Injury and Healing Within Sports Physiotherapy

Original Editor - Robin Tacchetti based on the course by Ian Horsley
Top Contributors - Wanda van Niekerk, Robin Tacchetti, Lucinda hampton, Kim Jackson, Jess Bell, Tarina van der Stockt and Ewa Jaraczewska

Intro

Soft tissues provide support and protective function in the body.  These tissues are made of cells, fibres and non-cellular matrix material with collagen being the most abundant component.  When soft tissue has been injuryed, the cardinal signs of inflammation occurs, redness, swelling, pain, loss of motion and heat.  The healing process will move through the inflammatory stage to repair and lastly to remodeling.  Each phase of healing has no definitive time frame as they overlap eachother as they help the tissue return to pre-injury level.

Inflammation

After injury, the first stage of healing is the inflammatory stage.  This stage which generally peaks between day 1-3  is marked by redness, swelling, pain, heat and disruption of function for the affected tissue.  The aim during the stage is prevent excessive inflammation and move through the next stages of healing to full recovery.

Physiologically the inflammatory process consists of the following events:

1. Histamine is released from damaged capillaries causing increased permeability and vessel dilation
2. Prostaglandins maintain vasodilation
3. Amines cause contraction of smooth muscle
4. Phagocytes clear debris
5. Mediators are released to stimulate proliferative phase

Inflammation can be seen as unwelcome, it is the first step to healing.  When it becomes excessive there are treatments designed to limit the above chemical process. There are two drug classes used to inhibit the inflammatory process; non-steroidal (NSAIDs) and corticosteroids.  NSAIDs not only have anti-inflammatory properties but are pain-relieving as well.   Corticosteroids are usually injected to the site of pathology and can reduce inflammation and pain, but can cause inhibition of collagen synthesis affecting healing.  ,

Chronic Inflammation (several months to years)

When macrophages have been unable to clear the wounded area of foreign substances, chronic inflammation occurs.  This area becomes surrounded with collagen/scar to isolate it from the body called a granuloma.  (book and Pawha)

Proliferation Phase

Once the inflammatory has been completed, tissue repair can occur.  This phase consists of two actions, fibroplasia (fibrous material production) and angiogenesis (new blood vessel formation).

Physiologically during this phase, the following occurs:

1. Capillary buds form and grow towards the injured area
2. Granulation tissue is created by capillaries loops and initiating blood flow
3. Phagocytosis by specialized white blood cell
4. Lymphatic vessels create a new drainage system
5. Fibroblasts contract wound pulling edges towards each other

Remodelling

The remodelling stage may last from 3 weeks to 12 months and overlaps the repair stage. The aim of remodelling is to decrease wound size, increase the scar strength and alter the direction of collagen fibres.  Altering and refining collagen during this time facilitate stable collagen to one of increased fibre strength.  Physiologically what occurs during this phase is the following:

1. Contraction of granulation tissue
2. Fibroblasts form intercellular bonds
3. Crossbonds between cells form increasing collagen strength
4. Continuous turnover of collagen
5. Type three collagen is replaced by type one collagen (speakeR)

The final fibre tissue arrangement should match the function of the tissue.  Alignment is dependent on stress imposed on the tissue during healing.  Mechanical damage to the tissues can reduce the

Therapy General

Healing begins immediately, however, collagen is generally not laid down until the 5th day post-injury. This period of time is referred to as the “lag phase”.   During lag time,  therapy goals are directed toward oedema control and resolving pain.  Therapy focused on the mobilisation of tissue and realigning collagen fibres can begin once collagen synthesis has been initiated.  Mild stress during this stage of rehabilitation is referred to as mechanical loading and is necessary because it stimulates collagen fibre alignment.  

(book) However,  care must be taken as to not overload or the process can revert back to the inflammatory phase.

Mechanical Loading

The goal of mechanical loading is to improve tensile strength of injured soft tissue  through compression, tension or shear force. (book)  A load can be very light like a tickle, to a very high load like a manipulation. (speaker)  If the load is applied is too little or too much, it can result in inappropriate repair of the tissues and create a chronic condition.   As the tissue strengthens, the applied load can increase being cautious not to go overload.  Too much tension can cause the collagen fibres to misalign causing adhesions leading to chronic  conditions.(speaker)However,  care must be taken as to not overload or the process can revert back to the inflammatory phase.

