Soft tissue injuries

Soft Tissue InjuriesSoft Tissue Injuries

Rohana PereraPrincipal

School of Physiotherapy and Occupational Therapy

National Hospital of Sri Lanka


Introductioninjuries to muscles, ligaments and tendons

EpidemiologyVery common as sports injuriesCommon as injuries of RTA, domestic and work-

site accidents


Acute Injuries and Overuse Injuries• Acute injuries occur suddenly• Overuse injuries occur gradually


TerminologyRemember

Ankle sprains often injure ligaments

Back strains strain of muscles

Rotator- Cuff tears – tendon or muscle rupture

Deep bruises – haematoma formation

Injury classification

1st Degree, Grade 1 or mild injury2nd Degree, Grade 2 or moderate injury3rd Degree, Grade 3 or severe injury


1st Degree, Grade 1 or mild injury• Microscopic structural damage• Slight local tenderness


2nd Degree, Grade 2 or moderate injury• Partial rupture of tissue• Visible swelling • Notable tenderness• Do not affect joint stability


3rd Degree, Grade 3 or severe injury• Complete rupture of tissue• Significant swelling• Significant instability


Structural Damage

Symptoms

Signs


Tissue predisposition to injury


Ligament Injuries


Ligament Injuries


Ligament Injuries – DiagnosisClinical Signs and Symptoms• Brusing, swelling tenderness• Pain on movement or loading, pain on

palpation• Instability ± depending on the severity• MRI scan for confirmation of injury type


Muscle and Tendon Injuries• Muscles and tendons function together• Injury may affect the muscle’s

originbellymuscle – tendon junctiontendontendon-periosteum junction

A common injury in sports


Types of Muscle Injuries1.Strains2.Contusions


Types of Muscle InjuriesTypes of Muscle Injuries1.Strains (1st, 2nd or 3rd degree)• caused by overstretching or eccentric overload• often at the muscle – tendon junction• occur as a result of the intrinsic force generated by

the muscle during the change between eccentric and concentric traction; either in rapid acceleration or deceleration actions or combinations of acceleration and deceleration.


Types of Muscle InjuriesTypes of Muscle Injuries1.Strains (Clinical features)

1ST degree strains– Minimum strength loss and movement restriction– Pain around the damaged area on active movement or passive

stretch – In the case of an athlete it can be as distressing as a more severe

injury


Types of Muscle InjuriesTypes of Muscle Injuries1.Strains (Clinical features)

2nd and 3rd degree strains– More significant functional loss – Pain will be aggravated by any attempt to contract the muscle– Defects may be palpable– In 3rd degree the muscle may bunch up resembling a tumour


Types of Muscle InjuriesTypes of Muscle Injuries1.Strains (Diagnosis)

– History suggesting acceleration / deceleration– Sharp pain felt at the moment of injury– Pain ↓with rest and ↑ or reproduced by attempted contraction – Palpable defects on superficial muscles– Local tenderness and swelling– Loss of active movement – Bruising after 24 hrs with spasm


Types of Muscle Injuries2.Contusions• Caused by direct blow on a muscle• The muscle is pressed against the bone• The muscle tears; heavy bleeding* deep within

muscle → Muscular haematoma* bleeding directly proportional to muscle blood flow and inversely

proportional to the tension of the muscle at the time of injury


Types of Muscle InjuriesTypes of Muscle Injuries2. Contusions (Clinical features)• Depend upon the size and site of haematoma produced• When superficial

– Same as in strains

• Intramuscular heamatoma– Bleeding is within the fascia covering the muscle– The intramuscular pressure builds up and counteract further bleeding– Resultant swelling lasts > 48hrs, accompanied tenderness, pain,

impaired mobility– Swelling tends to increase due to osmosis.


