrounding soft

tissue.

Dislocation

Displacement of a part.

It is leading to soft tissue damage inflammation, pain, and muscle spasm.

Muscle /Tendon rupture or tear

For partial rupture or tear, pain is experienced when the muscles are stretched or contract

against resistance.

For complete rupture or tear, stretching or contraction of the muscle does not cause pain

(because the muscle does not pull against the injury)

Tenosynovitis

Inflammation of the synovial sheath

Tendinitis

Inflammation of a tendon.

Scaring or calcium deposits in a tendon

Tenovaginitis

Thickening of a tendon sheath

Synovitis

Inflammation of synovial membrane.

Hemarthrosis

Bleeding into a joint

Due to severe trauma

Bursitis

Inflammation of bursa
Contusion

Bruising from a direct blow

RESULT IN

1. Capillary rupture

2. Bleeding

3. Oedema

4. Inflammatory response

Overuse syndromes

Repeated submaximal overload to muscles or tendon

Frictional wear to muscle or tendon

Results inflammation and pain

Clinical condition resulting from trauma or pathology

1. Dysfunction

LOSS OF NORMAL FUNCTION of a tissue or region

Due to adaptive soft tissue shortening, adhesion and muscle weakness

Results in loss of normal mobility

2. Joint dysfunction

1. Mechanical loss of normal joint play.

2. Causes loss of function and pain

3. Due to

Trauma

Immobilization

Disuse

Aging

Pathologic condition

4. Contractures

Shortening or tightening of the skin, fascia muscle or joint capsule

Prevent mobility or flexibility of the structure

5. Reflex muscle guarding

Prolonged contraction of a muscle.

Due to painful stimulus

The pain-causing lesion is nearby or underlying tissue or referred pain

The contracting muscle splints injured tissue against movement. To avoid motion in

painful areas- the PROTECTIVE MECHANISM

It ceases when a painful stimulus is relieved.

6. Muscle weakness

Reduce the strength of muscle contraction

Due to inactivity
Nerve lesion (CNS/PNS/myoneural junction

Severity of Tissue injury

Grade 1

Mild pain at the time of injury

Duration: within 24 hours

Grade 2

Moderate pain causes the activity to stop

Stress and palpation increase pain

If injury to the ligament, some fivers are torn causing less joint stability

Grade 3

Near complete or complete tear

Avulsion

Tendon/ligament

Stress to tissue is painless

Results in joint instability

Stages of inflammation & repair.

1. Acute stage

2. Subacute stage

3. Chronic stage

Inflammatory reaction

Repair and healing

Maturation and remodelling

 Inflammat Repair & Maturati
ion Healing on &
Reaction Remodell
ing

Characteri Vascular Removal Connective

stic changes of noxious tissue
stimuli maturation
Clot
formation Growth Scar tissue
capillary contracture
Early beds
fibroblastic Scar
activity Collagen remodeling
formation
Collagen
Granulatio aligns to
n tissue stress.
Fragile,
easy to re-
injure.

Clinical Inflammatio Inflammat No

sign n ion inflammati
decreases on.
Pain before
tissue Pain with Pain after
resistance tissue tissue
resistance resistance.
GENERAL TREATMENT GUIDELINES:

ACUTE STAGE (0-4DAYS)

Impairments

Inflammation pain and edema

Muscle spasm

Impaired movement

Joint effusion

Decrease the use of associated areas

Purpose of treatment in the acute phase

Control effect of inflammation

Facilitate wound healing

Maintain normal function in unaffected side or region

Acute stage : protection phase

1. Control effects of inflammation

modalities

immobilization.

Gentle movement.
2. Promote early healing

Early mobilization (within range limiting)

3.Prevent effect of rest

Passive movement

Mobilize unaffected side

Treatment goals & plan of care

Goals Plan of Care

To Control pain, edema & - Cold, compression, elevation (48 hours)

spasm - Immobilize (rest. Splint, tape, cast)

- Avoid positions of stress to the part.

- Gentle (grade I) joint oscillations with joint in pain-

free position.

To maintain soft-tissue & -Passive movement within pain limit.

joint integrity & mobility -Electrical stimulation

To reduce joint swelling -Medical intervention if swelling is rapid.

-Provide protection (splint, cast)

To maintain integrity & -active-assistive, free or resistive exercise to

function of associated associated areas

 areas - Work out is depends on the effect to primary

lesion.

- Adaptive or assistive devices to protect the part

during functional activities.

Precaution :

proper dosage of rest & movement must be used.

Signs of too much movement increase pain or increase inflammation.

Contraindication:

Stretching & resistance exercises are contraindicated when there are signs of

inflammation.

GENERAL TREATMENT GUIDELINES:

SUBACUTE STAGE (day 4 to day 14 or 21):

Impairments:

Pain at end of available range.

