Soft Tissue Injury Soft Tissue Injury by Mark Harmsworth

What is Soft Tissue? Skin Skin Ligaments – connects bones at joints Ligaments – connects bones at joints Tendons – attaches muscle to bone Tendons – attaches muscle to bone Fascia – dense connective tissue Fascia – dense connective tissue Skeletal Muscle – usually attached to bone and moves parts of the skeleton Skeletal Muscle – usually attached to bone and moves parts of the skeleton So, tissue that has not hardened into bone and cartilage So, tissue that has not hardened into bone and cartilage

What are the Type of Injuries? Sprain ligaments are commonly caused by indirect impact, over- stretching (twisting) Sprain ligaments are commonly caused by indirect impact, over- stretching (twisting) Muscle strains – pulling action, over stretching, rupture or direct trauma / overuse. Includes tendons Muscle strains – pulling action, over stretching, rupture or direct trauma / overuse. Includes tendons Contusions (bruise) – direct blow Contusions (bruise) – direct blow Intramuscular hematoma is confined to the muscle compartment which fills up with blood. Is more painful and restrictive of ROM Intramuscular hematoma is confined to the muscle compartment which fills up with blood. Is more painful and restrictive of ROM Intermuscular hematoma is when the blood escapes through the fascia and so becomes distributed, thus bruising will be evident Intermuscular hematoma is when the blood escapes through the fascia and so becomes distributed, thus bruising will be evident

Skeletal Muscle Skeletal Muscle

Sliding- Filament Theory Muscle cell ‘fibre’ includes myofibrils which consist of 2 types of protein called thick and thin filaments Muscle cell ‘fibre’ includes myofibrils which consist of 2 types of protein called thick and thin filaments Thick filaments are formed with myosin protein, while thin filaments with actin protein. Both form the main contractile elements of muscle and as a unit is called a sacromere Thick filaments are formed with myosin protein, while thin filaments with actin protein. Both form the main contractile elements of muscle and as a unit is called a sacromere The length of sacromere is determined by the sliding nature of the thick and thin filaments which overlap The length of sacromere is determined by the sliding nature of the thick and thin filaments which overlap

Muscle Arranged to correlate with the power needed Arranged to correlate with the power needed Grouped in orientation of their fibres – parallel / oblique or pinnate / spiral Grouped in orientation of their fibres – parallel / oblique or pinnate / spiral The agonist or prime mover (muscle) brings about movement The agonist or prime mover (muscle) brings about movement At the same time the antagonist relaxes At the same time the antagonist relaxes

Soft Tissue Healing from Injury Repairing damaged tissue Repairing damaged tissue Replaced by granulation tissue, which matures to form scar type tissue Replaced by granulation tissue, which matures to form scar type tissue Phases overlap Phases overlap Bleeding / inflammatory / proliferation / remodelling phases Bleeding / inflammatory / proliferation / remodelling phases

Bleeding Phase Bleeding Phase Bleeding time to stop will vary with the nature of both the injury and tissue Bleeding time to stop will vary with the nature of both the injury and tissue Short lived 6 – 8 hours (acute stage) Short lived 6 – 8 hours (acute stage) Reduces up to 24hrs Reduces up to 24hrs Muscles will bleed longer than other structures i.e. ligaments Muscles will bleed longer than other structures i.e. ligaments

Inflammatory Phase Essential component of tissue repair Essential component of tissue repair Rapid onset - first few hours Rapid onset - first few hours Quickly increases to maximum 2 – 3 days Quickly increases to maximum 2 – 3 days Gradually resolves over next few weeks Gradually resolves over next few weeks Largely beneficial Largely beneficial Is accompanied by debris removal and repair of damaged tissue Is accompanied by debris removal and repair of damaged tissue Over response can cause problems Over response can cause problems

