SOFT TİSSUE PAİN Prof. Dr. Ece AYDOĞ Physical Medicine and Rehabilitation.

SOFT TİSSUE PAİNSOFT TİSSUE PAİN

Prof. Dr. Ece AYDOĞ Prof. Dr. Ece AYDOĞ

Physical Medicine and Physical Medicine and RehabilitationRehabilitation

SOFT TİSSUESOFT TİSSUE

LigamentLigament TendonTendon MuscleMuscle CartilageCartilage FasciaFascia SynoviumSynovium Articular cartilageArticular cartilage Adipose tissueAdipose tissue Intervertebral discIntervertebral disc

MechanismMechanism

Soft tissues are susceptible to failure Soft tissues are susceptible to failure under conditions of stress and strain.under conditions of stress and strain.

The most common mechanism of The most common mechanism of injury include:injury include:– acute traumaacute trauma; sudden overloading; sudden overloading– repetetive overuserepetetive overuse or overload; or overload;

Acute injuriesAcute injuries Sudden onsetSudden onset Classic Classic

inflammatory inflammatory reactionreaction

ResolutionResolution

Chronic injuriesChronic injuries Insidious onset of Insidious onset of

pain pain Less intense Less intense

inflammationinflammation Progressive Progressive

functional functional impairmentsimpairments

Tendency toward Tendency toward reinjuryreinjury

soft tissue healingsoft tissue healing

Cellular response to injuryCellular response to injury Repair and regeneration; immature Repair and regeneration; immature

collagen is laid downcollagen is laid down Scar remodeling; continue for yearsScar remodeling; continue for years

Succesful healing of soft tissuesSuccesful healing of soft tissues

Type of injuryType of injury AgeAge VascularityVascularity NutritionNutrition Genetic and hormonal factorsGenetic and hormonal factors Activity levelActivity level

Overuse InjuriesOveruse Injuries

Intrinsic variablesIntrinsic variables

AgeAge Flexibility imbalanceFlexibility imbalance Muscle imbalance/weaknessMuscle imbalance/weakness Anatomic malalignmentAnatomic malalignment Genetic predispositionGenetic predisposition

Ekstrinsic variablesEkstrinsic variables Training errors/poor Training errors/poor

techniquetechnique Enviromental factorsEnviromental factors Equipment factorsEquipment factors

Ligament sprainsLigament sprainsFirst DegreeFirst Degree

Signs and SymptomsSigns and Symptoms Minimal pain and Minimal pain and

swellingswelling No ligamentous No ligamentous

instabilityinstability Minimal localized Minimal localized

tendernesstenderness

Functional Functional ImplicationsImplications

No significant loss No significant loss of functionof function

Bracing often Bracing often unnecessaryunnecessary

Rapid return to Rapid return to activityactivity

Ligament sprainsLigament sprainsSecond DegreeSecond Degree

Signs and SymptomsSigns and Symptoms Significant pain Significant pain

and swellingand swelling Subtle structural Subtle structural

instabilityinstability Occasional joint Occasional joint

effusioneffusion

Functional Functional ImplicationsImplications

Protective bracing Protective bracing indicatedindicated

Significant activity Significant activity limitationslimitations

Susceptible to Susceptible to recurrencerecurrence

Ligament sprainsLigament sprainsThird DegreeThird Degree

Signs and SymptomsSigns and Symptoms Marked swelling Marked swelling

and hemarthrosisand hemarthrosis Structural Structural

instabilityinstability

Functional Functional ImplicationsImplications

Immobilization Immobilization indicatedindicated

Surgery may be Surgery may be requiredrequired

Prolonged Prolonged functional functional limitationlimitation

Tendon InjuriesTendon Injuries Paratenonitis or/Paratenonitis or/ TenosynovitisTenosynovitis

TendinitisTendinitis

TendinosisTendinosis

InflammationInflammation of the paratenon of the paratenon withwith

associated pain, swelling, andassociated pain, swelling, and

tendernesstenderness

Inflammation of the tendon Inflammation of the tendon withwith

associated vascular distruption andassociated vascular distruption and

inflammationinflammation

Intratendinous athrophy andIntratendinous athrophy and

degenerationdegeneration with a with a relative absencerelative absence

of inflammationof inflammation; a palpable nodule; a palpable nodule

may be present over tendonmay be present over tendon

Tendon InjuriesTendon Injuries

Paratenonitis with Paratenonitis with tendinosistendinosis

Partial or complet Partial or complet rupturerupture

Acute inflammationAcute inflammation

superimposed onsuperimposed on

chronic tendinitischronic tendinitis

Acute inflammation isAcute inflammation is

often superimposed onoften superimposed on

chronic inflammationchronic inflammation

with tendinosiswith tendinosis

Tendon Injuries: Functional ScaleTendon Injuries: Functional Scale

GradeGrade11

22

33

44

55

SymptomsSymptomsPain after exercise, subsiding within 24 hoursPain after exercise, subsiding within 24 hours

