Basics of Tissue Injury

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Basics of Tissue Injury
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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.

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STAGES OF SOFT TISSUE HEALING
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INTRODUCTION

• WHEN AN INJURY OCCURS IT MUST GO THROUGH 3
  STAGES OF HEALING

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Stage 1 Acute Inflammatory

• Increase blood flow to the area that brings cells
  and chemicals to begin the healing process.
• Phagocytes- Eat up dead cells.
• Leukocytes- Infection fighting white blood cells.
• Platelets-Carry blood clotting materials.
• Vascular changes
• Vasoconstriction immediately decreased blood
  flow to area (approx. 5-10 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)
• THIS STAGE LASTS FOR ABOUT 2 DAYS

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Phase I Acute Inflammatory Phase

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

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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
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Phase 2 Proliferation/Repair

• The injured area has been filled with the blood,
  cells, and chemicals needed to rebuild the injury
• Fibroblasts begin building fibers across the
  injury and form the scar.
• THIS PROCESS LASTS FROM 6 WEEKS TO 3 MONTHS.

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Phase II Proliferation Phase

• Repair/Regeneration Phase
• Phase will extend from 48 hours to 3 months
• Phase removes debris temporary repair SCAR
  FORMATION (fibroplasia)
• Dependent on levels of debris removal, skin cell
  production, production of fibroblasts

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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

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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

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Phase II Proliferation Phase

• Phase II Goal
• Help new tissues start to align
• Wolffs Law

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Phase 3 Remodeling

• Goal
• Builds tissue strength in the repaired/replaced
  tissue of the tendons, ligaments or muscles in
  order to withstand stress applied to the body.
• THIS STAGE TAKES UP TO A YEAR OR MORE.

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Phase III Remodeling Phase

• Usually begins _at_ 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)

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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

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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

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Factors That Impede Healing

• Extent of injury
• Edema
• Hemorrhage
• Poor Vascular Supply
• Muscle Spasm

• Atrophy
• Infection
• Health, Age, and Nutrition

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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

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Types of Tissues and their Healing

• Bone
• Severity of injury
• Soft tissue damage
• Amount of necrotic tissue
• Disruption of blood supply
• Displacement of fragments
• Open fractures disrupts blood supply, severe soft
  tissue damage
• Union v Displaced/malunion fractures
• Skeletal Muscle
• Initial bleeding followed by laying down a
  ground substance
• Healing could last 6-8 weeks depending on muscle
  injured

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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 PRICE principle

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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
• Ice causes vasoconstriction and slows down
  swelling

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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

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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

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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

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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

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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 athletes ability to perform
  rehab after surgery

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Rehab Phases

• Phase 1 Acute Inflammatory Phase
• Phase 2 Proliferation Phase
• Phase 3 - Remodeling

• Inflammation
• Mobility
• Proprioception
• Resistance
• Endurance
• Sport Specific

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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

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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

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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

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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

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CONCLUSION

• Soft tissue healing requires the tissue to go
  through 3 stages
• Acute Inflammatory
• Repair
• Remodeling