View
227
Download
0
Category
Preview:
Citation preview
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 1/21
3/4/20
Soft Tissue Injuries
Physical Medicine & Rehabilitation
Lecture Series 6/6
Define the following
• Sprain
• Strain
• Bursitis
• Tendinitis
• Rupture
• Fibromyositis
• Fibrositis
• Myosistis
Sprain
• An injury involving the stretching or
tearing of a ligament (tissue that
connects bone to bone) or a jointcapsule (connective tissue secreting
synovial fluid), which help provide jointstability.
Sprain
• A severely damaged ligament or jointcapsule can cause instability in a joint.
Sprain
• Symptoms may include
– Pain
– Inflammation
– inability to move a limb (arm, leg, foot)
• Sprains occur when a joint is forcedbeyond its normal range of motion, such
as turning or rolling your ankle.
Types of ligament injury
• Partial
– a. part of the ligament may be torn while therest are undamaged
– b. & c. part of the ligament attachment mayhave been torn away from its insertion with orwithout a bone fragment
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 2/21
3/4/20
Types of ligament injury
• Complete
– a. ligament is totally torn and the endsseparated from each other
– b. the entire ligament attachment is detachedfrom the bone
– c. the fragment of bone to which the ligamentis attached has been torn away from the restof the bone
Grading of Sprains
• Grade I – disruption of few fibers
• Grade II
– Minor - disruption of less than half of fibers
– Major – disruption of more than 50% of fibers
• Grade III – disruption of all the fibers
Treatment
• Apply cold modalities
• Support the joint with elastic bandages
• Encourage rest and unloading
• Elevate the limb
Rehabilitation
• Healing ligament takes 6 weeks
• Early joint mobilization is desirable
• For unstable joints, bracing will be used at3 to 6 weeks
• Early protected motion exercises isimplemented
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 3/21
3/4/20
Strain
• Are injuries that involve the stretching or tearing
of a musculo-tendinous (muscle and
tendon) structure.• An acute (instant or recent) strain of the
musculo-tendinous structure occurs at the junction where the muscle is becoming atendon. These strains take place when a muscleis stretched and suddenly contracts, as withrunning or jumping.
Strain
• This type of injury is frequently seen inrunners who strain their hamstrings. Manytimes the injury will occur suddenly whilethe runner is in full stride.
Strain
• Symptoms for an acute muscle strain
– Pain
– muscle spasm
– loss of strength
– limited range of motion
Epidemiology
• 10-30% of all sport injuries
• Muscles may be damaged by direct trauma(impact) or by indirect trauma (overloading)
• Ruptures – can be partial or total and may besubdivided into distraction and compressionruptures
• Hematomas – either inter or intramuscular types
Bursitis
• Bursa – small fluid filled sacs whose
function is to distribute stress and reducefriction
• Conditions which affect bursae areinflammatory (bursitis) or caused byimpact with subsequent bleeding
(haemobursa)
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 4/21
3/4/20
Frictional Bursitis
• Occurs in athletes who carry out repetitivemovements.
• Mechanical irritation stimulates
inflammation which in turn causes fluid tobe secreted into the bursa with resultantswelling and tenderness
Chemical bursitis
• Caused by substances formed as a resultof inflammatory or degenerativeconditions of tendons
• Associated with calcium deposits from thetendon draining into the bursa (calcificbursitis)
Septic bursitis
• Caused by bacteria entering a bursa from
the bloodstream or from the outsideenvironment through damaged skin
Haemobursa
• Usually caused by direct trauma
• It may also be caused indirectly by tendonrupture or bleeding within a joint
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 5/21
3/4/20
Treatment
• The treatment of trochanteric bursitisusually begins with simple measures and
moves to more serious treatments if simple measures fail.
• The vast majority of patients withtrochanteric bursitis will never requiresurgery.
