Basics of Tissue Injury

1. Basics of Tissue Injury

2. Sports Medicine Injuries Learning TargetsUnit 3 – Tissue Repair and Rehabilitation • I can discuss what happens at the site of an injury during Phase 1: The AcuteInflammatory Phase. • I can discuss what happens at the site of an injury during Phase 2: The ProliferationPhase. • I can discuss what happens at the site of an injury during Phase 3: The Remodelling Phase. • I can explain the factors that impede healing. • I can describe the importance of controlling swelling and the PRICE principle. • I can explain the goals of rehabilitation foreach Phase of healing.

3. STAGES OF SOFT TISSUE HEALING

4. INTRODUCTION WHEN AN INJURY OCCURS IT MUST GO THROUGH 3 STAGES OF HEALING

5. Stage 1: Acute Inflammatory • Increase blood flow to the area that brings cells and chemicals to begin the healing process. • Phagocytes- Eat up dead cells. • Leukocytes- Infection fighting white blood cells. • Platelets-Carry blood clotting materials. • Vascular changes • Vasoconstriction – immediately; decreased blood flow to area (approx. 5-10 mins.); platelet plug formed; blood coagulation; produces local anemia • Vasodilation – increased blood flow; increased hydrostatic pressure in blood vessels ( capillary permeability, plasma proteins leak out; proteins attract H2O = edema) THIS STAGE LASTS FOR ABOUT 2 DAYS

6. Phase I: Acute Inflammatory Phase • Goal • Protect, • Localize, • Decrease injurious agents, • Prepare for healing and repair

7. Cardinal Signs of Inflammation

8. Phase 2: Proliferation/Repair • The injured area has been filled with the blood, cells, and chemicals needed to rebuild the injury • Fibroblasts begin building fibers across the injury and form the scar. THIS PROCESS LASTS FROM 6 WEEKS TO 3 MONTHS.

9. Phase II: Proliferation Phase • “Repair/Regeneration” Phase • Phase will extend from 48 hours to 3 months • Phase removes debris & temporary repair – SCAR FORMATION (fibroplasia) Dependent on levels of: debris removal, skin cell production, production of fibroblasts

10. Phase II: Proliferation Phase • Repaired through 3 phases • Resolution - dead cells & cellular debris are removed (tissue left with original structure & function in tact) • fibroblast (tissue cells) formation • tissue remodeling

11. Phase II: Proliferation Phase • Regeneration – damaged tissue is replaced by cells of the same type (structure retains some or all of its original structure & function) • synthesis of collagen (fencing) • Repair – original tissue is replaced with scar tissue (original structure & function is lost) • tissue alignment

12. Phase II: Proliferation Phase • Phase II Goal • Help new tissues start to align • Wolff’s Law

13. Phase 3: Remodeling • Goal • Builds tissue strength in the repaired/replaced tissue of the tendons, ligaments or muscles in order to withstand stress applied to the body. THIS STAGE TAKES UP TO A YEAR OR MORE.

14. Phase III: Remodeling Phase • Usually begins @ week 3 • Purpose is to increase strength of repaired/replaced tissues • First 3-6 weeks involves laying down of collagen and strengthening of fibers • 3 months to 2 years allowed for enhanced scar tissue strength • Balance must be maintained between synthesis & lysis • Build up (synthesis) and break down (lysis)

15. Phase III: Remodeling Phase • Take into consideration • forces applied, • immobilization time frames relative to tissue • healing time • Scars fade & eventually return to near normal color

16. Modifying Soft-Tissue Healing • Varying issues exist for all soft tissues relative to healing (cartilage, muscle, nerves) • Blood supply and nutrients is necessary for all healing • Healing in older athletes or those with poor diets may take longer • Certain organic disorders (blood conditions) may slow or inhibit the healing process

17. Extent of injury Edema Hemorrhage Poor Vascular Supply Muscle Spasm Atrophy Infection Health, Age, and Nutrition Factors That Impede Healing

18. Types of Tissues and their Healing Cartilage • Limited capacity to heal • Little or no direct blood supply • Articular cartilage that fails to clot heals very slowly Ligaments/ Tendons • Long full healing process (12 months) • Decent blood supply • Requires a lot of collagen being laid down

