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1. Soft Tissue Injury
Soft Tissue Injury
by
by
Mark Harmsworth
Mark Harmsworth

2. What is Soft Tissue?
What is Soft Tissue?
• Skin
Skin
• Ligaments – connects bones at joints
Ligaments – connects bones at joints
• Tendons – attaches muscle to bone
Tendons – attaches muscle to bone
• Fascia – dense connective tissue
Fascia – dense connective tissue
• Skeletal Muscle – usually attached to
Skeletal Muscle – usually attached to
bone and moves parts of the skeleton
bone and moves parts of the skeleton
• So, tissue that has not hardened into
So, tissue that has not hardened into
bone and cartilage
bone and cartilage

3. What are the Type of Injuries?
What are the Type of Injuries?
• Sprain ligaments are
Sprain ligaments are
commonly caused by
commonly caused by
indirect impact, over-
indirect impact, over-
stretching (twisting)
stretching (twisting)
• Muscle strains –
Muscle strains –
pulling action, over
pulling action, over
stretching, rupture or
stretching, rupture or
direct trauma /
direct trauma /
overuse. Includes
overuse. Includes
tendons
tendons
• Contusions (bruise) –
Contusions (bruise) –
direct blow
direct blow
• Intramuscular hematoma
Intramuscular hematoma
is confined to the muscle
is confined to the muscle
compartment which fills up
compartment which fills up
with blood. Is more painful
with blood. Is more painful
and restrictive of ROM
and restrictive of ROM
• Intermuscular hematoma
Intermuscular hematoma
is when the blood escapes
is when the blood escapes
through the fascia and so
through the fascia and so
becomes distributed, thus
becomes distributed, thus
bruising will be evident
bruising will be evident

4. Skeletal Muscle
Skeletal Muscle

5. Sliding- Filament Theory
Sliding- Filament Theory
• Muscle cell ‘fibre’ includes
Muscle cell ‘fibre’ includes
myofibrils which consist of
myofibrils which consist of
2 types of protein called
2 types of protein called
thick and thin filaments
thick and thin filaments
• Thick filaments are formed
Thick filaments are formed
with myosin protein, while
with myosin protein, while
thin filaments with actin
thin filaments with actin
protein. Both form the
protein. Both form the
main contractile elements
main contractile elements
of muscle and as a unit is
of muscle and as a unit is
called a sacromere
called a sacromere
• The length of sacromere is
The length of sacromere is
determined by the sliding
determined by the sliding
nature of the thick and
nature of the thick and
thin filaments which
thin filaments which
overlap
overlap

6. Muscle
Muscle
• Arranged to correlate with the power
Arranged to correlate with the power
needed
needed
• Grouped in orientation of their fibres –
Grouped in orientation of their fibres –
parallel / oblique or pinnate / spiral
parallel / oblique or pinnate / spiral
• The agonist or prime mover (muscle)
The agonist or prime mover (muscle)
brings about movement
brings about movement
• At the same time the antagonist relaxes
At the same time the antagonist relaxes

7. Soft Tissue Healing from Injury
Soft Tissue Healing from Injury
• Repairing damaged tissue
Repairing damaged tissue
• Replaced by granulation tissue, which
Replaced by granulation tissue, which
matures to form scar type tissue
matures to form scar type tissue
• Phases overlap
Phases overlap
• Bleeding / inflammatory / proliferation /
Bleeding / inflammatory / proliferation /
remodelling phases
remodelling phases

8. Bleeding Phase
Bleeding Phase
• Bleeding time to stop will vary with the
Bleeding time to stop will vary with the
nature of both the injury and tissue
nature of both the injury and tissue
• Short lived 6 – 8 hours (acute stage)
Short lived 6 – 8 hours (acute stage)
• Reduces up to 24hrs
Reduces up to 24hrs
• Muscles will bleed longer than other
Muscles will bleed longer than other
structures i.e. ligaments
structures i.e. ligaments

9. Inflammatory Phase
Inflammatory Phase
• Essential component of tissue repair
Essential component of tissue repair
• Rapid onset - first few hours
Rapid onset - first few hours
• Quickly increases to maximum 2 – 3 days
Quickly increases to maximum 2 – 3 days
• Gradually resolves over next few weeks
Gradually resolves over next few weeks
• Largely beneficial
Largely beneficial
• Is accompanied by debris removal and repair
Is accompanied by debris removal and repair
of damaged tissue
of damaged tissue
• Over response can cause problems
Over response can cause problems

