The document discusses muscle strains and ligament sprains, detailing the types of injuries, their pathophysiology, healing processes, signs and symptoms, and treatment protocols. It emphasizes the importance of early mobilization, proper rehabilitation techniques, and preventative measures to minimize recurrence. Additionally, it outlines the differences in healing between muscles and ligaments, highlighting the compensatory nature of scar tissue formation in ligament injuries.

1. MUSCLE STRAIN &
LIGAMENT SPRAIN
-Dr. Akshay (Com-PT)

2. MUSCLE STRAIN/TEAR
Types of muscle injuries:
• Laceration- cut by external trauma
• Contusion- compressive forces to muscle , contact
sports
• Strain- when muscle can not withstand
excessive tensile forces placed on them and are
therefore associated with eccentric muscle action.

3. • Muscles are strained or torn when some or all of
the fibers fail to cope with the demands placed
upon them.
• Muscles that are commonly affected are the
hamstrings, quadriceps and gastrocnemius;
these muscles are all biarthrodial (cross two
joints) and thus more vulnerable to injury.
• A muscle is most likely to tear during sudden
acceleration or deceleration(because muscle in
lengthened state and contracting forcefully).

4. • When the muscle is strained the initial injury is
usually associated with disruption of the distal
myotendinous junction and fibres distal to
this but still near the myotendinous junction.
• Injuries to the muscle belly only occur with the
application of very high forces.
• The contractile elements are the first tissues to be
disrupted; with the surrounding connective tissue
not being damage until high forces are applied.
PATHOPHYSIOLOGY

5. • The contractile elements are relative stiff in
comparison to the surrounding connective tissue
and hence become disrupted at lower forces than
the surrounding connective tissue.

6. • Muscle strains are classified in three grades.
• A grade I strain involves a small number of
muscle fibers and causes localized pain but no
loss of strength.
• A grade II strain is a tear of a significant
number of muscle fibers with associated pain
and swelling. Pain is reproduced on muscle
contraction. Strength is reduced and movement
is limited by pain.
• A grade III strain is a complete tear of the
muscle. This is seen most frequently at the
musculotendinous junction.

9. Healing
• Muscles heal by a repair process that can be
divided into two phases:
• (1) the destruction/injury phase resulting in
rupture and necrosis of the muscle fibres; and
• (2) Repair and regeneration.

10. Destruction/injury phase
• This phase results in damage to the vascular supply and as oxygen
can no longer reach the cells, they die and release lysosome.
• Excessive force to a musclefibre results in tearing of the
sarcoplasm and the cells respond by forming a contraction band ,
creating a protective barrier.
• Within 15 minutes of injury the damaged tissue consists of
disrupted extracellular tissue and dead cells, platelets and plasma,
which themselves release powerful enzymes such as thrombin
thereby setting off an inflammatory cascade.
• A haematoma is formed to fill the gap between ruptured
muscle fibres.

11. • Clinically tissue inflammation presents as redness,
heat, swelling and pain of the tissues.
• The redness, heat and swelling are due to an increased
blood flow and so blood within vascular beds in the
area, with the swelling developing as a result of the
increased local tissue pressure due to inflammatory
exudates leaking into the interstitial space.
• The pain is due to the initial damage to local nerves
and irritation of nerves in the area from the
inflammatory chemicals release by the damaged tissue.

12. Repair and regeneration phase
• The regeneration process starts within 3–6 days
following injury, reaching a peak between day 7 and
14.
• After the initial injury, the inflammatory
chemicals released from the injured tissues attract
lymphocytes and macrophages to the area.
• Macrophage phagocytosis of the necrotic material
then occurs removing the debris.

13. • In response to injury satellite cells proliferate
and differentiate into myoblasts and then
become multinucleated myotubes.
• These then fuse with parts of the muscle fibre
that have survived the initial injury and attempt
to breech the gap in the muscle.

14. • A number of factors predispose to muscle
strains:
• inadequate warm-up
• insufficient joint range of motion
• excessive muscle tightness
• fatigue/overuse/inadequate recovery
• muscle imbalance
• previous injury
• faulty technique/biomechanics
• spinal dysfunction.

15. SIGNS AND SYMPTOMS
• Pain
• Muscle spasm
• Muscle weakness
• Swelling
• cramp

16. Treatment of muscle injuries
• It is frequently cited within the sports medicine literature
that the initial treatment of musculoskeletal injuries should
be rest, ice, compression and elevation (RICE).
• However, this acrimony is likely to be more valid in the less
metabolically active tissues such as ligament and bone.
• Muscle with its capacity for rapid regeneration due to the
nature of its constituent tissues requires a modified
approach. This modification is based around the
balance between absolute rest and the absolute
level of loading to stimulate appropriately the
rapidly developing tissues.

17. Rest and mobilisation
• Early mobilisation, rather than immobilisation or
complete rest, has been advocated .
• Studies have shown early mobilisation aids with
regeneration of muscle fibres.
• The exact level of loading is difficult to judge, it must be
sufficient to stimulate and challenge the developing
tissues, but not so great that it causes tissue breakdown .
• This includes early weight bearing to help
promote scar tissue re-alignment and controlled
running to reduce muscle inhibition.