Physio loading

Physiotherapists can use many different techniques to apply mechanical loads to injured tissue such as massage, ultrasound and exercise. (speaker and book) These interventions can promote repair and remodeling of injured tissues. (book) An indicator that the tissue is being stimulated and remodeled is mild discomfort.  One example of mechanical loading is deep transverse friction massage which may improve adhesions and increase the tensile strength of the healing scar.   Please see the below video for an example of deep transverse friction massage:(book)

Loading Feedback

Patient feedback is critical during this stage to ensure collagen alignment and proper healing.  Asking the patient to monitor for swelling, stiffness and pain for 24 hours can help the therapist guage the correct loading application.  In addition, therapists can monitor swelling using tape measures.  (speaker)

Summary Soft Tissue Injury

Acute Injury

Traditional treatment for soft tissue injury as been referred to as RICE, rest, ice, compression and elevation.  Unfortunately, rest or Immobilzation of soft tissue inuruy can result in joint stiffness, weaken ligaments and delay healing.   Total immobilization should be dedicated to bone injury or a complete rupture where movement could cause further damage.  Conversely, exercise and painfree movement within a protected support can strengthen ligaments and increase collagen turnover. (book, vuurberg)

Acute to continuum

Contemporary acronyms for soft tissue injury management is referrred to as PEACE and LOVE. See below for a better understanding of the various steps:

PEACE (day 1-3)

P: protect the area

E: elevate

A: avoid anti-inflammatories medication to allow for natural inflammatory process to occur

C: compression

E:  educate the patient on an active approch to therapy versus a passive one.

LOVE (after a few days)

L: optimal loading to repair and remodel tissue

O: optimistic expectations by patient coincide with better outcome

V: vascularization- painfree aerobic exercise to increase blood flow

E: exercise- painfree exercise (dubious)

Initially following injury, the goal is to protect (P) the area, elevate (E), avoid anti-inflammatories medication (A) to allow for natural inflammatory process to occur, compression (C and educate (E) patient on an active approch to therapy versus a passive one.

Therefore, the new acronym for soft tissue healing is POLICE: protection (support), optimal loading (painfree movement), ice, compression, and elevation.

Healing Times

Healing times are dependent on the type of tissue involved.  Understanding the specific tissue injured helps target the appropriate timing for incremental loading during the remodelling stage.  With proper management, different tissues will take different amounts of time to heal fully.  Ian Horsley estimates below the time expected per tissue:(speaker)

Muscle: 6 months

Ligament: 1 year

Tendon: 2-3 years

Articular cartilage: greater than 3 years

Good clinical decision involves understanding the tissue, the timing to add mechanical loading, the amount of mechanical loading, monitoring for symptoms and asking for patient feedback all help give the best chance of tissue recovery to pre-injury level of strength.(speaker)

Norris C. Sports and soft tissue injuries: A guide for students and therapists. Routledge; 2018 Sep 3.

Vuurberg G, Hoorntje A, Wink LM, Van Der Doelen BF, Van Den Bekerom MP, Dekker R, Van Dijk CN, Krips R, Loogman MC, Ridderikhof ML, Smithuis FF. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug 1;52(15):956-.

Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine. 2020 Jan 1;54(2):72-3.

Pahwa R, Goyal A, Bansal P, Jialal I. Chronic Inflammation. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2021. PMID: 29630225.

Muire PJ, Mangum LH, Wenke JC. Time course of immune response and immunomodulation during normal and delayed healing of musculoskeletal wounds. Frontiers in immunology. 2020 Jun 4;11:1056.

inflammatory chart

POLICE

During the acute phase discussed above, the RICE-method: Rest, Ice, Compression and Elevation was suggested. Most people are familiar with the acronym RICE when dealing with musculoskeletal injury, however, current thoughts have expanded the RICE acronym to the POLICE method: Protection, Optimal Loading, Ice, Compression, Elevation. Optimal loading or mechanical loading is the time where physiotherapists need to use good clinical decision making to assist with recovery and prevent chronic conditions from forming.

Mechanical Loading

Understanding the specific injured tissue helps target the appropriate timing for incremental loading. During this remodelling stage collagen transitions from immature type three to type one collagen.Injured tissues need to learn how to adapt to mechanical loads to in order to return to pre-injury level.  A load can be very light like a tickle, to a very high load like a manipulation.  If the load is applied is too little or too much, it can result in inappropriate repair of the tissues and create a chronic condition.   As physiotherapists, we can use many different techniques to apply loads such as massage and ultrasound.  As tissues get stronger, the applied load can increase being careful not to go overboard.  Too much tension can cause the collagen fibres to misalign causing adhesions leading to chronic conditions.

Loading Feedback

Patient feedback is critical during this stage to ensure collagen alignment and proper healing.  Asking the patient to monitor for swelling, stiffness and pain for 24 hours can help the therapist gauge the correct loading application.  In addition, therapists can monitor swelling using tape measures.

Healing Times

Healing times are dependent on the type of tissue involved.With proper management, different tissues will take different amounts of time to heal fully.  Ian Horsley estimates below the time expected per tissue:

Ligament: 1 year

Tendon: 2-3 years

Articular cartilage: greater than 3 years

Good clinical decision involves understanding the tissue, the timing to add mechanical loading, the amount of mechanical loading, monitoring for symptoms and asking for patient feedback all help give the best chance of tissue recovery to pre-injury level of strength.

Resources

• Soft Tissue Healing
• Figure Eight Measurement of the Hand
• Figure of Eight Method of Measuring Ankle Joint Swelling