10. Proliferation Phase
Proliferation Phase
• Generation of the repair material
Generation of the repair material
• Production of scar tissue (collagen
Production of scar tissue (collagen
material), needs to be laid down in an
material), needs to be laid down in an
orientated way
orientated way
• Rapid onset 24 – 48 hours
Rapid onset 24 – 48 hours
• Peaks 2 – 3 weeks / bulk scar tissue
Peaks 2 – 3 weeks / bulk scar tissue
• Final products several months
Final products several months
• Repair tissue is different. Fibres shorter,
Repair tissue is different. Fibres shorter,
inelastic and different elasticity, increases
inelastic and different elasticity, increases
risk of recurrence of rupture
risk of recurrence of rupture

11. Remodelling Phase
Remodelling Phase
• Greatly overlooked phase
Greatly overlooked phase
• Results in organised / functional scar
Results in organised / functional scar
tissue
tissue
• Starts as early as 2 weeks
Starts as early as 2 weeks
• Continues for months to a year
Continues for months to a year
• With maturity, the collagen becomes
With maturity, the collagen becomes
more orientated in line with local stress
more orientated in line with local stress

12. Proliferation / Remodelling Phase
Proliferation / Remodelling Phase
–Important in Successful Healing
–Important in Successful Healing
• Collagen fibres need to be orientated to
Collagen fibres need to be orientated to
provide tensile strength in the right direction
provide tensile strength in the right direction
• Using normal stresses via movement, collagen
Using normal stresses via movement, collagen
can be laid down this way
can be laid down this way
• If not, collagen fibres are laid in haphazard and
If not, collagen fibres are laid in haphazard and
thus weakened pattern is caused
thus weakened pattern is caused
• With maturity, the collagen becomes even
With maturity, the collagen becomes even
more orientated in line with stress
more orientated in line with stress

13. What Does This Mean for
What Does This Mean for
Treatment ?
Treatment ?
• Excessive bleeding should be discouraged
Excessive bleeding should be discouraged
• Inflammation is normal and essential, though
Inflammation is normal and essential, though
when acute and continues, can cause problems.
when acute and continues, can cause problems.
A question re- NSAID’S use (See next slide)
A question re- NSAID’S use (See next slide)
• Early gradual mobilisation (active rest)
Early gradual mobilisation (active rest)
orientates scar tissue in the line of stress,
orientates scar tissue in the line of stress,
similar to normal tissue plus early movement
similar to normal tissue plus early movement
helps breaks down adhesions
helps breaks down adhesions
• Unhelpful adhesions / scar tissue will need
Unhelpful adhesions / scar tissue will need
direct intervention – Sports massage techniques
direct intervention – Sports massage techniques
• Remodelling is helped by gradual return to full
Remodelling is helped by gradual return to full
physical stress - rehabilitation programme
physical stress - rehabilitation programme

14. NSAID’s as pain relief for STI
NSAID’s as pain relief for STI
• As inflammation process is important can
As inflammation process is important can
NSAIS’s delay overall recovery?
NSAIS’s delay overall recovery?
• Inhibit COX enzymes and production of
Inhibit COX enzymes and production of
inflammatory prostaglandins (these introduce
inflammatory prostaglandins (these introduce
inflammatory cells to the area)
inflammatory cells to the area)
• Thus reduces pain, swelling , oedema which
Thus reduces pain, swelling , oedema which
can cause anoxia / cell damage
can cause anoxia / cell damage
• Inhibit COX can alter thromboxane and
Inhibit COX can alter thromboxane and
platelets and so increase bleeding / swelling at
platelets and so increase bleeding / swelling at
site.
site.

15. NSAID’s as pain relief for STI
NSAID’s as pain relief for STI
• Tendon injuries in those over 40 are usually
Tendon injuries in those over 40 are usually
due to tendonosis in nature rather than
due to tendonosis in nature rather than
inflammation
inflammation
• Research are inconclusive and involves use in
Research are inconclusive and involves use in
animals rather than human trials
animals rather than human trials
• Guidance – use NSAID’s for treating chronic
Guidance – use NSAID’s for treating chronic
inflammation and acute like bursitis and
inflammation and acute like bursitis and
confirmed tendonitis
confirmed tendonitis
• Use paracetamol for pain relief (though use of
Use paracetamol for pain relief (though use of
single NSAID doses won’t have any effect)
single NSAID doses won’t have any effect)

16. Overuse Syndrome / Sports
Overuse Syndrome / Sports
• Muscular system develops to the way it is used
Muscular system develops to the way it is used
• Individuals have unique pattern of imbalances
Individuals have unique pattern of imbalances
• Bundles of muscle fibres react fractionally in a
Bundles of muscle fibres react fractionally in a
different way, causing small areas to be under
different way, causing small areas to be under
slightly greater pressure than surrounding
slightly greater pressure than surrounding
areas
areas
• A few fibres are damaged at microscopic level
A few fibres are damaged at microscopic level
• Causes secondary muscle tension to the
Causes secondary muscle tension to the
surrounding tissue
surrounding tissue
OVERUSE SYNDROME BEGINS
OVERUSE SYNDROME BEGINS