Treatment
• Conservative
• Injection
• Surgery
• Rehabilitation
Tendinitis
• Inflammation of the tendon and its sheath(peritendinitis, tenovaginitis)
• An inflammatory reaction in a tendon and
its sheath may be initiated by repetitiveone-sided movements or by chronicmechanical irritation
Symptoms
• Tendinitis produces the following symptoms neara joint that is aggravated by movement: – Pain
– Tenderness
– Stiffness
Symptoms
• Tendinitis in various locations in your bodyproduces these specific types of pain: – Tennis elbow
– Achilles tendinitis
– Adductor tendinitis
– Patellar tendinitis
– Biceps tendinitis
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 6/21
3/4/20
Symptoms
• If the sheath of tissue that surrounds the tendonbecomes scarred and narrowed, it may cause
the tendon to lock in one position, such as in thecondition called trigger finger.
• The pain of tendinitis is usually worse withactivities that use the muscle that is attached tothe involved tendon.
Treatment
• The goals of tendinitis treatment areto relieve your pain and reduceinflammation.
• Often, simple home treatment —which includes rest, ice and over-the-counter pain relievers — is all that
you need.
Treatment
– Injected steroids.
– Strengthening exercises. People with tendinitisand tendonosis may also benefit from aprogram of specific exercise designed tostrengthen the force-absorbing capability of the muscle-tendon unit.
Treatment
– Surgery. When a tendon is torn, you mayneed a reconstructive operation to cleaninflamed tissue out of the tendon sheath or torelieve pressure on the tendon by removing
bone
Fibromyositis
• Fibromyalgia is a chronic disorder
characterized by pain throughout much of the body. The pain may begin gradually orhave a sudden onset.
• The exact cause of this disorder isunknown.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 7/21
3/4/20
· Fatigue.· Irritable bowel syndrome.· Sleep disorders.· Chronic headaches.
· Jaw pain.· Cognitive or memory impairment.· Muscle pain morning stiffness.
· Painful menstruation.· Numbness and tingling in the extremities.· Dizziness or light headedness.· Skin and chemical sensitivities.
Symptoms
• Muscle spasms
• Fatigue
• Muscle tissue stiffness
• Non- restorative (unrefreshing) sleep.
Symptoms
• Pain: The most prominent symptom of fibromyalgia ispain. Unlike arthritis, the discomfort is not in the jointsbut in the muscles and ligaments. The tenderness isworse in the mornings and has been described as flulike,burning, throbbing, aching, or stabbing.
• Fatigue: Another frequent complaint associated withfibromyalgia is fatigue. The severity of the fatigue canrange from mild to incapacitating. No amount of sleep atnight or rest during the day is helpful.
Symptoms
• Fibrofog: Another common symptom is a mentalhaziness some people call fibrofog. This refers to theinability to concentrate, memory loss, and depressionthat occurs with fibromyalgia.
• Other symptoms associated with fibromyalgia areheadaches, nervousness, numbness, dizziness, andintestinal disturbances.
Diagnosis
• According to the American College of Rheumatology, before the diagnosis of fibromyalgia can be made, the muscle pain mustbe present for longer than 3 months.
• Pain must occur at specific sites on the bodycalled tender points. There are 18 of thesesensitive spots. Most are located on the neck and back.
Treatment
• Although there is no cure for fibromyalgia, hometreatment can relieve some of the symptoms.
• The most important therapy for muscle pain isregular, low-impact exercise. Keeping musclesconditioned and healthy by exercising 3 times aweek decreases the amount of discomfort.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 8/21
3/4/20
Treatment
• Heat applied to sore muscles
• Stretching exercises
• Massage
Myosistis
• A rare disease in which the immune systemchronically inflames the body’s own healthy
muscle tissue. No one knows what triggers theimmune system’s attack.
• Persistent inflammation progressively weakensthe muscles.
• Myositis can take several forms, usually developsslowly over time and can range in severity frommild to debilitating or worse.
Symptoms
• Weakness and pain in the muscles of the hipsand shoulders is often a first sign of myositis.
• Myositis can affect the muscles in the front of the neck and throat, making it hard to speak orswallow (dysphagia).
• When it affects the lungs or chest muscles, youmay have trouble breathing.
Diagnosis
• Physical exam will probably include one ormore blood tests to look forautoantibodies and muscle enzymes suchas creatine kinase (CK).
• Other specialized tests such as anelectromyogram (EMG), which measuresthe electrical pattern of the muscles.