Decrease soft tissue edema.

Decrease joint effusion.

Developing soft tissue, muscle or joint contractures.

Developing muscle weakness from reduces usage

Decrease functional use of part & associated areas.

Subacute stage : Controlled-motion phase

Promote healing

Develop mobile scar

Prevent/minimize contracture & adhesion formation

Nondestructive active resistive, open & close chain stabilization.

Muscular endurance exercises

Carefully progress in low intensity & range.

Goals Plan of Care

To control pain, -Monitor response of tissue to exercise progression.

edema & swelling

-Decrease intensity if inflammation increases.

-Protect healing tissue with assistive devices, splints, tape or wrap.

-Gradually increase amount of time the joint is free to move.

To increase soft -progress passive to active assistive, then to active ROM (within limits of pain)

tissue, muscle, and

-Increase mobility of scar with soft tissue massage
joint mobility
- Use the specific technique to tight structure:

• Passive joint play within the pain limit

• Grade I and II

• Capsule stretching Grade II

 • No capsule stretching if the joint effusion is presented.

Goals Plan of Care

To strengthen muscle - Start with isometric.

- Within patient tolerate

- Start with mild resistance.

- Progress to isotonic ex when ROM, joint play & healing improved.

- Isotonic with tolerated resistance (use De forme principle)

- design for strength and/or endurance.

 To maintain integrity -Strengthening ex.

of the associated area

-Decrease the amount of support (eg: assistive devices) when strength increases.

Precautions

- Sign of inflammation/joint swelling decrease at an early stage.

- Some discomfort as activity level progresses.

- But, it should not last longer (hours).

- Sign of too much motion/activity are resting pain, fatigue, increased weakness & spasm.

CHRONIC STAGE (day 14 to 21/ until there is the pain-free functional use of part)

Impairments

Pain when stress is applied (pain after tissue resistance).

Soft tissue, muscle, and joint adhesions/contracture limit ROM or joint play.

Muscle weakness.

Decrease functional usage of involved parts.

Chronic stage: Return-to-function phase

Increase strength

Alignment of scar

Develop functional independence

Progressive stretching for mobility & flexibility

Strengthening endurance training.

Restore function.

Functional exercises

Specificity drills
Overview of Common Orthopaedic surgical Guidelines for soft tissue lesion

(postoperative care)
Guidelines for the repair of muscle

Muscle setting

When immobilization is removed, active ROM with control motion

Partial restricted weight bearing until achieving functional muscle strength &

flexibility.

Low intensity, high repetition ex.

Exercise progress very gradually

Should not elicit pain

Contraindication : Stretching, high resistance & return to full (within 6-8 weeks for

soft tissue healing).

Guidelines for the repair of tendon

A longer immobilization period require.

Muscle setting (to prevent adhesion, and promote alignment of healing tissue).

Passive motion within protected range after few days.

Control active ROM after several weeks to heal.

Weight-bearing (LL) and heavy lift (UL) are restricted within 6-8 wks.

Stretching & high intensity may initiate after the tendon is heal (after 8 wks).

Guidelines for ligament repair/reconstruction

Immobilization:

- in most limited tension on the structure.

Duration depends on the site, severity, and types of repair.

Rehabilitation to start early.

May take long process to return to high-intensity sports. ( 6-12 months)

Protected motion, strengthening & weight bearing: to be safe load on healing tissue,

depends on:

- Types of repair

Eg: ACL recons with patellar tendon graft & bone to bone fixation can progress more

rapidly than with transfer of ITB or hamstrings

- Site of repair

Eg: weight bearing is restricted longer the in unstable joint until muscle power

adequate to protect the joint.

Guidelines for tissue release, lengthening or decompression

Mobilize in a lengthened position.

To improve ROM, minimize/prevent deformity, and relieve pain.

Eg: myotomy, tenotomy, and fasciotomy. (carpal internal release)

CPM or active-assistive ROM exercise is performed after several days.

Progress with active ROM.

Strengthening of antagonist to start early, to maintain active control.

Guidelines for synovectomy

Synovectomy = removal of the synovium (indicated in chronic joint inflammation).

Muscle setting in a period of immobilization.

CPM or active-assistive ROM to start after immobilization.

Progress to active ROM exercise quickly.

Full weight bearing or lifting restricted 6-8 wks.

progression is based on pt’s response without increasing joint pain & inflammation.

Guidelines for arthrodesis

Fusion of bony surface to a joint with internal fixation.

Due to severe joint pain, instability, fail joint arthroplasty.

Joint immobilization 8-12 weeks (ensure bony fusion)

ROM and strength exercises above & below the immobilized joint.

Restricted weight bearing until evidence of bony unite by x-ray

Guidelines for arthroplasty

Joint reconstruction.

To relieve pain & restore joint motion.

Post of care: follow the protocols, depending on the site.