Acute Soft Tissue Injury Management

Bill Vicenzino
Department of Physiotherapy University of Queensland

Management Modalities
Advice & Education
Physical Ergogenic Aids Movement Therapy Electrophysical Agents

Signs of Inflammation
Pain Swelling Heat Redness Dysfunction

Pain
Trauma Cell hypoxia Chemical release (bradykinin, histamine, prostaglandin) Pressure on nerve endings

Swelling
Minimal (rarely arterial, distorts tissues & clots) Chemical release (histamine, prostaglandin, leukotrines & serotonin) Increase cell membrane permeability increase exudate High concentration of extra-cellular protein increase osmotic pressure gradient fluid drawn into extra-cellular space increased oedema

Lymphatics blocked with thick exudate

REDNESS & WARMTH

Chemical Release (Histamine, substance P) Vasodilation Increased blood supply

Inflammatory Phase:
Charaterised by: increasing fluctuating to plateauing swelling functional limitations of day to day activities Management Aims: Prevent complications & progression of injury Reduce pine & swelling Promote functional scar Improve function Education of patient

Management Approach
RELATIVE REST ELEVATION COMPRESSION ICE PAIN LIMITING EXERCISE

REMOVE / RELATIVE REST

Prevent further injury Protect the injury Reduce pain Immobilisation to maintain anatomical alignment of traumatised structures

ELEVATION
Decrease capillary pressure Assist lymphatic drainage
Reduces tissue pressure
Prevent accumulation
Assist dispersal of inflammatory exudate Reduces pain (When there is marked tissue pressure)

Effective

COMPRESSION
Increases hydrostatic pressure of the interstitial fluid Counteracts osmolarity Facilitates lymphatic drainage Facilitates venous drainage Prevent accumulation and Assist dispersal of Inflammatory exudate Effective (Wilkerson, 1985) CARE with amount of compression (Mateson et al 1974m Evans 1960)

ICE
Reduce inflammation1 Reduce pain2,3,4 Reduce muscle spasm5,4 Decrease metabolism4 ? Vasoconstriction/dilation ? Increase or decrease swelling1,6,7,4,8

PAIN LIMITED EXERCISE

Facilitate lymphatic and venous drainage REDUCE SWELLING Assist phagocytosis Increase deep blood supply ASSIST REGENERATION Facilitate appropriate architecture of the FUNCTIONAL SCAR TISSUE collagen bundles

Cellular proliferation

- fibroblasts - macrophage - max cells - vascular granulation tissue Vascular changes - endothelial capillary buds - increased content - increased type 3 and 1 - type 3> 1 - type 1 cross links - increased CAG and DNS - elastin INCREASING TENSILE STRENGTH of matrix correlates with changes

Management Philosophy
GOLDEN RULE (Hippocrates): DO NO HARM
FALSE ANALOGY IN SPORTS INJURY DO NOTHING REST (complete)

PAIN LIMITED EXERCISE

Facilitate lymphatic and venous drainage Assist phagocytosis Increase deep blood supply Facilitate appropriate architecture of the collagen bundles
reduce swelling

assist regeneration

functional scar tissue

PROLIFERATIVE PHASE
Characterised by: decreasing pain & swelling improving function in day to day activities improving range of motion & muscle function (3/4) Management Aims: prevent complications/deterioration promote functional scar improve function further reduce pain & swelling if present

OPTIMAL HEALING
1)

(ligaments)

controlled functional stresses must help stimulate and direct the healing response but at the same time there must be protection against harmful stresses during the collagen synthesis and remodelling or maturation phases
(Woo & Buckwalter, 1997)

2)

INFLAMMATORY PHASE: HIGH VOLTAGE STIMULATION

reduction of edema in animal studies has been documented with frequent applications of 10% submotor threshold @ 120Hz cathodal high voltage stimulation (Toons associated with Mendell & Fish 1990 through
1992 inclusive)

to

prevention of muscle atrophy following injury (Lake 1992)

Maturation Phase
Characterised by: higher level functioning in sporting activities improving muscle function possible muscle imbalances/altered movement patterns
Management Aims: prevent recurrence (Tertiary prevention) improve higher level function

Ligament healing stages influenced by:

1) Systemic factors - nutritional status (serum protein levels) - vitamin deficiency (vitamin c) - anemia - diabetes mellitus - uremia 2) Local factors - degree of injury - infection - blood supply - synovial environment - mechanical stress - mediators of inflammation - excessive scarring (Evans 1990, Antacchi 1999)

REMODELLING PHASE: ULTRASOUND

Enhancement of scar tissue is best achieved by early commencement of ultrasound in the inflammatory phase after the initial bleeding has settled (Dyson 1987).

Proliferation Phase: High Voltage Stimulation High voltage stimulation sufficient

to elicit a muscle contraction provides a stimulus for increasing blood flow (McMeeken 1994).

Proliferation Phase: Ultrasound

Superior healing as represented by increases in: the breaking strength of healing scar tissue
(Byl et al 1993)

the amount of collagen deposition (Byl et al 1993) the quantity of blood vessels in the granulation tissue in the first 5 days
(Young & Dyson 1990)

REMODELLING & MATURATION PHASE

Decreased fibroblasts & macrophages Decreased vascularity of the tissue Decreased cellular activity Increasing tensile strength to near normal cell decreased cellularity decreased synthetic activity

REMODELLING & MATURATION PHASE

Collagen
increased scar tissue density improved alignment increasing diameter of collagen fibrils packed more densely reduced turnover better organised, extracellular matrix biomechanical profile, normal looking type 3/type 1- normal normalising collagen, DNA levels slight increased GAGs