Minimal discomfort with exercise, withoutMinimal discomfort with exercise, without

activity limitationactivity limitation

Pain that interferes with exercisePain that interferes with exercise

Pain interfering with activities Pain interfering with activities

Rest pain that interfering with sleepRest pain that interfering with sleep

Muscular InjuriesMuscular Injuries

ContusionsContusions StrainsStrains AvulsionsAvulsions Delayed-onset muscle soreness Delayed-onset muscle soreness

(DOMS)(DOMS)

Muscular InjuriesMuscular Injuries Contusions:Contusions:Mild, moderate, severeMild, moderate, severe

– Soft tissue swellingSoft tissue swelling– Motion restrictionMotion restriction– Functional impairmentFunctional impairment

Strains:Strains:– result from result from overstreching or peak contractionoverstreching or peak contraction of the musculotendinous of the musculotendinous

unit, paticularly unit, paticularly during eccentric muscular contractionsduring eccentric muscular contractions– tend to occur more commonly at the tend to occur more commonly at the musculotendinous junctionmusculotendinous junction– The The injured muscle generatesinjured muscle generates reduced peak tensile loads and reduced peak tensile loads and

contractile forces, contractile forces, up to 50 % of its strengthup to 50 % of its strength– Contractile forces begin to recover as soon as Contractile forces begin to recover as soon as 1 week after1 week after an acute an acute

strainstrain– There is often There is often prolongedprolonged and sometimes and sometimes permanent losspermanent loss of complete of complete

contractile abilitycontractile ability– Premature return to activity may increase the risk for further injuryPremature return to activity may increase the risk for further injury

AvulsionsAvulsions Delayed-onset muscle soreness Delayed-onset muscle soreness (DOMS)(DOMS)

DOMSDOMS

occurs within the first 24 to 48 hours after occurs within the first 24 to 48 hours after an intense bout of exercise (often an intense bout of exercise (often repeated eccentric muscular contractions)repeated eccentric muscular contractions)

both inflammatory and metabolic both inflammatory and metabolic mechanismmechanism

self limitingself limiting occasionaly requires activity modification occasionaly requires activity modification

and antiinflammatory medicationand antiinflammatory medication

Rehabilitation of Soft-Tissue Rehabilitation of Soft-Tissue InjuriesInjuries

Prescribe activity-spesific trainingPrescribe activity-spesific training Correct functional deficienciesCorrect functional deficiencies Improve strength, flexibility, general Improve strength, flexibility, general

conditioningconditioning Address structural deficiencies Address structural deficiencies Promote healingPromote healing Control pain and inflammationControl pain and inflammation Establish correct diagnosisEstablish correct diagnosis

BursitisBursitis Subacromial Subacromial

(subdeltoid) bursitis:(subdeltoid) bursitis: Close relationship between Close relationship between

the subacromial bursa and the subacromial bursa and rotator cuffrotator cuff

Frequently used when Frequently used when describing the pathology of describing the pathology of impingementimpingement

Reactive phenomenaReactive phenomena

Acute traumatic bursitisAcute traumatic bursitis

Olecranon bursitisOlecranon bursitis Recurren elbow Recurren elbow traumatrauma:work :work

or leisure activitiesor leisure activities

InflammationInflammation; gout, RA; gout, RA

InfectionInfection

Treatment:Treatment:– AspirationAspiration– Rest, elbow protection and Rest, elbow protection and

NSAII drugsNSAII drugs– Corticosteroid injection (RA Corticosteroid injection (RA

and gout)and gout)– Antibiotic therapy for Antibiotic therapy for

infectioninfection– SurgerySurgery

Trochanteric bursitisTrochanteric bursitis Most common cause of pain Most common cause of pain

about the hip regionabout the hip region

Pain decreases at rest, Pain decreases at rest, worse at nigth, especially worse at nigth, especially lying on the affected sidelying on the affected side

