Basics of Tissue InjuryBasics of Tissue Injury

Sports Medicine Injuries Learning TargetsUnit 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 impede healing. I can describe the importance of controlling swelling

and the PRICE principle. I can explain the goals of rehabilitation for each Phase

of healing.

INTRODUCTIONINTRODUCTION

WHEN AN WHEN AN INJURY INJURY

OCCURS IT OCCURS IT MUST GO MUST GO

THROUGH 3 THROUGH 3 STAGES OF STAGES OF HEALINGHEALING

Stage 1: Acute Stage 1: Acute InflammatoryInflammatory Increase blood flow to the area that brings cells and chemicals to begin the healing process.Increase blood flow to the area that brings cells and chemicals to begin the healing process.

Phagocytes- Eat up dead cells.Phagocytes- Eat up dead cells. Leukocytes- Infection fighting white blood cells.Leukocytes- Infection fighting white blood cells. Platelets-Carry blood clotting materials.Platelets-Carry blood clotting materials.

Vascular changesVascular changes– VasoconstrictionVasoconstriction – immediately; – immediately; decreased blood flow to area (approx. 5-10 mins.); platelet plug decreased blood flow to area (approx. 5-10 mins.); platelet plug

formed; blood coagulation; produces local anemiaformed; blood coagulation; produces local anemia– VasodilationVasodilation – increased blood flow; increased hydrostatic pressure in blood vessels ( – increased blood flow; increased hydrostatic pressure in blood vessels ( capillary capillary

permeability, plasma proteins leak out; proteins attract Hpermeability, plasma proteins leak out; proteins attract H22O = edema)O = edema)

THIS STAGE LASTS FOR ABOUT 2 DAYSTHIS STAGE LASTS FOR ABOUT 2 DAYS

Phase I: Acute Inflammatory Phase I: Acute Inflammatory PhasePhase

Goal Goal – Protect, Protect, – Localize, Localize, – Decrease injurious agents, Decrease injurious agents, – Prepare for healing and repairPrepare for healing and repair

Cardinal Signs of Cardinal Signs of InflammationInflammation

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. endingsChemical irritants – bradykinin, histamine, prostaglandin

Increased pain/ swelling

Phase 2: Phase 2: Proliferation/RepairProliferation/Repair

The injured area has The injured area has been filled with the been filled with the blood, cells, and blood, cells, and chemicals needed chemicals needed to rebuild the injuryto rebuild the injury– Fibroblasts begin Fibroblasts begin

building fibers across building fibers across the injury and form the injury and form the scar.the scar.

THIS PROCESS LASTS THIS PROCESS LASTS FROM 6 WEEKS TO 3 FROM 6 WEEKS TO 3

MONTHS.MONTHS.

Phase II: Proliferation PhasePhase II: Proliferation Phase

““Repair/Regeneration” PhaseRepair/Regeneration” Phase Phase will extend from 48 hours to 3 Phase will extend from 48 hours to 3

monthsmonths Phase removes debris & temporary Phase removes debris & temporary

repair – SCAR FORMATION repair – SCAR FORMATION (fibroplasia)(fibroplasia)

Dependent on levels of: debris removal, Dependent on levels of: debris removal, skin cell production, production of skin cell production, production of fibroblastsfibroblasts

Phase II: Proliferation PhasePhase II: Proliferation Phase

Repaired through 3 phasesRepaired through 3 phases– ResolutionResolution - dead cells & cellular debris - dead cells & cellular debris

are removed (tissue left with original are removed (tissue left with original structure & function in tact)structure & function in tact) fibroblast (tissue cells) formationfibroblast (tissue cells) formation tissue remodeling tissue remodeling

Phase II: Proliferation Phase II: Proliferation PhasePhase

– RegenerationRegeneration – damaged tissue is – damaged tissue is replaced by cells of the same type replaced by cells of the same type (structure retains some or all of its (structure retains some or all of its original structure & function)original structure & function) synthesis of collagen (fencing)synthesis of collagen (fencing)

– RepairRepair – original tissue is replaced – original tissue is replaced with scar tissue (original structure & with scar tissue (original structure & function is lost)function is lost) tissue alignmenttissue alignment

Phase II: Proliferation Phase II: Proliferation PhasePhase Phase II GoalPhase II Goal

– Help new tissues start to alignHelp new tissues start to align Wolff’s LawWolff’s Law

Phase 3: RemodelingPhase 3: Remodeling

GoalGoal– Builds tissue strength in the Builds tissue strength in the

repaired/replaced tissue of the repaired/replaced tissue of the tendons, ligaments or muscles in order tendons, ligaments or muscles in order to withstand stress applied to the to withstand stress applied to the body. body.

THIS STAGE TAKES UP TO A YEAR OR THIS STAGE TAKES UP TO A YEAR OR MORE.MORE.

