Soft Tissue InjurySoft Tissue Injurybyby

Mark HarmsworthMark Harmsworth

What is Soft Tissue?What is Soft Tissue?

• SkinSkin• Ligaments – connects bones at jointsLigaments – connects bones at joints• Tendons – attaches muscle to boneTendons – attaches muscle to bone• Fascia – dense connective tissueFascia – dense connective tissue• Skeletal Muscle – usually attached to Skeletal Muscle – usually attached to

bone and moves parts of the skeletonbone and moves parts of the skeleton• So, tissue that has not hardened into So, tissue that has not hardened into

bone and cartilagebone and cartilage

What are the Type of Injuries?What are the Type of Injuries?

• Sprain ligaments are Sprain ligaments are commonly caused by commonly caused by indirect impact, over-indirect impact, over-stretching (twisting)stretching (twisting)

• Muscle strains – Muscle strains – pulling action, over pulling action, over stretching, rupture or stretching, rupture or direct trauma / direct trauma / overuse. Includes overuse. Includes tendonstendons

• Contusions (bruise) – Contusions (bruise) – direct blow direct blow

• Intramuscular hematoma Intramuscular hematoma is confined to the muscle is confined to the muscle compartment which fills compartment which fills up with blood. Is more up with blood. Is more painful and restrictive of painful and restrictive of ROMROM

• Intermuscular hematoma Intermuscular hematoma is when the blood escapes is when the blood escapes through the fascia and so through the fascia and so becomes distributed, thus becomes distributed, thus bruising will be evidentbruising will be evident

Skeletal MuscleSkeletal Muscle

Sliding- Filament Sliding- Filament TheoryTheory

• Muscle cell ‘fibre’ includes Muscle cell ‘fibre’ includes myofibrils which consist of myofibrils which consist of 2 types of protein called 2 types of protein called thick and thin filamentsthick and thin filaments

• Thick filaments are formed Thick filaments are formed with myosin protein, while with myosin protein, while thin filaments with actin thin filaments with actin protein. Both form the protein. Both form the main contractile elements main contractile elements of muscle and as a unit is of muscle and as a unit is called a sacromerecalled a sacromere

• The length of sacromere is The length of sacromere is determined by the sliding determined by the sliding nature of the thick and thin nature of the thick and thin filaments which overlapfilaments which overlap

MuscleMuscle

• Arranged to correlate with the power Arranged to correlate with the power neededneeded

• Grouped in orientation of their fibres – Grouped in orientation of their fibres – parallel / oblique or pinnate / spiralparallel / oblique or pinnate / spiral

• The agonist or prime mover (muscle) The agonist or prime mover (muscle) brings about movementbrings about movement

• At the same time the antagonist relaxesAt the same time the antagonist relaxes

Soft Tissue Healing from InjurySoft Tissue Healing from Injury

• Repairing damaged tissueRepairing damaged tissue

• Replaced by granulation tissue, Replaced by granulation tissue, which matures to form scar type which matures to form scar type tissuetissue

• Phases overlapPhases overlap

• Bleeding / inflammatory / Bleeding / inflammatory / proliferation / remodelling phasesproliferation / remodelling phases

Bleeding PhaseBleeding Phase

• Bleeding time to stop will vary with Bleeding time to stop will vary with the nature of both the injury and the nature of both the injury and tissuetissue

• Short lived 6 – 8 hours (acute stage)Short lived 6 – 8 hours (acute stage)

• Reduces up to 24hrsReduces up to 24hrs

• Muscles will bleed longer than other Muscles will bleed longer than other structures i.e. ligamentsstructures i.e. ligaments

Inflammatory PhaseInflammatory Phase

• Essential component of tissue repairEssential component of tissue repair

• Rapid onset - first few hoursRapid onset - first few hours

• Quickly increases to maximum 2 – 3 daysQuickly increases to maximum 2 – 3 days

• Gradually resolves over next few weeksGradually resolves over next few weeks

• Largely beneficial Largely beneficial

• Is accompanied by debris removal and Is accompanied by debris removal and repair of damaged tissuerepair of damaged tissue

• Over response can cause problemsOver response can cause problems

Proliferation PhaseProliferation Phase

• Generation of the repair materialGeneration of the repair material• Production of scar tissue (collagen Production of scar tissue (collagen

material), needs to be laid down in an material), needs to be laid down in an orientated wayorientated way

