Sprain and strain – Stages of Healing

Our body has lots of soft tissues like skin, muscles, tendons, nerves, blood vessels, fascia, synovial membrane etc. They connect, support and surround different parts of the body. Injuries to soft tissues can result from a direct trauma, as in a fall/sports injury (i.e. macro trauma) or from repetitive strain from day to day routine.  Sprain is injury to the ligament which connects a bone to another bone and strain is injury to the tendons connecting muscle to the bone. It is good to know what happens after a soft tissue injury, the signs and symptoms and what can be done to manage the symptoms and to ensure maximum recovery.

The process of healing after a soft tissue injury is divided into three stages:

  1. Inflammatory phase ( 1-7 days)

Inflammatory phase presents with pain, swelling, warmth, redness, muscle spasm and reduced range of motion. This is the first phase right after an injury. These signs and symptoms happens as a result of body’s natural protective mechanism to guard the injured area from moving by creating muscle spasm and swelling, to kill any bacteria that has entered into the body through the open wound if any, to clean any tissue debris and to start the healing process by pooling more blood in to the affected area. During this phase patient will notice a lot of limitation due to the constant pain and swelling and will feel like it is constantly annoying and limiting many activities of daily living.

This acute phase of healing will not be present in overuse injuries or derangement syndromes.

It is extremely important to make sure that the acute inflammatory phase stays under control as it can spread to other areas, kill healthy tissue and also compromise the strength and mobility there by resulting in some serious secondary complications.

The following are the things that you can do to help manage the signs and symptoms of acute inflammatory phase.

Rest – Rest enough to avoid unnecessary stress placed on the affected tissues. Avoid any heavy or prolonged activities. It is essential to understand that complete rest is not recommended unless and until advised by a healthcare professional which could be the case in some special cases. Do not use a brace to immobilise the injured area unless recommended by your healthcare provider. Movement is the key to recovery!!!

Ice/heat – Do short duration frequent icing lasting for 10 -15 mins every couple of hours for the first 48-72 hours, you can use a gel pack from the freezer or frozen veggie bag wrapped with a paper towel, after 72 hours when the symptoms starts to subside you can start using heat.

Medicine – Anti-inflammatory drugs prescribed by the family doctor is also something that will help in managing the situation.

Exercises – You can start with passive range of motion (ROM) or active assisted range of motion exercises, within pain free range to maintain the range of motion and strength of the affected joints and muscles based on a doctors or physiotherapist recommendation. This will help to recover quicker in most cases and also prevent any secondary complication resulting from immobilisation and muscle disuse.

  1. Proliferative phase /repair phase (6 days to 2-3 weeks).

This phase follows the acute inflammatory phase. This is the time when your body is laying new tissues (collagen) to replace the injured tissues resulting in scar formation. Patient will start to feel better as the constant pain, swelling, redness and all the acute symptoms subsides. Patient continues to experience pain with movement and palpation/pressure of the affected area. Activities of daily living get easier even though there will be limitation with challenging activities like heavy household chores, workout routine and sports activities.

Medicine – Some studies have shown that using the anti-inflammatory drugs or NSAIDs beyond the acute inflammatory phase will actually slow down the process of healing. During the proliferative phase Anti-inflammatory medication or pain killers must be taken only after discussing with your family doctor.

Heat – The use of heat to the affected areas for 15 minutes twice a day is recommended as it will help to promote more blood circulation to the injured tissue which will help in facilitating the healing process. Application of heat will also help in pain management when needed.

Exercises – Active range of motion exercises, resisted isometric exercises and some stretching exercises can be started in this phase. The new scar tissues should be stretched carefully as it is being formed, otherwise it tends to shorten. The active ROM exercises through full range itself will put some stretch to the affected tissues.  The collagen that makes the scar tissue is very weak and can be easily torn, so the stretches and strengthening exercises should be done according to the tolerance of the affected tissues and possibly under the guidance of your healthcare provider. Your physiotherapist is the best person to plan a good exercise routine for you at this phase.

  1. Remodelling phase (2 weeks to 6 months or may be up to two years)

This is the last phase in the healing process of the soft tissue injury. The proper moulding and alignment of the newly laid tissues (collagen) at the injured site happens in this phase.The collagen that is laid during the proliferative phase is not organised and the scar is thick. The proper stretch and alignment of scar tissue happens with appropriate stretching and strengthening exercises. By the time of remodelling phase most people will feel 80% better with no problem during activities of daily living.  People often forget to exercise, strengthen and stretch the tissues at this phase as they feel mostly good, but until the proper stretching and alignment of the scar tissue happens with consistent challenging exercise routine, it is easy to reinjure the new tissue and result in recurrent injury of the same area/tissues.