Forms of myositis
• Polymyositis (PM)
• Dermatomyositis (DM)
• Inclusion Body Myositis (IBM)
• Juvenile Myositis (JM)
Polymyositis (PM)
• PM inflames and weakens muscles inmany parts of the body, especially thoseclosest to the trunk (proximal). Dysphagiais common, as is fatigue and pain in the joints and muscles.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 9/21
3/4/20
Dermatomyositis (DM)
• DM inflammation damages both musclefibers and skin. Like PM, you develop
muscle weakness, pain and fatigue. Inaddition, you have a distinctive patchy,reddish rash on the eyelids, cheeks, bridgeof the nose, back or upper chest, elbows,knees and knuckles. In some cases, youmay develop hardened bumps under theskin.
Inclusion Body Myositis (IBM)
• Symptoms of IBM typically begin after age 50with very gradual weakening of muscles
throughout the body. You may developdysphagia, weak wrists or fingers and atrophy of the forearms and/or thigh muscles. Unlike otherforms of myositis, IBM occurs more often in menthan in women and, unfortunately, there are noeffective treatments known for IBM.
Juvenile Myositis (JM)
• Although some children develop juvenileforms of PM and IBM, children usually get juvenile DM with symptoms of muscleweakness, skin rash and dysphagia.
Treatment
• Medications: Corticosteroids (i.e., prednisone) andother drugs that suppress the immune system(immunosuppresants) may slow down the attack onhealthy tissue and improve skin rash.
• Exercise: After drug treatment takes effect, a programof regular stretching exercises prescribed by your doctorcan help maintain range of motion in weakened armsand legs. Physical therapy may also help preventpermanent muscle shortening.
• Rest: Getting enough rest is an important component of
managing myositis.
Wound Healing
• The past decade has seen an explosive growth
of wound healing research that promises to
facilitate clinical wound repair.
TISSUE INJURY AND
TYPES OF HEALING
• Primary intention
• Secondary intention
• Third intention
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 10/21
3/4/20
Primary intention
• Primary or first intention healing occurs in
closed wounds in which the edges are
approximated, such as a clean skin incision
closed with sutures. The incisional defect re-
epithelializes rapidly, and matrix deposition
seals the defect.
Secondary intention
• Healing occurs when the wound edges are not
apposed, such as an open punch skin biopsy
wound, a deep burn, and an infected wound
left open to granulate. Granulation tissue fills
the wound, and the wound contracts and re-
epithelializes.
Third intention
• Also called delayed primary healing
• Healing occurs when an open wound is
secondarily closed several days after injury.
Such a wound is initially left open because of
gross contamination.
Common Features
of Wound Helaing
• The formation of granulation tissue to fill the
wound space, and resurfacing with
epithelium, serosa, mucosa, endothelium, or
mesothelium.
Repair Process
• Inflammation
• Granulation
• Epithelialization
• Fibroplasia
• Contraction
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 11/21
3/4/20
Inflammation
• Inflammation is the first stage of wound
healing.
• After tissue injury, vessels immediately
constrict, thromboplastic tissue products are
exposed, and the coagulation and
complement cascades are initiated.
Inflammation
• At least three types of storage organelles
– (1) alpha granules contain growth factors such as platelet-
derived growth factor (PDGF), transforming growth factor-beta (TGF-b), and insulin-like growth factor-1 (IGF-1), aswell as adhesive glycoproteins such as fibronectin,fibrinogen, thrombospondin, and von Willebrand's factor;
– (2) dense bodies store vasoactive amines such asserotonin, which increase microvascular permeability; and
– (3) lysosomes contain hydrolases and proteases.
Inflammation
• Monocytes infiltrate later at the wound site and
differentiate into macrophages that are crucial in theorchestration of tissue repair.
• Most wound macrophages are converted monocytesthat are recruited from the circulation, but some aretissue macrophages that can proliferate locally.
• Macrophages continue to consume tissue andbacterial debris but, more important, secrete aplethora of growth factors
Granulation
• Granulation tissue is characterized by its
beefy-red appearance, a consequence of
endothelial cell division and migration to form
a rich bed of new capillary networks
(angiogenesis) at the wound site.
• Granulation is most prominent in wounds
healing by second intention.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 12/21
3/4/20
Granulation
• The initial provisional wound matrix is
composed of fibrin, fibronectin, and the
glycosaminoglycan (GAG) hyaluronic acid.