Types of Muscle InjuriesTypes of Muscle Injuries2.2. Contusions Contusions (Clinical features)(Clinical features)• Intermuscular heamatoma

– Damage includes facia and adjacent blood vessels– Bleeding occurring between muscles– No pressure building up as in intramuscular type– Bruising and swelling appear distally to damage area within

24- 48 hrs.– Muscle function returns – Prognosis is better than intramuscular type


Tendon Injuries• Acute injuries to tendons

– classified according to 1st ,2nd and 3rd degree– are common in sports; superficial tendons are susceptible to

penetrating trauma – caused by rapid acceleration / deceleration– usually occur in connection with eccentric force generation– mid-tendon substance, muscle-tendon junction or avulsion

fractures – Injured tendons may have had a predisposition to injury due to

overuse or disease


Tendon InjuriesTendon Injuries• Tendons are most susceptible to overuse injury

– Tendinitis (tendon inflammation)– Tenosynovitis (tendon sheath inflammation)– Tenoperiostitis (tendon attachments’ inflammation)


Tendon Injuries (Diagnosis)• History suggesting acute or overuse types• Clinical examination to evaluate continuity• US or MRI scans → precise diagnosis


Treatment PrinciplesCommon to all acute injuries are internal bleeding and likely

acute inflammation. Therefore:• prevent bleeding and pain as first aid by following PRICE

principleP - ProtectionR - RestI – Ice for coolingC – CompressionE - Elevation




Treatment of Ligament Injuries• PRICE immediate administration and contd. up to

2 – 3 days• The doctor’s role:

– determine the stability– exclude possible #; establish diagnosis (type of injury)– if the joint is stable →

• early mobilisation• supportive taping or orthosis• rehabilitation

– if the joint is unstable →• decide whether opn necessary; • protection and rehabilitation


Treatment of Ligament InjuriesTreatment of Ligament Injuries• Rehabilitation (aim to:)

– identify any predisposing cause with a view to remove it– prevent adhesion formation– strengthen muscles related to the ligament– re-educate proprioception– restore full mobility of the ligament and corresponding

joint– restore patient’s confidence– restore full functional activity


Treatment of Ligament InjuriesTreatment of Ligament Injuries• Rehabilitation

(time frame for ankle joint) PRICE

Taping /splintingStatic cycle / Theraband activity for antagonist groups

Close-kinematic exs; wobbloboard activity while seated

Gradual incease of loading Wobble board

switch on to functional

activity


WEEKS 1 2 3 4 5 6 11 12





Treatment of Acute Muscle Injury• Immediately start PRICE; be strict on P, R and E up to

36 hrs• No massaging the hurt muscle within 48 -72 hrs.• Close observation for possible compartment

syndrome– Decreasing swelling and rapid recovery of function may be expected in

intermuscular bleeding– Persistent or increasing swelling with poor function suggest

intramuscular bleeding


Treatment of Acute Muscle InjuryTreatment of Acute Muscle Injury• It is important that the accurate diagnosis is made

within 48 – 72 hrs. premature exercising

– ↑bleeding in intramuscular haematoma situation– ↑bleeding and scar tissue formation complicating the

injury and delaying recovery


Treatment of Acute Muscle InjuryTreatment of Acute Muscle InjuryAfter initial acute treatment:

1. Gr 1 and 2 strains, intermuscular haematomas and minor intramuscular haematomas are treated with• Elastic support bandage• Local application of heat, contrast treatment with heat and cold• Exercises are started after 2-5 days rest; progression as follows:

– Static without load → with load →free dynamic → PRE →stretches →Proprioceptive training → functional / sport specific training

2. Gr 3 strains and severe intramuscular haematomas demand surgical intervention or conservative treatment over a prolonged period


Treatment of Acute Tendon Injury• PRICE as in all other injuries administered initially• A wide range of approaches to management based

on tendon damaged, age, the degree of disability and handicap etc. Theoretically all severed tendons need to be sutured to restore continuity and allowed to heal.

• Early (within 2 weeks) mobilisation favours functional recovery.


Treatment of Acute Tendon Injury• PRICE as in all other injuries administered initially• A wide range of approaches to management based

on tendon damaged, age, the degree of disability and handicap etc. Theoretically all severed tendons need to be sutured to restore continuity and allowed to heal.

• Early (within 2 weeks) mobilisation favours functional recovery.


Soft tissue injuries

Healthcare