Treatment:Treatment:– RestRest– Abductor and iliotibial band Abductor and iliotibial band

strechingstreching– NSAİDsNSAİDs– Infiltration of a local Infiltration of a local

anesthetics and anesthetics and corticosteroidscorticosteroids

– SurgerySurgery

Prepatellar bursitisPrepatellar bursitis

"housemaid's "housemaid's knee"knee"

Anserine bursitisAnserine bursitis

Overuse of the hamstringsOveruse of the hamstrings, , especially in especially in athletes(runners) with tight athletes(runners) with tight hamstrings is a common hamstrings is a common cause of goosefootcause of goosefoot

TraumaTrauma OsteoarthritisOsteoarthritis

Treatment:Treatment:– reducing Inflammation reducing Inflammation  – hamstring stretcheshamstring stretches    – quadriceps quadriceps

strengtheningstrengthening– InjectionInjection– surgerysurgery

Biceps Biceps tenosynovitisi:tenosynovitisi:

Yergason's supination sign

Speed test

Treatment:– rest, analgesics, rest, analgesics,

NSAIDs, and local NSAIDs, and local injection of injection of glucocorticoids. glucocorticoids.

Supraspinatus tendinitis Supraspinatus tendinitis (painful arc syndrome):(painful arc syndrome):

often associated with often associated with shoulder impingement syndrome. .

inflammation of the inflammation of the supraspinatus/rotator supraspinatus/rotator cuff tendon and/or the cuff tendon and/or the contiguous contiguous peritendinous soft peritendinous soft tissuestissues

Supraspinatus tendinitisSupraspinatus tendinitis

injury, overuse, or injury, overuse, or with aging as the with aging as the tendon loses elasticity tendon loses elasticity

TreatmentTreatment– relieve pain and reduce relieve pain and reduce

inflammationinflammation– flexibility training and flexibility training and

strengthening exercisesstrengthening exercises– injectioninjection

Infrapatellar tendinitisInfrapatellar tendinitisJumpers KneeJumpers Knee

Overuse injuryOveruse injury and is often and is often associated with jumpingassociated with jumping

Tenderness at the tibial Tenderness at the tibial tubercletubercle or at the or at the inferior inferior pole of the patellapole of the patella

Rupture of the patella Rupture of the patella tendontendon usually occurs in usually occurs in patients younger than 40 patients younger than 40 years old and is associated years old and is associated with chronic patella with chronic patella tendinitistendinitis– Patients usually present Patients usually present

with with anterior knee painanterior knee pain and the and the inability to extend inability to extend the knee.the knee.

Aschilles TendinitisAschilles Tendinitis The Achilles tendon is The Achilles tendon is

the largest tendon in the largest tendon in the human body the human body

The The most frequentlymost frequently ruptured ruptured tendontendon

Achilles tendonitisAchilles tendonitis, a , a common common overuse overuse injuryinjury and and inflammationinflammation of the of the tendon. tendon.

EnthesopatiesEnthesopaties

Lateral epicondylitis Lateral epicondylitis ((tennis elbow):tennis elbow):

commonly caused by commonly caused by inflammation of the inflammation of the extensor carpi radialis extensor carpi radialis brevis tendonbrevis tendon at  at 

the outer edge of the the outer edge of the elbowelbow

caused by overusing caused by overusing the forearm extensor the forearm extensor muscles muscles

Medial Medial epicondylitis epicondylitis (Golfer elbow):(Golfer elbow):

Brachialis Brachialis Brachioradialis Brachioradialis Pronator teresPronator teres

Flexor carpi radialisFlexor carpi radialis– help to flex and help to flex and

pronate wrist and pronate wrist and fingersfingers

Overuse injuryOveruse injury

Lateral epicondylitisLateral epicondylitis Medial epicondylitis Medial epicondylitis

Treatment:Treatment:– ice, ice, – rest, rest, – NSAIDs, NSAIDs, – compression, compression, – streching, streching, – strength exercise,strength exercise,– corticosteroid corticosteroid

injection,injection,– surgery surgery

Myofascial Pain Syndrome (MPS)Myofascial Pain Syndrome (MPS)

Myofascial pain is a chronic condition that Myofascial pain is a chronic condition that affects the muscle and fasciaaffects the muscle and fascia– involve either a single muscle or a muscle involve either a single muscle or a muscle

group group

– pain usually originatespain usually originates in specific areas of the in specific areas of the body, called myofascial body, called myofascial trigger pointstrigger points (TrPs) (TrPs)