Phase III: Remodeling PhasePhase III: Remodeling Phase Usually begins @ week 3Usually begins @ week 3 Purpose is to increase strength of Purpose is to increase strength of

repaired/replaced tissuesrepaired/replaced tissues– First 3-6 weeks involves laying down of First 3-6 weeks involves laying down of

collagen and strengthening of fiberscollagen and strengthening of fibers– 3 months to 2 years allowed for enhanced 3 months to 2 years allowed for enhanced

scar tissue strengthscar tissue strength Balance must be maintained between Balance must be maintained between

synthesis & lysissynthesis & lysis– Build up (synthesis) and break down (lysis)Build up (synthesis) and break down (lysis)

Phase III: Remodeling Phase III: Remodeling PhasePhase

Take into consideration Take into consideration – forces applied, forces applied, – immobilization time frames relative immobilization time frames relative

to tissueto tissue– healing time healing time

Scars fade & eventually return to Scars fade & eventually return to near normal colornear normal color

Modifying Soft-Tissue Modifying Soft-Tissue HealingHealing

Varying issues exist for all soft tissues Varying issues exist for all soft tissues relative to healing (cartilage, muscle, relative to healing (cartilage, muscle, nerves)nerves)

Blood supply and nutrients is necessary Blood supply and nutrients is necessary for all healingfor all healing

Healing in older athletes or those with Healing in older athletes or those with poor diets may take longerpoor diets may take longer

Certain organic disorders (blood Certain organic disorders (blood conditions) may slow or inhibit the conditions) may slow or inhibit the healing processhealing process

Factors That Impede Factors That Impede HealingHealing

Extent of Extent of injuryinjury

EdemaEdema HemorrhageHemorrhage Poor Vascular Poor Vascular

SupplySupply Muscle SpasmMuscle Spasm

AtrophyAtrophy InfectionInfection Health, Age, Health, Age,

and Nutritionand Nutrition

Types of Tissues and their Types of Tissues and their HealingHealing

CartilageCartilage Limited capacity to healLimited capacity to heal Little or no direct blood supplyLittle or no direct blood supply Articular cartilage that fails to clot heals Articular cartilage that fails to clot heals

very slowlyvery slowlyLigaments/ TendonsLigaments/ Tendons Long full healing process (12 months)Long full healing process (12 months) Decent blood supplyDecent blood supply Requires a lot of collagen being laid Requires a lot of collagen being laid

downdown

Types of Tissues and their Types of Tissues and their HealingHealing

BoneBone– Severity of injurySeverity of injury

Soft tissue damageSoft tissue damage Amount of necrotic tissueAmount of necrotic tissue Disruption of blood supplyDisruption of blood supply Displacement of fragmentsDisplacement of fragments

– Open fractures disrupts blood supply, severe soft tissue damageOpen fractures disrupts blood supply, severe soft tissue damage– Union v Displaced/malunion fracturesUnion v Displaced/malunion fractures

Skeletal MuscleSkeletal Muscle– Initial bleeding followed by laying down a Initial bleeding followed by laying down a

ground substance ground substance – Healing could last 6-8 weeks depending on Healing could last 6-8 weeks depending on

muscle injuredmuscle injured

Importance of Controlling Importance of Controlling SwellingSwelling Initial injury management an swelling Initial injury management an swelling

control is criticalcontrol is critical Swelling can result in increased pressure Swelling can result in increased pressure

to the injured area, causing pain and to the injured area, causing pain and altered neuromuscular functionaltered neuromuscular function

Swelling slows the healing process and Swelling slows the healing process and normal function is not regained until normal function is not regained until swelling is eliminatedswelling is eliminated

To limit swelling use the PRICE principleTo limit swelling use the PRICE principle

Importance of Controlling Importance of Controlling SwellingSwelling

Protection & IceProtection & Ice– Protect the injury Protect the injury

from further damagefrom further damage– Splint, wrap, Splint, wrap,

immobilize the immobilize the injured siteinjured site

– If the lower If the lower extremity is extremity is involved, crutches involved, crutches should be suppliedshould be supplied

– Ice causes Ice causes vasoconstriction and vasoconstriction and slows down swellingslows down swelling

Importance of Controlling Importance of Controlling SwellingSwelling

Restricted Activity (Rest)Restricted Activity (Rest)– Healing immediately begins after injuryHealing immediately begins after injury– Without rest, external stresses are still placed Without rest, external stresses are still placed

on the injured area, interfering with the on the injured area, interfering with the healing process- prolonging recoveryhealing process- prolonging recovery

– Controlled mobility is superior to Controlled mobility is superior to immobilizationimmobilization

– 24-48 hours of rest should be applied prior to 24-48 hours of rest should be applied prior to active rehabilitation – active rehabilitation – depends on severitydepends on severity

– Rest applies to the injured body part – Rest applies to the injured body part – cardiovascular fitness, strengthening and cardiovascular fitness, strengthening and flexibility should be maintained flexibility should be maintained