Proliferation Phase Generation of the repair material Generation of the repair material Production of scar tissue (collagen material), needs to be laid down in an orientated way Production of scar tissue (collagen material), needs to be laid down in an orientated way Rapid onset 24 – 48 hours Rapid onset 24 – 48 hours Peaks 2 – 3 weeks / bulk scar tissue Peaks 2 – 3 weeks / bulk scar tissue Final products several months Final products several months Repair tissue is different. Fibres shorter, inelastic and different elasticity, increases risk of recurrence of rupture Repair tissue is different. Fibres shorter, inelastic and different elasticity, increases risk of recurrence of rupture

Remodelling Phase Greatly overlooked phase Greatly overlooked phase Results in organised / functional scar tissue Results in organised / functional scar tissue Starts as early as 2 weeks Starts as early as 2 weeks Continues for months to a year Continues for months to a year With maturity, the collagen becomes more orientated in line with local stress With maturity, the collagen becomes more orientated in line with local stress

Proliferation / Remodelling Phase – Important in Successful Healing Collagen fibres need to be orientated to provide tensile strength in the right direction Collagen fibres need to be orientated to provide tensile strength in the right direction Using normal stresses via movement, collagen can be laid down this way Using normal stresses via movement, collagen can be laid down this way If not, collagen fibres are laid in haphazard and thus weakened pattern is caused If not, collagen fibres are laid in haphazard and thus weakened pattern is caused With maturity, the collagen becomes even more orientated in line with stress With maturity, the collagen becomes even more orientated in line with stress

What Does This Mean for Treatment ? Excessive bleeding should be discouraged Excessive bleeding should be discouraged Inflammation is normal and essential, though when acute and continues, can cause problems. A question re- NSAID’S use (See next slide) Inflammation is normal and essential, though when acute and continues, can cause problems. A question re- NSAID’S use (See next slide) Early gradual mobilisation (active rest) orientates scar tissue in the line of stress, similar to normal tissue plus early movement helps breaks down adhesions Early gradual mobilisation (active rest) orientates scar tissue in the line of stress, similar to normal tissue plus early movement helps breaks down adhesions Unhelpful adhesions / scar tissue will need direct intervention – Sports massage techniques Unhelpful adhesions / scar tissue will need direct intervention – Sports massage techniques Remodelling is helped by gradual return to full physical stress - rehabilitation programme Remodelling is helped by gradual return to full physical stress - rehabilitation programme

NSAID’s as pain relief for STI As inflammation process is important can NSAIS’s delay overall recovery? As inflammation process is important can NSAIS’s delay overall recovery? Inhibit COX enzymes and production of inflammatory prostaglandins (these introduce inflammatory cells to the area) Inhibit COX enzymes and production of inflammatory prostaglandins (these introduce inflammatory cells to the area) Thus reduces pain, swelling, oedema which can cause anoxia / cell damage Thus reduces pain, swelling, oedema which can cause anoxia / cell damage Inhibit COX can alter thromboxane and platelets and so increase bleeding / swelling at site. Inhibit COX can alter thromboxane and platelets and so increase bleeding / swelling at site.

NSAID’s as pain relief for STI Tendon injuries in those over 40 are usually due to tendonosis in nature rather than inflammation Tendon injuries in those over 40 are usually due to tendonosis in nature rather than inflammation Research are inconclusive and involves use in animals rather than human trials Research are inconclusive and involves use in animals rather than human trials Guidance – use NSAID’s for treating chronic inflammation and acute like bursitis and confirmed tendonitis Guidance – use NSAID’s for treating chronic inflammation and acute like bursitis and confirmed tendonitis Use paracetamol for pain relief (though use of single NSAID doses won’t have any effect) Use paracetamol for pain relief (though use of single NSAID doses won’t have any effect)

Overuse Syndrome / Sports Muscular system develops to the way it is used Muscular system develops to the way it is used Individuals have unique pattern of imbalances Individuals have unique pattern of imbalances Bundles of muscle fibres react fractionally in a different way, causing small areas to be under slightly greater pressure than surrounding areas Bundles of muscle fibres react fractionally in a different way, causing small areas to be under slightly greater pressure than surrounding areas A few fibres are damaged at microscopic level A few fibres are damaged at microscopic level Causes secondary muscle tension to the surrounding tissue Causes secondary muscle tension to the surrounding tissue OVERUSE SYNDROME BEGINS OVERUSE SYNDROME BEGINS