• Rapid onset 24 – 48 hoursRapid onset 24 – 48 hours• Peaks 2 – 3 weeks / bulk scar tissuePeaks 2 – 3 weeks / bulk scar tissue• Final products several monthsFinal products several months• Repair tissue is different. Fibres Repair tissue is different. Fibres

shorter, inelastic and different shorter, inelastic and different elasticity, increases risk of recurrence elasticity, increases risk of recurrence of ruptureof rupture

Remodelling PhaseRemodelling Phase

• Greatly overlooked phaseGreatly overlooked phase

• Results in organised / functional scar Results in organised / functional scar tissuetissue

• Starts as early as 2 weeksStarts as early as 2 weeks

• Continues for months to a yearContinues for months to a year

• With maturity, the collagen becomes With maturity, the collagen becomes more orientated in line with local more orientated in line with local stressstress

Proliferation / Remodelling Proliferation / Remodelling Phase –Important in Successful Phase –Important in Successful

HealingHealing• Collagen fibres need to be orientated to Collagen fibres need to be orientated to

provide tensile strength in the right provide tensile strength in the right directiondirection

• Using normal stresses via movement, Using normal stresses via movement, collagen can be laid down this waycollagen can be laid down this way

• If not, collagen fibres are laid in haphazard If not, collagen fibres are laid in haphazard and thus weakened pattern is causedand thus weakened pattern is caused

• With maturity, the collagen becomes even With maturity, the collagen becomes even more orientated in line with stressmore orientated in line with stress

What Does This Mean for What Does This Mean for Treatment ?Treatment ?

• Excessive bleeding should be discouragedExcessive bleeding should be discouraged• Inflammation is normal and essential, though Inflammation is normal and essential, though

when acute and continues, can cause when acute and continues, can cause problems. A question re- NSAID’S use (See next problems. A question re- NSAID’S use (See next slide)slide)

• Early gradual mobilisation (active rest) Early gradual mobilisation (active rest) orientates scar tissue in the line of stress, orientates scar tissue in the line of stress, similar to normal tissue plus early movement similar to normal tissue plus early movement helps breaks down adhesions helps breaks down adhesions

• Unhelpful adhesions / scar tissue will need Unhelpful adhesions / scar tissue will need direct intervention – Sports massage direct intervention – Sports massage techniquestechniques

• Remodelling is helped by gradual return to full Remodelling is helped by gradual return to full physical stress - rehabilitation programmephysical stress - rehabilitation programme

NSAID’s as pain relief for STINSAID’s as pain relief for STI

• As inflammation process is important can As inflammation process is important can NSAIS’s delay overall recovery?NSAIS’s delay overall recovery?

• Inhibit COX enzymes and production of Inhibit COX enzymes and production of inflammatory prostaglandins (these inflammatory prostaglandins (these introduce inflammatory cells to the area)introduce inflammatory cells to the area)

• Thus reduces pain, swelling , oedema Thus reduces pain, swelling , oedema which can cause anoxia / cell damagewhich can cause anoxia / cell damage

• Inhibit COX can alter thromboxane and Inhibit COX can alter thromboxane and platelets and so increase bleeding / platelets and so increase bleeding / swelling at site.swelling at site.

NSAID’s as pain relief for STINSAID’s as pain relief for STI

• Tendon injuries in those over 40 are usually Tendon injuries in those over 40 are usually due to tendonosis in nature rather than due to tendonosis in nature rather than inflammationinflammation

• Research are inconclusive and involves use Research are inconclusive and involves use in animals rather than human trialsin animals rather than human trials

• Guidance – use NSAID’s for treating chronic Guidance – use NSAID’s for treating chronic inflammation and acute like bursitis and inflammation and acute like bursitis and confirmed tendonitisconfirmed tendonitis

• Use paracetamol for pain relief (though use Use paracetamol for pain relief (though use of single NSAID doses won’t have any effect)of single NSAID doses won’t have any effect)

Overuse Syndrome / SportsOveruse Syndrome / Sports• Muscular system develops to the way it is usedMuscular system develops to the way it is used• Individuals have unique pattern of imbalancesIndividuals have unique pattern of imbalances• Bundles of muscle fibres react fractionally in a Bundles of muscle fibres react fractionally in a

different way, causing small areas to be under different way, causing small areas to be under slightly greater pressure than surrounding areasslightly greater pressure than surrounding areas