19. Types of Tissues and their Healing • Bone • Severity of injury • Soft tissue damage • Amount of necrotic tissue • Disruption of blood supply • Displacement of fragments • Open fractures disrupts blood supply, severe soft tissue damage • Union v Displaced/malunion fractures • Skeletal Muscle • Initial bleeding followed by laying down a ground substance • Healing could last 6-8 weeks depending on muscle injured

20. Importance of Controlling Swelling • Initial injury management an swelling control is critical • Swelling can result in increased pressure to the injured area, causing pain and altered neuromuscular function • Swelling slows the healing process and normal function is not regained until swelling is eliminated • To limit swelling use the PRICE principle

21. Importance of Controlling Swelling • Protection & Ice • Protect the injury from further damage • Splint, wrap, immobilize the injured site • If the lower extremity is involved, crutches should be supplied • Ice causes vasoconstriction and slows down swelling

22. Importance of Controlling Swelling • Restricted Activity (Rest) • Healing immediately begins after injury • Without rest, external stresses are still placed on the injured area, interfering with the healing process- prolonging recovery • Controlled mobility is superior to immobilization • 24-48 hours of rest should be applied prior to active rehabilitation – depends on severity • Rest applies to the injured body part – cardiovascular fitness, strengthening and flexibility should be maintained

23. Importance of Controlling Swelling • Compression • Single most important factor in swelling control • Mechanically reduces space available for swelling accumulation • Using an elastic wrap, firm, evenly applied pressure can be achieved • Compression should be maintained continuously for 72 hours – depends on severity • With chronic inflammatory conditions compression should be applied until the swelling is almost entirely gone

24. Importance of Controlling Swelling • Elevation • Used to eliminate the effects of gravity on blood pooling • Assists venous and lymphatic drainage of blood and other fluids from the injured area • Elevation should occur as often as possible during the first 72 hours of the acute injury – depends on severity

25. Grades of Sprains/Strains • Grade I – some pain, minimal loss of function, no abnormal function, & mild point tenderness • Grade II – pain, moderate loss of function, swelling & instability • Grade III – extremely painful, inevitable loss of function, swelling

26. Managing the Healing Process through Rehabilitation • Pre-surgical Phase: • If surgery can be delayed, exercise may help to improve outcome • Maintaining or improving ROM, strength, cardiovascular fitness, neuromuscular control may enhance the athlete’s ability to perform rehab after surgery

27. Phase 1 – Acute Inflammatory Phase Phase 2 – Proliferation Phase Phase 3 - Remodeling Inflammation Mobility Proprioception Resistance Endurance Sport Specific Rehab Phases

28. Managing the Healing Process through Rehabilitation • Phase I: Acute Inflammatory Phase • Initial swelling management & pain control are crucial • PRICE • If you are too aggressive in the 1st 48 hours the inflammatory process may not have time to accomplish what it needs to • By days 3-4 some mobility exercises should be performed along with gradual increase of weight bearing status • Use of NSAIDs

29. Managing the Healing Process through Rehabilitation • Phase II: Fibroblastic Phase: • As inflammatory phase begins to subside & pain decreases with PROM, add • Cardiorespiratory fitness • Restore full ROM • Restore or increase strength • Re-establish neuromuscular control • Continued use of modalities for pain control

30. Managing the Healing Process through Rehabilitation • Phase III: Remodeling Phase: • Longest phase with the ultimate goal of returning to activity • Continued collagen realignment • Pain continues to decrease • Regain sports-specific skills • Dynamic functional activities • Sports-directed strengthening activities • Plyometric strengthening • Functional testing • Determine specific skill weakness

31. Pain Management • Reduce pain! • Control acute pain! • Protect the patient from further injury while encouraging progressive exercise • Minimize further tissue damage • Encourage psychological interaction (positive thinking, etc.) • Medications • Communication with athlete • Use of modalities to reduce pain

32. CONCLUSION Soft tissue healing requires the tissue to go through 3 stages: Acute Inflammatory Repair Remodeling