Soft Tissue Injuries and Sports Injuries
Injuries to soft tissue, such as muscles, tendons and ligaments oc from a variety of causes and the effects of injury are legion beca people are different. The effects on a sedentary worker will differ fr those on one who is active; housewives will be affected different from their husbands; there are also age differences to be taken in account. The matter is further complicated if those affect, participate in sport and more so if it plays an important part in the lives.
EXAMINATION AND ASSESSMENT
The reader is referred to Problem Orientated Medical Syst˘ (POMR) (Weed, 1968, 1971; Graves, 1971; Cross, 1974; Heath, 19 as a means of keeping medical records and providing a logical forn for patients' notes.
This method of note-keeping organises information re]ating to patient by providing a continued narrative under the headings ofd base, problem list, initial plans and progress notes. The latter written as 'narrative' notes with sub-headings of:
Subjective - what the patient says
Objective - the physiotherapist's observations and evah
Assessment - the physiotherapist's professional opinion
the short- and long-term goals of treatment
Plan - the development of a treatmen.t program
designed to reach those goals.
Examination and assessment of any region should follow the for outlined by Adams, 1981; Cyriax, 1978; Lee, 1978; with emphasis inspection, palpation, range of movement and power. The nature of any pain and its distribution should be noted, as should temperature change, local swelling and joint stability. Sensory testing should not be overlooked. Examination of the upper limb should be conducted with the patient stripped to the waist; for the lower limb, shorts or other appropriate attire should be worn. For examination the padent ideally should be in standing, but may be lying or sitting depending on. his age, height and degree of deformity, and the height of the physiotherapist. It is very difficult for a short physiotherapist to conduct a full examination on a tall patient who is standing. It is tiring and uncomfortable for the elderly or infirm to remain standing for long periods..
The physiotherapist should have at hand a tape measure, scissors, a safety pin, protractor (or goniometer) to aid the examination and should be familiar with the use of a patella hammer.
Once the examination and assessment are completed the physiotherapist is in a position to make a plan of treatment and can then modify and progress the treatment as often as necessary in conducting an 'audit'.
PRINCIPLES OF PHYSIOTHERAPY
The objectives should include:
1. Prevention of further damage
2. Limitation of any bleeding
3. Reduction of pain
, Reduction of swelling
S. Prevention of immobility/stiffness in joints and soft tissues
: i. Maintenance of muscle power
The objectives should include:
1. Restoration of kinaesthetic/proprioceptive mechanisms
2. Reeducation of movement
3. Increase mobility of joint and soft tissue
4. Increase power of muscle
5. Restoration of function and return to daily living
6. Restoration of confidence in affected part
7. Prevention of the return of oedema/swelling
8. Prevention of recurrence of the injury
The modalities of treatment that are used will include ice, compression wtth or without elevation, exercises, ultrasound, interferential, pulsed and unpulsed short wave diathermy.
This type of bandage provides an even pressure and is a well-tried
method of applying compression: It has two main obiectives: 1. To prevent bleeding.
2. To reduceswelling.
(a) The pressure is applied firmly and evenly over a wide area above and below'the joint even though the pressure is needed locally. (Local pressure is more likely to damage underlying soft tissues and blood vessels and thus preiudice the blood supply.)
(b) The area should be well 13added using cotton wool or gamgee in three layers. The padding should be retained using a flannelette or cr6pe bandage.
1st layer: A thick layer of padding is held on by the bandage which is not taken right to the limit of the padding as this prevents the bandage cutting in. Opportunity is taken at this layer to fill in any hollows, e.g. the coulisses at the ankle.
2rid and 3rd layers: As the first with each layer being covered by the bandage.
(c) The limb should be elevated while the bandaging is applied as this reduces the trapping of blood on the distal part of the limb.
(d) The bandages are applied from distally, working proximally. If possible the limb should be in the neutral or shortened position for the ligaments.
GENERAL RULES FOR APPLYING THE BANDAGE
1. An even pressure should be maintained.
2. Obtain two-thirds to three-quarters overlap of each turn.
3. Keep the edges parallel.
4. Bandage from within out and from below upwards (distal proximal).
5. Support the part being bandaged.
6. Use a bandage of appropriate width, e.g. 7.5-10cm (3--4in) for the ankle region; and 10-15cm (4-6in) for the knee or thigh region.
7. Ensure that the bandage stabilises the chosen area.
8. A back splint can be incorporated.
CLINICAL TYPES OF SOFT TISSUE INJURIES
To simplify the understanding of soft tissue injuries they can be classified as: strains; sprains; ruptures; and contusions.
Although it is accepted that a strain may be a milder form of a sprain and be applied to both joints and muscles, in this chapter it is defined as damage to muscle of less than complete rupture. Sprains are concerned with ligaments and joints. For example, a biceps femoris strain is distinct from a sprained lateral ligament of the knee joint. It is doubtful whether contusion can occur without strains or sprains of some degree; haematoma formation is always associated with strains.