• A few fibres are damaged at microscopic levelA few fibres are damaged at microscopic level• Causes secondary muscle tension to the Causes secondary muscle tension to the

surrounding tissuesurrounding tissue

OVERUSE SYNDROME BEGINSOVERUSE SYNDROME BEGINS

• Same as normal tissue response of bleeding / Same as normal tissue response of bleeding / inflammation and formation of scar tissue, yet at a inflammation and formation of scar tissue, yet at a microscopic levelmicroscopic level

• Secondary muscle micro-tension may cause soreness but Secondary muscle micro-tension may cause soreness but no real pain and activity continues as inflammatory no real pain and activity continues as inflammatory response is smallresponse is small

• Moderate activity is helpful at this stage yet further Moderate activity is helpful at this stage yet further continuous stress prevents recoverycontinuous stress prevents recovery

• Adjacent fibres work harder due to micro tissue damage, Adjacent fibres work harder due to micro tissue damage, which is less contractual and stretchywhich is less contractual and stretchy

• More micro trauma / scar tissue occurs so less elasticity More micro trauma / scar tissue occurs so less elasticity and the circle continuesand the circle continues

Overuse SyndromeOveruse Syndrome

Overuse SyndromeOveruse Syndrome

You are full into overuse syndromeYou are full into overuse syndrome

• As small parts of muscle deteriorate, As small parts of muscle deteriorate, imbalance in the muscle and the group occursimbalance in the muscle and the group occurs

• 1 muscle problem then effects different 1 muscle problem then effects different muscle systems. May still be unnoticed !muscle systems. May still be unnoticed !

• Tendon tension increases and may tear Tendon tension increases and may tear (acute)(acute)

• Biomechanical faults develop, causing more Biomechanical faults develop, causing more problems elsewhere in the musculoskeletal problems elsewhere in the musculoskeletal systemsystem

How to Treat / Stop Overuse How to Treat / Stop Overuse SyndromeSyndrome

• Effective and efficient training, includes Effective and efficient training, includes correct biomechanics. Be prepared to adaptcorrect biomechanics. Be prepared to adapt

• Have rest days (please), vary trainingHave rest days (please), vary training• Use soft tissue massage (STM) techniques Use soft tissue massage (STM) techniques

to identify and treat problems before any to identify and treat problems before any symptoms are recognisedsymptoms are recognised

• STM to intervene in soft tissue problem i.e.STM to intervene in soft tissue problem i.e. adhesions / scar tissueadhesions / scar tissue

FIND THE CAUSEFIND THE CAUSE

Soft Tissue Injury ApproachSoft Tissue Injury Approach

• Facilitate / promote normal tissue Facilitate / promote normal tissue repairrepair

• Immobilization and early mobilizationImmobilization and early mobilization• Enhance sequence of eventsEnhance sequence of events• Promote normalityPromote normality• Appropriate therapy to influence the Appropriate therapy to influence the

process in a positive wayprocess in a positive way• Intervene if needed i.e. adhesions / Intervene if needed i.e. adhesions /

infection / overuse syndromeinfection / overuse syndrome

ReferencesReferences

Soft tissue issuesSoft tissue issues• Anderson, C., et al Anderson, C., et al

2004*2004*• Fox, S and Pritchard, Fox, S and Pritchard,

D., 2004D., 2004• Watson, T., 2006 *Watson, T., 2006 *

Overuse syndromeOveruse syndrome• Cash, M., 1996*Cash, M., 1996*• Paine, T., 2007Paine, T., 2007• Sanderson, M., 2002Sanderson, M., 2002

Sliding – filament theorySliding – filament theory www.ivyrose.co.ukwww.ivyrose.co.uk (Accessed April (Accessed April

2008)2008)

Scar / collagen orientation inScar / collagen orientation in the lines of stressthe lines of stress• Forrest, L., 1983 Forrest, L., 1983 • Hardy, M., 1989Hardy, M., 1989• Norris, C., 2004*Norris, C., 2004*• Watson, T., 2006*Watson, T., 2006*

NSAID’S / INFLAMMATIONNSAID’S / INFLAMMATION• Becker, D., 2010Becker, D., 2010• Braund, R., 2006*Braund, R., 2006*• Khan, K. et al 2000.Khan, K. et al 2000.• McGriff-Lee, M., 2003McGriff-Lee, M., 2003• Stovitz, S and Johnson R., Stovitz, S and Johnson R.,

2003*2003*• Watson, T., 2006Watson, T., 2006