2. Basics of Tissue Injury

3. Sports Medicine Injuries Learning Targets Unit 3 – Tissue Repair and Rehabilitation I can discuss what happens at the site of an injury during Phase 1: The Acute Inflammatory Phase. I can discuss what happens at the site of an injury during Phase 2: The Proliferation Phase. I can discuss what happens at the site of an injury during Phase 3: The Remodelling Phase. I can explain the factors that impedehealing. I can describe the importance of controlling swelling and the PRICE principle. I can explain the goals of rehabilitation for each Phase of healing.

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

6. Stage 1: Acute Inflammatory IIIIncrease blood flow to the area that brings cells and chemicals to begin the healing process. PPPPhagocytes- Eat up dead cells. LLLLeukocytes- Infection fighting white blood cells. PPPPlatelets-Carry blood clotting materials. Vascular changes –V–V–V–Vasoconstriction – immediately;decreased blood flow to area (approx. 5-10 mins.); platelet plug formed; blood coagulation; produces local anemia –V–V–V–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

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

8. Cardinal Signs of Inflammation RednessHeatSwellingPainLoss of Function Caused by dilation of arterioles/ increased blood flow Increased chemical activity & increased blood flow to skin surface Caused by accumulation of blood & damaged tissue cells Direct injury of nerve fibers, pressure of hematoma on n. endings Chemical irritants – bradykinin, histamine, prostaglandin Increased pain/ swelling

9. Phase 2: Proliferation/Repair The injured area has been filled with the blood, cells, and chemicals needed to rebuild the injury 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.

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

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

12. 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) synthesis of collagen (fencing) –Repair – original tissue is replaced with scar tissue (original structure & function is lost) tissue alignment tissue alignment

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

14. Phase 3: Remodeling Goal 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.

15. Phase III: Remodeling Phase Usually begins @ week 3 Usually begins @ week 3 Purpose is to increase strength of repaired/replaced tissues 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 Balance must be maintained between synthesis & lysis –Build up (synthesis) and break down (lysis)

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

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

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

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

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

21. Importance of Controlling Swelling Initial injury management an swelling control is critical 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 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 Swelling slows the healing process and normal function is not regained until swelling is eliminated To limit swelling use the PRICE principle To limit swelling use the PRICE principle

22. Importance of Controlling Swelling Protection & Ice 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

23. Importance of Controlling Swelling Restricted Activity (Rest) 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

24. Importance of Controlling Swelling Compression 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

25. Importance of Controlling Swelling Elevation 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

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

27. Managing the Healing Process through Rehabilitation Pre-surgical Phase: 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

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

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

30. Managing the Healing Process through Rehabilitation Phase II: Fibroblastic Phase: Phase II: Fibroblastic Phase: As inflammatory phase begins to subside & pain decreases with PROM, add 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 Continued use of modalities for pain control

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

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

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