Importance of Controlling Importance of Controlling SwellingSwelling

CompressionCompression– Single most important factor in swelling controlSingle most important factor in swelling control– Mechanically reduces space available for Mechanically reduces space available for

swelling accumulationswelling accumulation– Using an elastic wrap, firm, evenly applied Using an elastic wrap, firm, evenly applied

pressure can be achievedpressure can be achieved– Compression should be maintained Compression should be maintained

continuously for 72 hours – continuously for 72 hours – depends on depends on severityseverity

– With chronic inflammatory conditions With chronic inflammatory conditions compression should be applied until the compression should be applied until the swelling is almost entirely goneswelling is almost entirely gone

Importance of Controlling Importance of Controlling SwellingSwelling

ElevationElevation– Used to eliminate the effects of gravity on Used to eliminate the effects of gravity on

blood poolingblood pooling– Assists venous and lymphatic drainage of Assists venous and lymphatic drainage of

blood and other fluids from the injured blood and other fluids from the injured areaarea

– Elevation should occur as often as possible Elevation should occur as often as possible during the first 72 hours of the acute injury during the first 72 hours of the acute injury – – depends on severitydepends on severity

Grades of Sprains/StrainsGrades of Sprains/Strains

Grade I – some pain, minimal loss Grade I – some pain, minimal loss of function, no abnormal function, of function, no abnormal function, & mild point tenderness& mild point tenderness

Grade II – pain, moderate loss of Grade II – pain, moderate loss of function, swelling & instabilityfunction, swelling & instability

Grade III – extremely painful, Grade III – extremely painful, inevitable loss of function, inevitable loss of function, swellingswelling

Managing the Healing Managing the Healing Process through Process through RehabilitationRehabilitation Pre-surgical Phase: Pre-surgical Phase:

– If surgery can be delayed, exercise If surgery can be delayed, exercise may help to improve outcomemay help to improve outcome

– Maintaining or improving ROM, Maintaining or improving ROM, strength, cardiovascular fitness, strength, cardiovascular fitness, neuromuscular control may enhance neuromuscular control may enhance the athlete’s ability to perform rehab the athlete’s ability to perform rehab after surgeryafter surgery

Rehab PhasesRehab Phases

Phase 1 – Acute Phase 1 – Acute Inflammatory Inflammatory PhasePhase

Phase 2 – Phase 2 – Proliferation PhaseProliferation Phase

Phase 3 - Phase 3 - RemodelingRemodeling

IInflammationnflammation MMobilityobility PProprioceptionroprioception RResistanceesistance EEndurancendurance SSport port SSpecificpecific

Managing the Healing Managing the Healing Process through Process through RehabilitationRehabilitation Phase I: Acute Inflammatory PhasePhase I: Acute Inflammatory Phase

– Initial swelling management & pain control Initial swelling management & pain control are crucialare crucial

PRICEPRICE If you are too aggressive in the 1If you are too aggressive in the 1stst 48 hours the 48 hours the

inflammatory process may not have time to inflammatory process may not have time to accomplish what it needs toaccomplish what it needs to

By days 3-4 some mobility exercises By days 3-4 some mobility exercises should be performed along with gradual should be performed along with gradual increase of weight bearing statusincrease of weight bearing status

Use of NSAIDsUse of NSAIDs

Managing the Healing Managing the Healing Process through Process through RehabilitationRehabilitation

Phase II: Fibroblastic Phase: Phase II: Fibroblastic Phase: As inflammatory phase begins to subside As inflammatory phase begins to subside

& pain decreases with PROM, add& pain decreases with PROM, add– Cardiorespiratory fitnessCardiorespiratory fitness– Restore full ROMRestore full ROM– Restore or increase strengthRestore or increase strength– Re-establish neuromuscular controlRe-establish neuromuscular control

Continued use of modalities for pain Continued use of modalities for pain controlcontrol

Managing the Healing Managing the Healing Process through Process through RehabilitationRehabilitation

Phase III: Remodeling Phase:Phase III: Remodeling Phase: Longest phase with the ultimate goal of Longest phase with the ultimate goal of

returning to activityreturning to activity– Continued collagen realignmentContinued collagen realignment– Pain continues to decreasePain continues to decrease

Regain sports-specific skillsRegain sports-specific skills– Dynamic functional activitiesDynamic functional activities– Sports-directed strengthening activitiesSports-directed strengthening activities– Plyometric strengtheningPlyometric strengthening

Functional testingFunctional testing– Determine specific skill weaknessDetermine specific skill weakness

Pain ManagementPain Management

Reduce pain!Reduce pain! Control acute pain!Control acute pain! Protect the patient from further injury Protect the patient from further injury

while encouraging progressive exercisewhile encouraging progressive exercise Minimize further tissue damageMinimize further tissue damage Encourage psychological interaction Encourage psychological interaction

(positive thinking, etc.)(positive thinking, etc.) MedicationsMedications Communication with athleteCommunication with athlete Use of modalities to reduce painUse of modalities to reduce pain

CONCLUSIONCONCLUSION

Soft tissue healing requires the Soft tissue healing requires the tissue to go through 3 stages: tissue to go through 3 stages:

Acute InflammatoryAcute Inflammatory Repair Repair

RemodelingRemodeling