– these trigger points commonly develop these trigger points commonly develop throughout the body, typically where the fascia throughout the body, typically where the fascia comes into contact with a musclecomes into contact with a muscle

Myofascial Pain SyndromeMyofascial Pain Syndrome

– nonprogressive nonprogressive – nondegenerativenondegenerative– noninflammatorynoninflammatory

It is caused by the activation of one or more trigger It is caused by the activation of one or more trigger pointspoints

Majority of these people will not develop severe Majority of these people will not develop severe symptoms and will be able to continue on with their symptoms and will be able to continue on with their normal routinesnormal routines

However, about 14% of the population will develop However, about 14% of the population will develop a chronic form of the syndrome, resulting in a chronic form of the syndrome, resulting in persistent pain and discomfortpersistent pain and discomfort

Myofascial Pain SyndromeMyofascial Pain Syndrome

Myofascial pain disorder is very common in Myofascial pain disorder is very common in fibromyalgia sufferersfibromyalgia sufferers

It was once thought that myofascial pain It was once thought that myofascial pain syndrome was actually a kind of fibromyalgiasyndrome was actually a kind of fibromyalgia

However, this is now known not to be the caseHowever, this is now known not to be the case

It is possible to have both fibromyalgia and It is possible to have both fibromyalgia and chronic myofascial syndrome chronic myofascial syndrome

Aggravating FactorsAggravating Factors

Poor posturePoor posture and body mechanics and body mechanics

Repetitious exercisesRepetitious exercises or work or work Anything that restricts movement or Anything that restricts movement or decreases decreases

oxygen supply to the musclesoxygen supply to the muscles

PPerpetuating erpetuating FFactorsactors

Impaired sleepImpaired sleep Chewing gum Chewing gum Smoking cigarettesSmoking cigarettes Dental workDental work Exposure to organic chemicals or heavy metals Exposure to organic chemicals or heavy metals İnhalant and food allergiesİnhalant and food allergies Nutritional deficienciesNutritional deficiencies Metabolic and endocrine dysfunctionMetabolic and endocrine dysfunction Malabsorptive conditions in the gutMalabsorptive conditions in the gut Chronic infectionsChronic infections FibromyalgiaFibromyalgia Alcohol ingestionAlcohol ingestion Stress (physical and/or mental)Stress (physical and/or mental)

Signs and symptoms of myofascial Signs and symptoms of myofascial pain syndrome may include: pain syndrome may include:

Deep, aching pain in a Deep, aching pain in a musclemuscle

Pain that persists or Pain that persists or worsensworsens

Muscle stiffnessMuscle stiffness

Joint stiffness near the Joint stiffness near the affected muscleaffected muscle

Area of tension in the Area of tension in the

muscle that may feel muscle that may feel like a like a knot or tight spotknot or tight spot and may be particularly and may be particularly sensitive (“sensitive (“trigger" or trigger" or "tender" points"tender" points))

Other SymptomsOther Symptoms

FatiqueFatique AnxietyAnxiety StressStress Abnormal REM Abnormal REM

sleepsleep HeadacheHeadache Irritable bowel Irritable bowel

syndromesyndrome DepressionDepression

MPS Versus FMMPS Versus FM Some people believe that MPS and FM are not Some people believe that MPS and FM are not

entirely distinct entitiesentirely distinct entities

Both MPS and FM may fall under the umbrella of Both MPS and FM may fall under the umbrella of “Central Sensitivity Syndromes” (CSS) or “Central Sensitivity Syndromes” (CSS) or “Dysregulation Spectrum Syndrome” (DSS)“Dysregulation Spectrum Syndrome” (DSS)

Other conditions included under this umbrella are Other conditions included under this umbrella are migraine head-aches, tension headaches, migraine head-aches, tension headaches, temporomandibular pain syndrome, primary temporomandibular pain syndrome, primary dysmenorrhea, chronic fatigue syndrome, dysmenorrhea, chronic fatigue syndrome, irritable bowel syndrome, periodic limb irritable bowel syndrome, periodic limb movement disorder, restless leg syndromemovement disorder, restless leg syndrome

TreatmentTreatment

Multi-disciplinary approach Multi-disciplinary approach Essential to identify and eliminate or Essential to identify and eliminate or

correct perpetuating factorscorrect perpetuating factors

TreatmentTreatment

1-1-Physical therapy

– ""Stretch and spray"Stretch and spray" technique technique – MassageMassage therapy therapy

2-2-Trigger point injection

3-3-MedicationMedication is used to treat other is used to treat other conditions that often occur with conditions that often occur with myofascial pain, such as insomnia myofascial pain, such as insomnia and depression.and depression.

