1. Tissue Response to Injury

2. Cardinal Signs of Inflammation
Redness
Heat
Swelling
Pain
Loss 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

3. Three Phases of Healing
Phase I: Acute Inflammatory Phase
Phase II: Proliferation/Fibroblastic/ Repair/Regeneration Phase
Phase III: Remodeling/ Maturation Phase

4. Phase I: Acute Inflammatory Phase
Begins almost right away, lasts approx. 2-4 days
Goal
Protect,
Localize,
Decrease injurious agents,
Prepare for healing and repair

5. Acute Inflammatory Response
Vascular changes
Vasoconstriction – immediately; decreased blood flow to area (approx 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)
Cellular Changes – chemical reactions start immediately
Protein presence – proteins are the building blocks.
Neutralizes/destroys offending agents, restricts tissue damage to the smallest possible tissue & prepares area for healing

6. Phase II: Proliferation Phase
“Repair/Regeneration”
Phase will extend from 48 hours to 3-6 weeks
Phase removes debris & temporary repair – SCAR FORMATION (fibroplasia)
Dependent on levels of: debris removal, skin cell production, production of fibroblasts

7. 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

8. 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

9. Phase III: Remodeling Phase
Usually 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)

10. 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

11. 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

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

13. 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

14. Skeletal Muscle Healing
Initial bleeding followed by laying down a ground substance
Healing could last 6-8 weeks depending on muscle injured

15. 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 RICE principle

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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