Tissue Response to Injury

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. endingsChemical irritants – bradykinin, histamine, prostaglandin

Increased pain/ swelling

Three Phases of Healing

Phase I: Acute Inflammatory Phase

Phase II: Proliferation/Fibroblastic/ Repair/Regeneration Phase

Phase III: Remodeling/ Maturation Phase

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

Acute Inflammatory Response

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)

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

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

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

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

Phase III: Remodeling Phase Usually begins @ 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)

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

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

Factors That Impede Healing

Extent of injury

Edema Hemorrhage Poor Vascular

Supply Muscle Spasm

Atrophy Infection Health, Age,

and Nutrition

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

down

Skeletal Muscle Healing Initial bleeding followed by laying down a

ground substance Healing could last 6-8 weeks depending on

muscle injured

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

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

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

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

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

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

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

Rehab Phases Phase 1 – Acute

Inflammatory Phase

Phase 2 – Proliferation Phase

Phase 3 - Remodeling

Inflammation Mobility Proprioception Resistance Endurance Sport Specific

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

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

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

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