1. Therapeutic Exercise I Chapter 10
Soft Tissue Injury, Repair, and Management

2. Three Stages of Tissue Recovery
Acute (Inflammatory reaction) redness, swelling, heat, pain at rest and lost of
motion; muscle guarding is a way to immobilize the area and usually last 4-6 days
Sub-Acute (Repair and healing) signs of inflammation decreases, pain is felt when stressing
new tissue beyond its tolerance, muscle may test weak and function will be limited; usually
lasts days (14-21 days after onset) and may last up to 6 weeks
Chronic (Maturation and remodeling) no signs of inflammation, may have contractures/adhesions with limited ROM and weakness, poor endurance and neuromuscular control limiting function, connective tissue remodel/strengthen during this stage and may last
up to 6 months to 1 year pending the amount of damage
The Physical Therapist will examine, evaluate, and create a program to assess the impairments and develop functional and obtainable goals for the patient. The programs will be patient specific and appropriate for the stage of healing

3. Examples of Soft Tissue Lesions-Musculoskeletal Disorders
Strain
Sprain
Dislocation
Subluxation
Muscle/Tendon rupture or tear
Tendinous lesion/tendinopathy
Tenosynovitis
Tenovaginitis
Tendinosis

4. Continued: Examples of Soft Tissue Lesions-Musculoskeletal Disorders
Synovitis
Hemarthrosis
Ganglion
Bursitis
Contusion
Overuse Syndrome

5. Clinical Conditions Resulting from Trauma Pathology
Dysfunction
Joint dysfunction
Contractures
Adhesions
Reflex muscle guarding
Intrinsic muscle spasm
Muscle weakness
Myofascial compartment syndromes

6. Severity of Tissue Injury
Grade 1 (first degree)-Mild pain within the first 24 hours, with mild swelling, local tenderness, and pain when the tissues are stressed
Grade 2 (second degree)-Moderate, requires stopping the activity, stress and palpation to the tissue causing increase pain, when it is a ligament-some fibers are torn resulting in increase joint mobility
Grade 3 (third degree)-Severe, near complete/complete tear of avulsion of the tissue (tendon/ligament) with severe pain, stresses to the joint do not involve pain and palpation may reveal defect, torn ligaments results in instability of the joint

7. Irritability of Tissue: Stages of Inflammation and Repair
Acute Stage
Subacute Stage Discussed in earlier slide
Chronic Stage
Chronic Inflammation (Overuse syndrome)-increase complaints of pain, swelling, and muscle guarding lasting more than several hours after activities, stiffness, loss of ROM 24 hours after activity
Chronic Pain Syndrome – persistent pain longer than 6 months-physical, emotional, and psychosocial parameters; pain inconsistent with source of irritation, inflammation, functional limitation, disability

8. Management Guidelines- Protection Phase
Control the effects of swelling, facilitate wound healing and maintain normal joint function
Patient education (HEP)
Minimize pain/swelling by 1st hours with
rest, cold, compression and elevation
Prevent adverse reactions from immobilization
Tissue specific movement to prevent abnormal adherence
Gentle intensity to prevent increase pain/swelling
General movements to uninjured tissue and to aid
in circulation/lymphatic flow

9. Specific Interventions And Dosage For The Protection Phase
PROM
Low-dosage joint mobilization techniques
Muscle setting
Massage
Interventions for Associated Areas- ROM, Muscle performance, functional activities, and circulation

10. Management Guidelines- Controlled Motion Phase
During the 2nd-4th day after tissue injury, the inflammation begins to decrease
Clots start and repair begins
Last days and may last up to 6 weeks
Noxious stimuli are removed, and capillary beds begin to grow
Fibroblastic activity, collagen formation, and granulation tissue development increases
Production of new collagen takes place of the formed clot
Scar linkage caused by myofibroblastic activities occurs at
day 5
Wound closure in muscles and skin takes 5-8 days
Wound closure in tendons and ligaments takes 3-6 weeks

11. Management Guidelines- Controlled Motion Phase-Continued
The key is to initiate and progress nondestructive exercises/activities
Patient education (HEP)
Management of pain and inflammation prior to initiating active exercise and stretching….there should be no increase signs of pain/swelling
Monitor activities and exercise specifically new ones and modify as needed

12. -In The Controlled Phase- Initiation of:
Active Exercises
--Multiangle, submaximal isometrics
--Active ROM
--Muscular endurance
--Protected weight bearing
activities
Stretching
--Warm the tissues
--Inhibition techniques
--Joint mobilization
--Stretching techniques
--Massage
--Use of new range
--Correction of contributing
factors

13. Management Guidelines- Return to Function Phase
Scar retraction from activity of the myofibrobalsts is usually complete by the 21st day and it stops increasing in size
From day, there is a predominance of fibroblasts that are easily remodeled
Maturation begins late in the sub-acute stage and continues for several months
Remodeling time is influenced by factors: how long immobilized, stress placed on tissue, location of lesion, and vascular supply
Maturation of tissue is possible up to 10 weeks and at
14 weeks the tissue becomes unresponsive to
remodeling

14. Management Guidelines- Return to Function Phase-Continued
Safe combination of stretches and strengthening to maturing tissue…this should be a balanced combo
Patient education (HEP)
To avoid pain/soreness, contractures need to be stretched/mobilized or adhesions broken up ie: cross friction massage
Proper performance/guidelines set up
Consideration of progression of exercises—as long as no adverse reaction is felt

15. Tissue Response To Chronic Inflammation- (Prolong/Recurring Pain)
Tissue that is stressed beyond the ability to repair itself, the inflammation is perpetuated
New immature collagen is produced, which weakens the effect of tissue
Microfibroblastic activities continues, which may lead to loss of motion
With efforts to stretch the inflamed tissue, this may lead to additional irritation and progressive limitations
Mechanical causes need to be identified

16. Management of Chronic Inflammation
Start treatment as it is an acute condition with the focus on decreasing the inflammation to avoid continued tissue breakdown and excessive scar formation-
avoid cross friction massage
Once inflammation is down, treat impairments and functional limitation
Acute stage with use of modalities and rest and correct faulty biomechanics
Educate the patient in repeated trauma and the lack of healing process
Allow only non-stressful activities/exercises

17. Sub-acute and chronic stages of healing following Chronic Inflammation
Once decreased, progress exercises slowly to allow connective tissue to be able to withstand the stresses in functional activities
May need to mobilize a scar
If ROM is lost, too much stretching has been applied
Remember: Muscle guarding is a protective mechanism
Identify faulty movements
Work on muscle endurance to sustain repetitive activities
Progress towards function (HEP)
May use work-conditioning/work-hardening programs or sports-specific exercises

18. (If time permits may review LE’s)
Break for Lab with Lecture on UE Manual Resistance Exercises, Mechanical Resisted Exercises, Selected Resistance Training Regimens, Equipment for Resisted Training
Resistance Techniques in Anatomical Planes of Motion/Diagonals of the UE’s
(If time permits may review LE’s)