Effect of Immobilization and Injury on

muscle

By Sonali Tushamer
MPT 2ND Sem
 Muscle Injury
 Muscle injuries can be caused by bruising, stretching or laceration.
 Regarding the mechanism, they are classified as Direct and Indirect

Direct Injuries (lacerations Indirect injuries(complete

and contusions): or incomplete muscle strain):
• Direct crush trauma or • Over-elongation of muscle
compressive injury results in fibres, during active
contusions and haematomas. contraction or passive
stretching, leads to muscle
strains and ruptures
Muscle strain
 single high force contraction of the muscle while the muscle is
lengthened by external forces (such as body weight)
 The muscle usually fails at the junction between the muscle and
tendon..
Muscle strains classification
 Grade I – tear of few muscle fibers with minimal swelling and
discomfort
Minimal loss of strength with almost no limitation of movements
 Grade II- A greater damage of muscle
Partial loss of strength and limitation of movements
 Grade III – A severe tear across the whole section of the muscle
Total loss of the muscle function
 Structural changes seen in US
Grade I
 the myosin and actin filaments are distracted above their level of
maximum physiologic elongation without being torn apart, thus no
filament or muscle fibre rupture is present.
 Capillary vessels at the contractile apparatus and at the surrounding
endomysium probably are injured, this may result in diffuse bleeding
(haemorrhage).
Grade 2
 Ongoing distraction forces will cause contractile fibres and
endomysium discontinuity, and may tear perimysium apart.
 There is some destruction of the connective tissue skeleton of the
muscle.
 The location of muscle strain injury will vary along with the type of
muscle.
 In unipennate muscles, the musculotendinous junction is located
superficially and in these circumstances, epimysium (fascial) injury
may be present in low grade injury. Injury to the epimysium causes
perimuscular fluid or bleeding and is often followed by scarring.
 In contrast, in parallel or circumpennate muscles the tears are more
frequently located centrally.
Grade 3
 injury corresponds to complete muscle rupture with injury of the
epimysium. In grade 2 and grade 3, clinically, tissue loss with a gap is
often felt at the rupture site.
 Occasionally a subcutaneous ecchymosis can occur but this usually
develops 12–24 h later (Peterson and Renstrom 1986).
 This ecchymosis is probably only found in cases of epimysium tear. It
is located typically distally to the tear where the fascial planes abut the
subcutis and gravitation brings it to the surface.
 Pathophysiology of muscle damage and
repair
•Musculoskeletal injuries resulting in the necrosis of muscle fibers
•Physiologically, healing progresses over a series of overlapping
phases
Phase 1: Phase 2: growth.
 consists of destruction   consists of repair and Phase 3: 
 characterized by remodeling, with  consists of remodeling,
tearing and subsequent phagocytosis of the with maturation of the
necrosis of myofibrils, necrotic tissue, regenerated myofibrils,
 formation of a
regeneration of the contraction and
myofibrils reorganization of the
hematoma in the space
 concomitant scar tissue and
created in the torn
muscle and production of recovery of muscle
proliferation of connective scar tissue, functional capacity.
inflammatory cells. along with
neoformation of
vessels and neural
Day 2: The necrotized part of the transected Day 3: Satellite cells have become
myofibers is being removed by activated into myoblasts within
macrophages. Connective tissue formation the basal lamina cylinders in the
by fibroblasts has begun in the central zone. regeneration zone.
Day 5: Myoblasts in the regeneration
zone have fused into myotubes. The
connective tissue in the central zone has
become denser.
Day 7: The regenerating muscle cells
extend out of the old basal lamina
cylinders into the central zone and
begin to pierce through
the scar.
Day 14: The scar of the central zone Day 21:The scar is formed between the
has further condensed and the interlacing myofibers with little
regenerating myofibers have nearly intervening connective tissue.
crossed the gap of the central zone.
Eccentric Exercise-Induced Muscle Injury
 Injuries to muscles may occur as a result of even a single bout of eccentric
exercise.
 After 30 to 40 minutes of eccentric exercise (walking downhill) or as few as
15 to 20 repetitions of high-load eccentric contractions, significant and
sustained reductions in maximal voluntary contractions occur. Also, a loss
of coordination, delayed-onset muscle soreness (DOMS), swelling, and a
dramatic increase in muscle stiffness have been reported.
 The DOMS reaches a peak 2 to 4 days after exercise.
 DOMS occurs in muscles performing eccentric exercise but not in muscles
performing concentric exercise.
 Pain increases in intensity for the first 24 h after exercise, peaks between 24
and 72 h, and then subsides in 5 to 7 days.
 Temporary loss of strength, up to 50%, can be present
 The diminished performance results from reduced voluntary effort due
to pain as well as reduced capacity of the muscle to produce force.
 The soreness is believed to be due to reversible structural damage at
the cellular level.
 Morphologic evidence shows deformation of the Z disk (Z-disk
streaming) and other focal lesions after eccentric activity that induces
soreness.
 There is no associated long-term damage or reduced function in the
muscles. Some authorities believe that the clinical syndrome of
exertional rhabdomyolysis may represent a severe form of DOMS.
 US demonstrates no obvious abnormalities in either stage of DOMS.
Immobilization
 Immobilization may be externally imposed by a cast, bed rest,
weightlessness, or denervation or may be self-imposed as a reaction to
pain and inflammation
 Muscle tissue is characterized by performing contractions (cycles of
stretch / shortening) and this contractile activity seems to have an
important role in determining muscle mass and may precede the
endocrine signals for the muscle proteins depletion.
 Immobilization affects both muscle structure and function:- The effects
of immobilization depend on:
 Length of the immobilization period
 Percentage of fiber types within the muscle,
 Immobilization position (shortened or lengthened)
Effect of Immobilization
Immobilization position (shortened or lengthened)
 An injured joint or joint subjected to inflammation and swelling will
assume a loose-packed position to accommodate
 the increased volume of fluid within the joint space. This position may
be referred to as the position of comfort because pain is decreased in
this position.
 In shortened position
Structural changes
 Decrease in the number of
sarcomeres
 Increase in sarcomere length
 Increase in the amount of
perimysium
 Thickening of endomysium
 Increase in the amount of collagen
 Increase in ratio of connective tissue
to muscle fiber tissue
 Loss of weight and muscle atrophy 
Functional changes
 Greatest loss of strength
 The greater slack placed on muscle
fibers immobilized, - specifically
promote degradation of contractile
proteins.
 Example - “postural” muscles and
some single-joint muscles show a
more rapid atrophy .These muscles
include the soleus, vastus medialis,
vastus intermedius, and multifidus.
In the lower extremity, the knee
extensors generally demonstrate
greater disuse atrophy and relative
loss in strength than the knee flexor
(hamstring) muscles.
In lengthen position
Structural changes
 Increase in the number of
sarcomeres,
 Decrease in their length
 Muscle hypertrophy that may
be followed by atrophy
Functional changes
 An increase in maximum
tension-generating capacity and
displacement of the length-
tension curve close to the
longer immobilized position.
 Passive tension in the muscle
approximates that of the muscle
before immobilization.
Percentage of fiber types within the
muscle:

 Protein synthesis is reduced in all muscle fiber types within a

chronically immobilized limb, but most notably in the slow twitch
(type I) fibers.
 Because slow twitch fibers are used so frequently throughout most
routine daily activities, they are subjected to greater relative disuse
when the limb is immobilized compared with fast twitch fibers.
 As a consequence, whole muscles of immobilized limbs tend to
experience a relative transformation toward faster twitch
characteristics, and
 this shift can occur as early as 3 weeks after the onset of
immobilization.
Length of the immobilization period:
Structural changes
 The rate of protein synthesis
begins to decline six hours after
the onset of disuse.
 These relatively early changes
suggest some neurologic basis
for the reduced strength, in
addition to the loss in the
muscle’s contractile proteins.
 Reduced strength after
immobilization is usually twice
that of the muscle atrophy—a
20% reduction in fiber cross-
sectional area is associated with
a 40% decline in strength.
Functional changes
 The loss of muscle mass
associated with loss of strength is
one of the first and most obvious
changes,
 the first seventy-two hours, with
rates decreasing from 14 to 17%
 Having lasted about a week, the
pace of muscle loss seems to
come down, up to 3% to 6% per
day in the first week alone.
 After only 10 days of
immobilization - up to a 40%
decrease of initial 1 RM strength.
 Consecutively three weeks of
immobilization may result in a
References
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