Same as normal tissue response of bleeding / inflammation and formation of scar tissue, yet at a microscopic level Same as normal tissue response of bleeding / inflammation and formation of scar tissue, yet at a microscopic level Secondary muscle micro-tension may cause soreness but no real pain and activity continues as inflammatory response is small Secondary muscle micro-tension may cause soreness but no real pain and activity continues as inflammatory response is small Moderate activity is helpful at this stage yet further continuous stress prevents recovery Moderate activity is helpful at this stage yet further continuous stress prevents recovery Adjacent fibres work harder due to micro tissue damage, which is less contractual and stretchy Adjacent fibres work harder due to micro tissue damage, which is less contractual and stretchy More micro trauma / scar tissue occurs so less elasticity and the circle continues More micro trauma / scar tissue occurs so less elasticity and the circle continues Overuse Syndrome

You are full into overuse syndrome You are full into overuse syndrome As small parts of muscle deteriorate, imbalance in the muscle and the group occurs As small parts of muscle deteriorate, imbalance in the muscle and the group occurs 1 muscle problem then effects different muscle systems. May still be unnoticed ! 1 muscle problem then effects different muscle systems. May still be unnoticed ! Tendon tension increases and may tear (acute) Tendon tension increases and may tear (acute) Biomechanical faults develop, causing more problems elsewhere in the musculoskeletal system Biomechanical faults develop, causing more problems elsewhere in the musculoskeletal system

How to Treat / Stop Overuse Syndrome Effective and efficient training, includes correct biomechanics. Be prepared to adapt Effective and efficient training, includes correct biomechanics. Be prepared to adapt Have rest days (please), vary training Have rest days (please), vary training Use soft tissue massage (STM) techniques to identify and treat problems before any symptoms are recognised Use soft tissue massage (STM) techniques to identify and treat problems before any symptoms are recognised STM to intervene in soft tissue problem i.e. STM to intervene in soft tissue problem i.e. adhesions / scar tissue adhesions / scar tissue FIND THE CAUSE

Soft Tissue Injury Approach Facilitate / promote normal tissue repair Facilitate / promote normal tissue repair Immobilization and early mobilization Immobilization and early mobilization Enhance sequence of events Enhance sequence of events Promote normality Promote normality Appropriate therapy to influence the process in a positive way Appropriate therapy to influence the process in a positive way Intervene if needed i.e. adhesions / infection / overuse syndrome Intervene if needed i.e. adhesions / infection / overuse syndrome

References Soft tissue issues Anderson, C., et al 2004* Anderson, C., et al 2004* Fox, S and Pritchard, D., 2004 Fox, S and Pritchard, D., 2004 Watson, T., 2006 * Watson, T., 2006 * Overuse syndrome Cash, M., 1996* Cash, M., 1996* Paine, T., 2007 Paine, T., 2007 Sanderson, M., 2002 Sanderson, M., 2002 Sliding – filament theory (Accessed April 2008) (Accessed April 2008) Scar / collagen orientation in Scar / collagen orientation in the lines of stress the lines of stress Forrest, L., 1983 Forrest, L., 1983 Hardy, M., 1989 Hardy, M., 1989 Norris, C., 2004* Norris, C., 2004* Watson, T., 2006* Watson, T., 2006* NSAID’S / INFLAMMATION NSAID’S / INFLAMMATION Becker, D., 2010 Becker, D., 2010 Braund, R., 2006* Braund, R., 2006* Khan, K. et al Khan, K. et al McGriff-Lee, M., 2003 McGriff-Lee, M., 2003 Stovitz, S and Johnson R., 2003* Stovitz, S and Johnson R., 2003* Watson, T., 2006 Watson, T., 2006