Epithelialization
• Within minutes after injury, morphologic
changes in keratinocytes at the wound margin
are evident. In skin wounds, the epidermis
thickens, and marginal basal cells enlarge and
migrate over the wound defect.
• Keratinocytes lay down laminin and Type IV
collagen as part of their basement membrane.
Epithelialization
• Cell adhesion glycoproteins such as fibronectin,
vitronectin, and tenascin provide a railroad track to
facilitate epithelial cell migration over the wound
matrix.
• Subsequent epithelial thickening and keratinization
produce fibrotic reactions, cysts, and/or sterile
abscesses centered on the suture.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 13/21
3/4/20
Fibroplasia
• Scar is defined morphologically as the lack of tissueorganization compared with surrounding normal
tissue architecture.• The initially dense capillary network and fibroblast
infiltrate regress until relatively few capillaries andfibroblasts remain.
• Wounds become stronger with time.
• The tensile strength of a skin wound increasesrapidly from 1 to 6 weeks after wounding
Fibroplasia
• Tensile strength increases at a slower pace and hasbeen documented to increase up to 1 year afterwounding in animal studies.
• The overall tensile strength of various woundedtissue varies (by 3 weeks % to normal healing) – skin obtains 30%
– fascia about 20%,
– intestine 65%,
– urinary bladder 95%.
• At best, the tensile strength of wounded skin reachesonly about 80% that of unwounded skin.
Contraction
• The destruction of soft tissue and its eventual repair
involve the migration of a number of different cell
types into the wound site, forming a new connective
tissue matrix.
• The myofibroblast is a mesenchymal cell with
functional and structural characteristics in common
with fibroblasts and smooth muscle cells.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 14/21
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 15/21
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 16/21
3/4/20
TGF-b
• The topical application of TGF-b accelerates normal
healing.
• The name TGF-b is derived from the observation thatnormal cells exposed to TGF-b while grown in soft
agar proliferate as though they had been virally
transformed.
• The mammalian TGF-b family consists of three
known isoforms—b1, b2, and b3—that are closely
related both structurally and functionally.
TGF-b
• TGF-b is released from platelets and macrophages in
the wound. In addition, TGF-b is released from
fibroblasts and acts in an autocrine manner tofurther stimulate its own synthesis and secretion.
• TGF-b stimulates the deposition of collagen and
other matrix components by fibroblasts, inhibits
collagenase, blocks plasminogen inhibitor, enhances
angiogenesis, and is chemotactic for fibroblasts,
monocytes, and macrophages.
PDGF
• Is released from platelet alpha granules immediatelyafter injury. PDGF attracts neutrophils, macrophages,and fibroblasts to the wound and serves as apowerful mitogen.
• Macrophages, endothelial cells, and fibroblasts alsosynthesize and secrete PDGF.
• PDGF stimulates fibroblasts to synthesize newextracellular matrix, predominantly noncollagenouscomponents such as GAGs and adhesion proteins.
PDGF
• PDGF also increases the amount of fibroblast-
secreted collagenase, indicating a role for this
cytokine in tissue remodeling.
aFGF and bFGF
• Angiogenesis is stimulated by acidic and basic
fibroblast growth factors
• Angiogenesis is the formation of new blood
vessels by directed endothelial cell migration
and growth. This widespread process occurs in
development, cancer, and wound healing.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 17/21
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 18/21
3/4/20
Proteoglycans
• Alterations in the synthesis of proteoglycans
(PGs) and their constituent GAGs correlate
with the cell proliferation, migration, and
collagen synthesis that accompany adult
wound healing.
Adhesion Glycoproteins
and Integrins
• As cells become mobile during wound repair.
• Specific interactions occur between them and
the extracellular matrix that allow cells todetach and migrate.
• The matrix provides the scaffolding for cellattachment and migration through variousglycoprotein components
Glycoprotein Components
• fibronectin
• tenascin
• laminin
• fibrinogen
• thrombospondin
• vitronectin
Integrins
• Cell-surface adhesion receptors
• Integrins provide a bond among a cell'scytoskeleton, its surrounding extracellularmatrix, and adjacent cells.