18. • Immobilisation and poorly controlled early
loading (low or high), have been shown to lead
to the development of contracted scar tissue,
which blocks the linking of myotubes across the
injury, thereby stopping the formation of a
functional contractile element, and the
surrounding areas then become more
susceptible to further injury.

19. Ice
• Studies have shown that ice results in a significantly
smaller haematoma and less inflammation in the initial
stages of the injury.
• Reducing tissue temperature results in vasoconstriction,
thereby limiting the amount of bleeding in the area .
• It also reduces the metabolic rate of the tissue and
therefore reduces the demand for oxygen , decreasing the
hypoxic damage.
• 5–10 minutes in the initial stages and repeat every
60minutes within the first24–48hour to reduce the
inflammatory effects.

20. Compression and elevation
• Compression is an area where research is lacking, it
has been stated that it results in a reduction in the
severity of bleeding and swelling following an injury ,
though the only evidence often present in support of
this theory is from studies involving ligament injuries.
• A recent clinical study by Thorsson et al. (2007)
utilising 40 athletes with calf injuries found
compression resulted in no significant
difference in reducing muscle haematoma, or speed
of recovery of the injury using compression.

21. • Elevation is still one of the preferred and easiest
methods of immediate management used in sports
medicine for muscular injuries.
• It simply relies on the use of gravity to promote
venous return and lymphatic flow to drive
swelling/oedema from the area.
• It would appear that the greatest benefit that comes
from compression and elevation is that it ensures
that the athlete rests during the acute inflammatory
phase of the first 72 hours following injury.

22. Strengthening exercise
• Isometric exercise can begin after 2–5 days and
should be performed within the limits of pain .
• Frequency, duration and intensity are limited by the
patients’pain.
• Some therapists advocate three sets of 10 repetitions
using 5–10 second holds to begin with at intensity
within pain tolerance.
• These then are undertaken at multiple angles,
beginning in mid range then progressing to inner range
(shortened position) then outer range (lengthened
position).

23. • Once these can be undertaken in a pain-free
manner throughout the available range, then
isotonic exercises can commence.
• Dynamic movement and isotonic contraction is
then incorporated again starting in the strongest
position (mid range, close to a 90◦ joint angle)
progressing to and finishing in the functionally
most relevant (outer range with eccentric and
concentric contractions most often).

24. • There is preferential atrophy of type 1 muscle
fibres with disuse.
• Therefore, initially an endurance based
programme should be used, (three sets of 15
repetitions at 40–60% of one repetition
maximum) this would be progressed to
strength (4–6 sets of 3–6 repetitions at 85–
95% of one repetition maximum and then
power training (3–5 sets of 3-5 repetitions at
75–85% of one repetition maximum) or
plyometrics depending on the specific
requirements of the muscle.

25. Stretching
• Passive stretching (at the end of available range) should be
avoided for the first 72 hours as a minimal period, possibly the
athlete should not stretch for the first 7–10 days following injury.
• The reasons for this are twofold.
• Firstly, the healing tissue is weak and intolerant of tensile
loading and so is likely to be damaged by uncontrolled stretching.
• The second reason is there is no physiological need in the early
stages to stretch, as the scar does not beginning to shrink
until around the tenth day post injury when fibroblasts begin
to be converted to myofibroblasts and contract and draw the
wound ends together.

26. • Prior to the tenth day post injury it would be more
appropriate to take the muscle through its full available
pain-free range without any attempt to force the
muscle beyond this point.
• Each stretch should be held at the end of available
range within the limits of pain. Time, frequency,
duration and intensity of stretch remain debateable in
the literature. Some research suggests passive
stretching should be held for a minimum of 15
seconds with 6–8 sets per day.

27. Electrotherapy
• Pulsed shortwave diathermy is particularly helpful
for enabling re-absorption of the muscular
haematoma as it is particularly effective in more
vascularised tissues such as skeletalmuscle.
• It is thought to work at the cell membrane level,
resulting in an ‘up regulation’ of cellular behaviour. This
results in an improved rate of oedema
dispersion,resolution of the inflammatory
process and promotes a more rapid rate of fibrin
fibre orientation and deposition of collagen.

28. • Therapeutic ultrasound
• This is the use of high intensity sound waves,
which research has been shown can help
recovery of tissues at a cellular level by
increasing ion transport across cells and
increasing metabolism within the cell and
increasing fibroblastic and angiogenic activity.

29. • Muscle stimulation may prove a further useful
electrotherapeutic adjunct for the treatment of muscle
injuries.
• It has been shown to decrease oedema, muscle
inhibition and the rate of strength loss with
inactivity .
• However, muscle stimulation has not been shown to
be useful in the regaining of strength in the
injured athlete.

30. Summary key points of muscle healing and
rehabilitation
• RICE should be implement as soon as possible following acute injury.
• Early mobilisation and weightbearing should also be encouraged
• Stretching and strength exercises can start within pain-free range as
soon as possible
• Fitness and conditioning of the athlete should be incorporated within
the early rehabilitation programme without compromising the injury
• Specificity, and functional fitness are imperative to help return the
athlete back to sport without recurrence.