Muscle and tendon injuries are referred to as strains and are the result of overstretch. They may be sub-divided as follows:
1. Chronic strain: The iniury develops over a long period of time which leads to fatigue, muscle spasm, myositis and ischaemia and varying degrees of damage.
2. Acute strain: The result of a single violent force to a muscle, usually one that is acting over two ioints, which occurs when the contracting muscle is forcibly stretched; for example, the body-weight of a goalkeeper or iumper when landing acts in opposition to the contracting quadriceps.
Ryan (1969) considered strains in four categories; Williams (1979, 1980) describes three, namely, complete, partial intramuscular and partial interstitial. This is not purely an academic exercise, as accurate classification of the extent of the damage (and so by inference the amount of bleeding, muscle spasm and loss of function) will determine the correct line of treatment.
GRADE I: FIRST DEGREE (MILD CONTUSION OR STRAIN)
The initiating trauma is usually crushing and can be the result of a blow from an outside agency, for example the corner of a desk knocking against the thigh on getting up from the chair behind it. There will be tearing of a small number of muscle fibres, the fascia remains intact and bleeding will be minimal. The resulting muscle spasm, pain and tenderness will be locaiised; pain and spasm in the muscle resists stretching. It is usual with these injuries to have limited local muscle endurance but no interference with function.
If the injury is to an active games player treatment should start immediately after injury by the application of ice for 15-20 minutes followed by a compression bandage applied with moderate pressure. After 20-60 minutes the patient is encouraged to stretch the muscle actively but gently; for example, the quadriceps of a sportsman may be stretched by half squats, partial weight-bearing or he may lie prone and carry out non-weight-bearing knee bending. The maxim is 'little activity taken often'. Ultrasound of low power and dosage may be applied immediately. Ideally the patient should be seen four times a day, or at least morning and late afternoon, then reduced progressively after two to three days. Massage may be given around the site of injury but not directly to it.
If the pain is minimal then light work can be resumed on the next day; pain guides the progression but the site of injury should be protected for two to three days to avoid accidental knocks by the application of a sorbo pad and bandaging. A more conservatiw approach will restrict activity for longer, usually until the pain and an! swelling have been resolved for a week.
GRADE 'II: SECOND DEGREE (MODERATE STRAIN)
The trauma is more severe- a greater blow is required. There will be a larger number of muscle cells crushed and torn over a wider area. The fascia is still intact and so the haematoma is confined within the muscle even though the bleeding is considerable. The undamaged muscle and subcutaneous fat will be displaced with the formation of a definite palpable mass which is partially liquid and partially clotted blood. The area of the injury will be very tender with considerable pain. The resulting spasm is more severe than it is with Grade I injuries so there is very little muscle extensibility or contractility. There is a longer time scale for recovery with this level of injury.
Initial treatment starts immediately, or at least within 24 hours, by the application of ice, compression with elevation using a Robert Jones bandage or Tubigrip. No active movement or stretching of affected muscle is allowed for at least 24 hours, although active exercises may be encouraged for unaffected parts in an attempt to maintain basic fitness. If the patient can tolerate the discomfort or pain then'rhythmical static contractions (auto-esisted if possibleI are allowable but no movement of the joints above and below the'injury.
The patient with lower limb muscle damage is allowed to be non-weight-bearing on crutches with a pressure bandage. Dispersal agents containing hyaluronidase can be applied to the injury if there is no wound. Gentle effleurage and kneading proximally is particularly helpful. The patient should be seen at least twice, preferably four times, a day.
After 24 hours: After removal of the pressure bandage, active muscle contraction is encouraged. Extensibility is gained by moving antagonist muscles. Proprioceptive neuromuscular facilitation techniques (PNF) such as slow reversals,, hold-relax and timing for emphasis are of particular benefit. Stretching may be started within the tolerance of the patient. Non-weight-bearing, massage and dythmical static contractions may need to be continued; ultrasound, if of low power output and duration, may be used.
472 hours: All previous treatment is continued with more emphasis .n active unresisted contractions and extensibility, altfiougfi a hbld-relax contract-relax proprioceptive neuromuscular facilitation technique can be adopted, If a good range of movement and full static contraction are obtained then the patient can be progressed to partial .weight-bearing if applicable. Transverse frictions to the affected area • an be added to the massage manoeuvres.
72 hours: Continue the above treatment regime while allowing increasing progression. The pressure bandage can be removed and need not be replaced unless the swelling increases rapidly. Progressive resisted exercises can be instituted with the weight and load commensurate with pain and discomfort. Fowler (1977) outlined a technique for finding the 10-12 Repetition Maximum (RM) which can be useful later. By trial and error, the amount of weight that can just be lifted (the one repetition maximum- 1RM) once by the patient has first to be found; then the 10-12RM is calculated by taking either two-thirds or three-quarters of the IRM which is the amount of weight that will allow maximal power to be developed.