Complex Regional Pain Syndrome Complex Regional Pain Syndrome (CPRS)(CPRS)

Reflex Sympathetic Reflex Sympathetic Dystrophy (RSD)Dystrophy (RSD)

CausalgiaCausalgia Sudeck's AtrophySudeck's Atrophy

DefinitionDefinition

Chronic condition affecting the nerves and Chronic condition affecting the nerves and blood vessels of one or more extremitiesblood vessels of one or more extremities

Extremely unpleasant burning sensations, Extremely unpleasant burning sensations, swelling, sweating, color changes, and swelling, sweating, color changes, and other distressing symptomsother distressing symptoms

CRPS 1CRPS 1

(Reflex sympathetic dystrophy- RSD)(Reflex sympathetic dystrophy- RSD)– No nerve damage existsNo nerve damage exists

CRPS 2CRPS 2 (causalgia) (causalgia)– This produces similar symptoms after a nerve This produces similar symptoms after a nerve

injury has occurredinjury has occurred

CausesCauses

Not known:Not known:– overactivity of the sympathetic nervous overactivity of the sympathetic nervous

systemsystem

– inflammation inflammation

Risk FactorsRisk Factors

Trauma Fractures Fractures Lacerations Lacerations Burns Burns Frostbite Frostbite Surgery Surgery Penetrating injury Penetrating injury Crush injury Crush injury An injection into the muscle An injection into the muscle Blood draws Blood draws Diabetic neuropathy Diabetic neuropathy Multiple sclerosis Multiple sclerosis StrokeStroke

SymptomsSymptoms

Within Hours or Days After Injury:Within Hours or Days After Injury: Deep aching or burning pain, typically more severe than Deep aching or burning pain, typically more severe than

expected from the injury expected from the injury

Sensitivity to touch or even a light breeze Sensitivity to touch or even a light breeze

Swelling in the arm or leg Swelling in the arm or leg

Unusual sweating Unusual sweating

Excessively warm or cool skin Excessively warm or cool skin

Hair and nails changesHair and nails changes

SymptomsSymptoms

3-6 Months After Injury:3-6 Months After Injury: Burning pain moves to above and below the initial injury Burning pain moves to above and below the initial injury

Swelling in the arm or leg hardens Swelling in the arm or leg hardens

Muscle spasms or weakness develop Muscle spasms or weakness develop

Extremity becomes cold Extremity becomes cold

Hair growth slows Hair growth slows

Nails become brittle or crackNails become brittle or crack

Six Months or Later After Injury:Six Months or Later After Injury: A pale, blue, and/or shiny appearance to A pale, blue, and/or shiny appearance to

the skin the skin

Limited joint movement Limited joint movement

Muscle lossMuscle loss

DiagnosisDiagnosis

Medical historyMedical history X-rayX-ray Bone scanBone scan Nerve conduction studiesNerve conduction studies EMGEMG

TreatmentTreatment

BiofeedbackBiofeedback AcupunctureAcupuncture Physical therapyPhysical therapy Mirror box therapyMirror box therapy TENSTENS

MedicationMedication Sympathetic nerve Sympathetic nerve

block block Sympathectomy Sympathectomy Psychological Psychological

support support

MedicationMedication

Anti-inflammatory drugs/immunomodulators Anti-inflammatory drugs/immunomodulators Anticonvulsants/neuromodulators Anticonvulsants/neuromodulators Antidepressants/anxiolytics Antidepressants/anxiolytics Opioids Opioids N-methyl-D-aspartate (NMDA) receptor antagonists N-methyl-D-aspartate (NMDA) receptor antagonists Anti-hypertensives and alpha-adrenergic antagonists Anti-hypertensives and alpha-adrenergic antagonists Calcitonin Calcitonin Bisphosphonates Bisphosphonates Additional systemic drug treatment options Additional systemic drug treatment options Topical treatmentsTopical treatments

PreventionPrevention

Quick mobilization after surgery or injuryQuick mobilization after surgery or injury Early use of pain relievers after trauma Early use of pain relievers after trauma

Use of sympathetic nerve block after trauma Use of sympathetic nerve block after trauma

Desensitization techniques (if needed) Desensitization techniques (if needed)

Use of vitamin C —In a study, this was shown to Use of vitamin C —In a study, this was shown to reduce the risk of CRPS after a wrist fracture. reduce the risk of CRPS after a wrist fracture.