• Cell motility direction may be determined bythe relative integrin-ligand binding affinities of the various adhesion glycoproteins bound to aparticular cell.
Fibronectin
• Fibronectins are prominent matrix molecules
involved in wound contraction, cell migration,
collagen matrix deposition, and re-epithelialization.
• Fibronectin is one of the first proteins to be laid
down in a wound and forms part of the preliminary
matrix.
• Fibronectin acts as the scaffold for cell migration and
collagen deposition.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 19/21
3/4/20
Fibronectin
• Fibronectin is produced by fibroblasts, epithelialcells, and macrophages, and it can bind a wide
variety of molecules involved in wound healing,including collagens, actin, fibrin, HA, heparin,fibronectin itself, and cell-surface receptors onfibroblasts.
• Granulation tissue fibroblasts are coated with a layerof fibronectin matrix, and myofibroblasts are coveredwith fibronectin, which forms part of the fibronexusattachment that effects wound contraction.
CLINICAL FACTORS THAT AFFECT
WOUND HEALING
• Nutrition
• Oxygen, Anemia, and Perfusion
• Diabetes Mellitus and Obesity
• Corticosteroids, Chemotherapy, and Radiation
Therapy
• Infection
Nutrition
• Protein depletion impairs wound healing if recent weight loss exceeds 15% to 25% of body weight.
– Vitamin C is necessary for hydroxylation of prolineand lysine residues. Without hydroxyproline,newly synthesized collagen is not transported outof cells. Without hydroxylysine, collagen fibrils arenot cross-linked.
Nutrition
– Vitamin A (retinoic acid) requirements increase
during injury. Severely injured patients requiresupplemental vitamin A to maintain normal serumlevels. Vitamin A also partially reverses theimpaired healing in chronically steroid-treatedpatients.
– Vitamin B 6 (pyridoxine) deficiency impairscollagen cross-linking. Vitamin B 1 (thiamine) andvitamin B 2 (riboflavin) deficiencies causesyndromes associated with poor wound repair.
Nutrition
• Deficiencies of trace metals such as zinc and
copper have been implicated in poor wound
repair, since these divalent cations are
cofactors in many important enzymatic
reactions.
• Zinc deficiency is associated with poor
epithelialization and chronic, nonhealing
wounds.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 20/21
3/4/20
2
Oxygen, Anemia, and Perfusion
• Oxygen is required for successful inflammation,angiogenesis, epithelialization, and matrix
deposition.• Conversely, increased oxygen delivery at the wound
improves healing.
• Anemia in a normovolemic patient is not detrimentalto wound repair as long as the hematocrit is greaterthan 15%, because oxygen content in blood does notaffect wound collagen synthesis
Oxygen, Anemia, and Perfusion
• Tissue perfusion is the ultimate determinant
of wound oxygenation and nutrition.
Diabetes Mellitus and Obesity
• Wound healing is impaired in diabetic patients byunknown mechanisms.
• Healing is enhanced if glucose levels are wellcontrolled.
• Obesity interferes with repair independently of diabetes.
• Obese patients with diabetes have impaired woundhealing regardless of the degree of glucose controland insulin therapy.
Corticosteroids, Chemotherapy, and
Radiation Therapy
• Use of pharmacologic steroids impairs healing,especially when given in the first 3 days afterwounding.
• Steroids reduce wound inflammation,epithelialization, and collagen synthesis.
• Both radiation and chemotherapeutic agents havetheir greatest effects on dividing cells. The division of endothelial cells, fibroblasts, and keratinocytes isimpaired in irradiated tissue, which slows wound
healing
Corticosteroids, Chemotherapy, and
Radiation Therapy
• Irradiated tissue usually has some degree of
residual endothelial cell injury and
endarteritis, which causes atrophy, fibrosis,
and poor tissue repair.
• Chemotherapeutic agents are not
administered until at least 5 to 7 days
postoperatively to prevent impairment of the
initial healing events.
Infection
• Wound contamination by bacteria causes
clinical wound infection and delays healing if
more than 10 5 organisms per mg. tissue are
present.
8/14/2019 Physical Medicine & Rehabilitation 6of6(2)
http://slidepdf.com/reader/full/physical-medicine-rehabilitation-6of62 21/21
3/4/20
FIN
Recommended