Compared to the three phases of healing, the remodelling phase is when exercising is most important. Regular stretches and challenging strengthening exercises will ensure that you obtain maximum recovery to the preinjury status.

So remember to continue with your rehabilitation sessions well in to the remodelling phase of recovery and continue with your home exercise program as per the physiotherapist even after discharge to prevent re-injury/recurrence and to ensure maximum recovery.

 

References:-

http://emedicine.medscape.com/article/884594-overview#a3

http://www.wrha.mb.ca/professionals/woundcare/documents/PrinciplesWoundHealing_WCCSpring2011.pdf

http://whenithurtstomove.org/about-orthopaedics/conditions-and-ailments/strains-and-sprains/

 

 

Knee pain

 

Knee pain

My knee started to hurt a little bit while climbing stairs, a pain that I ignored as it was only a little bit and  felt only when climbing has recently started getting worse. Are you wondering what happened to your knee? You have never injured it, never fallen, then why is it hurting?

A gradual onset of knee pain is usually due to a mechanical defect that has been setting in over the last few weeks to months.  Most common diagnosis in a condition like this is Patellofemoral Pain Syndrome or PFPS. PFPS is a broad term used to describe a gradual onset of pain in the front of the knee, around the patella or knee cap. Pain resulting from PFPS makes it difficult to perform activities like climbing stairs, kneeling down and any activity that involves squatting or lunges.

Knee Joint Anatomy

Looking at the anatomy of the knee joint and muscle function will help you understand why your knee is hurting and what physiotherapy/individualised exercise program can do to treat this condition.

The knee joint consists of three bones, the lower part of thigh bone (femur), upper part of leg bone (tibia) and the knee cap (patella). The patella is resting in a groove on the femur and is moving up and down in this groove (track) during knee movements. The soft cartilage covering the joint surfaces and the fluid (synovial fluid) filled in the joint space keeps the movements very smooth.

Patellofemoral Pain syndrome( PFPS)

Pain felt beh­ind or around the patella is known­­ as Patellofemoral Pain syndrome. Damage to the structures around patella usually causes patellofemoral pain, which is most commonly of gradual onset.

Common Risk factors

Over use of the knee joint, while exercising or doing sports is a risk factor for PFPS, as in running, jogging, squatting, ­­step classes or spinning classes. And improper training techniques can predispose PFPS. Poor foot/knee hip biomechanics, quadriceps and gluteus muscle weakness or dysfunction, tight thigh muscles like IT band, hamstrings etc. are also responsible for poor patella tracking in the groove resulting in wearing out of the cartilage leading to patellofemoral irritation resulting in PFPS. Any trauma to the front of the knee or patella can also produce PFPS.

Symptom presentation

Usually it starts with slight pain during activities like climbing stairs, running or squatting to sit on to a chair or getting up from a chair. Later on this can become a dull or constant ache causing irritation during activities or sharp pain during an activity. For example pain after sitting for long duration with knees bent as in long drives or watching movie. Most of the time it is activity dependent and staying away from the irritating activity will temporarily help to manage the symptoms. As your PFPS gets worse it can also present in the form of swelling or joint effusion and severe pain.

Diagnosis and treatment

Diagnosis of PFPS is done through a thorough evaluation of the lower back and the lower extremity biomechanics. Physiotherapy is the best way to manage and clear the symptoms of PFPS. If  you have started  experiencing pain while climbing stairs, during your gardening  or sitting down/ getting up from the floor and the pain is been kind of consistent without getting better. A consultation with a physiotherapist will help you with proper assessment of the lower extremity biomechanics and the presence of PFPS.

Once PFPS is diagnosed patients will be provided with a specific exercise program along with manual therapy and taping. The exercises will mostly focus on strengthening the weak hip and thigh muscles and stretching the tight ones. Depending on the assessment findings you may also be suggested to use a patella tracking brace and/or orthotics during physical activity or at work.

From my experience 6-8 weeks of passive physiotherapy followed by another 6-8 weeks of prescribed home exercise program will help in improving the PFPS symptoms in a majority cases.  If symptoms are not improving with 6-8 weeks of physiotherapy and home exercise routine, it will be a good option to go see your family doctor to analyse the need for further diagnostic imaging and consultation with an orthopedic specialist.

So please do not wait till that knee pain gets worse and starts affecting all your activities of daily living. Consult a physiotherapist and you can easily fix it when things are still under your control.

Reference:

http://www.patellofemoral.org/pfoe/c2/sta.html

http://www.physio-pedia.com/Patellofemoral_Pain_Syndrome#cite_note-1

http://orthoinfo.aaos.org/topic.cfm?topic=A00680

http://www.aafp.org/afp/2007/0115/p194.html

https://www.ucsfhealth.org/conditions/patellofemoral_pain_syndrome/

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