31. LIGAMENT SPRAINS
4/9/2018

32. LIGAMENT SPRAINS
• The stability of a joint is increased by the presence
of a joint capsule of connective tissue, thickened at
points of stress to form ligaments.
• The ends of the ligament attach to bone. Ligament
injuries range from mild injuries involving the
tearing of only a few fibers to complete tears of the
ligament, which may lead to instability of the joint.
• Most common ???

33. Pathology
• Pathological changes in ligaments may occur due to
structural and functional failure.
• Any strain to a ligament may cause a long-term joint
instability.
• Following a strain, ligaments do not heal by producing
an identical tissue; instead, a scar tissue is formed.
(The scar tissue presents with an uneven matrix, smaller
in diameter collagen fibers, weaker collagen crosslinking
and a limited creep.)

35. • The blood circulation is also affected with a long term
reduction in blood circulation to the scar tissue.
• Although scar tissue is formed relatively fast, there are still
mechanical and chemical changes months and years after
the injury, though it never has a normal appearance
or function again, resulting in a high level of
reoccurrences.
• Ankle sprains, for example, reoccur in 73% of all athletes
(Yeung et al. 1994).
• As ligaments provide the proprioceptive sensory nerve
supply to the central nervous system, any ligament injury
may cause further problems in the neuromuscular system.

36. healing process
• Following a strain injury, the gap within the ligament fills
with blood to start the inflammation phase.
• Fibroblasts proliferate, the ligaments revascularise and the
gap becomes filled with scar tissue .
• Fibroblasts start producing scar tissue made by type III
collagen. This collagen-type material creates a rapid,
disorganised structure with weaker cross links to fill
the gap between the ligament’s edges quickly.
• Followed is the long remodelling period, which can take
months or even years as the matrix and collagen fibres are
rearranged to have stronger bonds.

37. • Ligament injuries are divided into three grades.
• A grade I sprain represents some stretched fibers
but clinical testing reveals normal range of motion
on stressing the ligament.
• A grade II sprain involves a considerable
proportion of the fibers and, therefore, stretching of
the joint and stressing the ligament show increased
laxity but a definite end point.
• A grade III sprain is a complete tear of the
ligament with excessive joint laxity and no firm end
point. Although they are often painful conditions,
grade III sprains can also be pain-free as sensory
fibers are completely divided in the injury.

39. SIGNS AND SYMPTOMS
• Pain
• Swelling
• Bruising
• Joint instability
• Not be able to move the joint

40. Treatment
• The viewpoints of the main two treatments are
1) the immobility, long rest and braces versus
2) the sooner-than-later active treatment.
• A systematic review finds no data to support any benefits from
using braces in sprained ligament (Pietrosimone et al. 2008).
• Another study found that early activity, rather than long
immobility, would make
the healing time shorter,
more complete and that
the ligaments would appear stronger.

41. MANAGEMENT
• For grades I–II a non-operative active treatment
approach is the most common and usually comprises
rest(for a limited period),ice, compression and elevation
(RICE), isometric and isotonic exercises and
proprioceptive training.
• RICE therapy (Rest, Ice, Compress, Elevate) for the
first 24 to 48 hours.
• 1. Rest the injured area (reduce regular exercise or
activities as needed)

42. • 2. Ice the injured area, 20 minutes at a time,
four to eight times a day (cold pack, ice bag, or
plastic bag filled with crushed ice and wrapped
in a towel can be used)
• 3. Compress the injured area, using bandages,
casts, boots, elastic wraps or splints to help
reduce swelling.
• 4. Elevate the injured area, above the level of
the heart, to help decrease swelling while you are
lying or sitting down.

43. Proprioceptive training
• Proprioceptive training concentrates mostly on the
lower limb, in particularly post sprain in the ankle joint.
• To maintain the proprioceptive neural function
by continuously using the joint in a challenged position.
• It has been found that even the use of unsupervised,
home proprioceptive exercises reduces the rate of
reoccurance in atheletes.
Example: balanced and coordination training performed
on the wobble board, both as a treatment and
preventative measurements.

44. • For grade I and II sprains, treatment aims to
promote tissue healing, prevent joint stiffness,
protect against further damage and strengthen
muscle to provide additional joint stability.
• The treatment of a grade III sprain may be either
conservative or surgical.

45. PREVENTION
• Although we cannot prevent all sprains and
strains from occurring, there are some tips on
how to avoid them:
• Stretch before you workout with heavy items
• Use proper footwear for the activity you are
doing
• Warm up adequately before activities

46. Summary key points of ligaments
• Ligaments offer joints stability with sensory
feedback to the central nervous system.
• Ligaments’ blood supply is the limiting factor in
many healing process of sprain.
• Ligaments heal by the process of laying down scar
tissue, which exhibits structurally different tissue
organisation and is weaker compared to the
original ligament.

47. • Most frequent treatment for grade I–II sprains
are RICE, early mobilisation, isometric and
isotonic strengthening exercise, neuromuscular
rehabilitation and return to normal function as
soon as possible.
• For grade III injury, reconstructive surgery is an
option.