17. • Same as normal tissue response of bleeding / inflammation
Same as normal tissue response of bleeding / inflammation
and formation of scar tissue, yet at a microscopic level
and formation of scar tissue, yet at a microscopic level
• Secondary muscle micro-tension may cause soreness but
Secondary muscle micro-tension may cause soreness but
no real pain and activity continues as inflammatory
no real pain and activity continues as inflammatory
response is small
response is small
• Moderate activity is helpful at this stage yet further
Moderate activity is helpful at this stage yet further
continuous stress prevents recovery
continuous stress prevents recovery
• Adjacent fibres work harder due to micro tissue damage,
Adjacent fibres work harder due to micro tissue damage,
which is less contractual and stretchy
which is less contractual and stretchy
• More micro trauma / scar tissue occurs so less elasticity and
More micro trauma / scar tissue occurs so less elasticity and
the circle continues
the circle continues
Overuse Syndrome
Overuse Syndrome

18. Overuse Syndrome
Overuse Syndrome
You are full into overuse syndrome
You are full into overuse syndrome
• As small parts of muscle deteriorate, imbalance
As small parts of muscle deteriorate, imbalance
in the muscle and the group occurs
in the muscle and the group occurs
• 1 muscle problem then effects different muscle
1 muscle problem then effects different muscle
systems. May still be unnoticed !
systems. May still be unnoticed !
• Tendon tension increases and may tear (acute)
Tendon tension increases and may tear (acute)
• Biomechanical faults develop, causing more
Biomechanical faults develop, causing more
problems elsewhere in the musculoskeletal
problems elsewhere in the musculoskeletal
system
system

19. How to Treat / Stop Overuse
How to Treat / Stop Overuse
Syndrome
Syndrome
• Effective and efficient training, includes
Effective and efficient training, includes
correct biomechanics. Be prepared to adapt
correct biomechanics. Be prepared to adapt
• Have rest days (please), vary training
Have rest days (please), vary training
• Use soft tissue massage (STM) techniques to
Use soft tissue massage (STM) techniques to
identify and treat problems before any
identify and treat problems before any
symptoms are recognised
symptoms are recognised
• STM to intervene in soft tissue problem i.e.
STM to intervene in soft tissue problem i.e.
adhesions / scar tissue
adhesions / scar tissue
FIND THE CAUSE
FIND THE CAUSE

20. Soft Tissue Injury Approach
Soft Tissue Injury Approach
• Facilitate / promote normal tissue repair
Facilitate / promote normal tissue repair
• Immobilization and early mobilization
Immobilization and early mobilization
• Enhance sequence of events
Enhance sequence of events
• Promote normality
Promote normality
• Appropriate therapy to influence the
Appropriate therapy to influence the
process in a positive way
process in a positive way
• Intervene if needed i.e. adhesions /
Intervene if needed i.e. adhesions /
infection / overuse syndrome
infection / overuse syndrome

21. References
References
Soft tissue issues
Soft tissue issues
• Anderson, C., et al 2004*
Anderson, C., et al 2004*
• Fox, S and Pritchard, D.,
Fox, S and Pritchard, D.,
2004
2004
• Watson, T., 2006 *
Watson, T., 2006 *
Overuse syndrome
Overuse syndrome
• Cash, M., 1996*
Cash, M., 1996*
• Paine, T., 2007
Paine, T., 2007
• Sanderson, M., 2002
Sanderson, M., 2002
Sliding – filament theory
Sliding – filament theory
www.ivyrose.co.uk
www.ivyrose.co.uk (Accessed April 2008)
(Accessed April 2008)
Scar / collagen orientation in
Scar / collagen orientation in
the lines of stress
the lines of stress
• Forrest, L., 1983
Forrest, L., 1983
• Hardy, M., 1989
Hardy, M., 1989
• Norris, C., 2004*
Norris, C., 2004*
• Watson, T., 2006*
Watson, T., 2006*
NSAID’S / INFLAMMATION
NSAID’S / INFLAMMATION
• Becker, D., 2010
Becker, D., 2010
• Braund, R., 2006*
Braund, R., 2006*
• Khan, K. et al 2000.
Khan, K. et al 2000.
• McGriff-Lee, M., 2003
McGriff-Lee, M., 2003
• Stovitz, S and Johnson R., 2003*
Stovitz, S and Johnson R., 2003*
• Watson, T., 2006
Watson, T., 2006