If the lower limb muscle is involved then progress to full weight-bearing should start; when full range of movement .is attained progress from fast walking to jogging to running is allowed.
Assessment and fitness testing is essential before full training is allowed although the return to work may be very much earlier.
If a hard mass is still present in the muscle after four weeks from injury time, myositis ossificans should be suspected; treatment must be stopped and the patient referred back to the doctor.
GRADE III: THIRD DEGREE (SEVERE STRAIN)
This level of injury involves a larger area of muscle. The fascia is torn at least partially, more than one muscle may be involvect and more than one area in the muscle affected. The bleeding, though considerable, is more diffuse due to the fascial tear and an intermuscular haematoma forms.
Treatment: This follows that oudined for Grade II but the patient should be admitted for a period of in-patient care. Progression is much slower; although the patient can mobilise non-weight-bearing in 24-48 hours, partial weight-bearing should not be started too early. Stretching can start five to seven days after injury and active exercises on the second day. Analgesics may be necessary for any pain.
GRADE IV: COMPLETE RUPTURE
The force causing this injury is more than that required to produce Grade III. There is an immediate contraction of muscle ends, with an obvious gap between them. In some instances the sound of rupture may be heard.
Muscle spasm is very severe and widespread with very acute pain.
of the muscle, and inversely proportional to the spasm of the muscle. There is considerable swelling. Active contraction will be absent;
theoretically, there is no limit to extensibility but the acute spasm will prevent it.
Unless joints are involved in the trauma there is no loss of movement produced by the antagonists except the inhibition by the muscle spasm and pain. There is obvious loss of movement produced by agonists in the active range.
Treatment: It is not considered useful to suture the muscle ends together. It is more important to try and secure the fascial sheath, evacuate blood and secure haemostasis. Then a compression bandage is applied and the muscle immobilised for 10-21 days in a shortened position. Physiotherapy may include movement of all free joints; exercises to all unaffected muscles of other groups; and rhythmic static contractions in the area of the injury if possible. If a lower limb muscle is involved the patient may be allowed up non-weight-bearing after 48 hours. Treatment is as outlined for a Grade III injury with slower progression. The use of low frequency current (e.g. faradism) to produce passive contraction, assist mobility of muscle fibres and affect recovery of muscle fibres probably by influencing fast and slow twitch fibres and the distribution of motor units and fusimotor systems, is still under investigation (Pette, 1980). It should be considered as a treatment modality. Physiotherapists will use short wave diathermy, interferential and diapulse as appropriate.
The regime described refers to the muscle belly but there are other sites where the muscle can be damaged:
1. Musculo-periostealjunction: This occurs usually by indirect trauma with pain, little or no swelling and some loss of function. (The degree of swelling will depend upon the extent or degree of damage.)
2. Musculo-tendinousjunction: Shows similar signs and symptoms but a greater loss of function.
3. In the tendon: The tendon is painful and swollen especially if there is a sheath. There is marked loss of function and no high level activity is possible.
4. At the tendon-periosteal junction: There is usually very little tenderness or swelling but considerable loss of function.
General signs and symptoms of soft tissue injury
The level o pain, swelling, tenderness and loss of function are determined by the degree of damage.
There will be increased pain on passive stretch and on active .contraction. To differentiate between the pain caused by moving an inert structure or by contraction of a muscle it is necessary to cause contraction of the muscle against resistance but allow no movement to take place. If this isometric effort produces pain the possibility of there being a damaged ligament is eliminated (Cyriax, 1978). There is varying loss of function and muscle spasm. Tenderness which is local at first will spread later. Swelling may be of very rapid onset and there will be bruising due to tracking under the influence of gravity.
Treatment: The general aims of treatment will be to relieve pain and muscle spasm, restore function and stop- and limit the effects of- the bleeding. Further damage and injury should be prevented by using techniques which are effective and appropriate for the stage of the injury.
Contusions or bruises
These are usually caused by direct blunt violence, crush or direct contact with another person or a hard landing surface. More often than not the skin is unbroken with extravasatJon of blood into the subcutaneous tissue due to capillary damage. The normal blood flow is affected because of occlusion of capillaries and pressure of any swelling. Normal tissue nutrition is impaired. There is stiffness of the part because of pain, swelling and muscle spasm.
The aim of first aid is to limit any bleeding and a hyaluronidase/ heparinoid type of dispersant such as Lasonil, Hirudoid or Movelat cream or gel, is very useful if used within 48 hours and if there is no wound present. Cold compresses and pressure bandages will also be effective in limiting the bleeding and reducing the pain. Depending on the extent of the bruising there may or may not be loss of function. If there is loss of function then it is reasonable to assume that there is at least Grade II/III muscle damage and appropriate action has to be taken.
In addition to the superficial haematoma of a contusion there are two Other types described which are decided by the state of the muscle sheath. Both are caused by damage to blood vessels within the muscle resulting in extravasation.
In this category the blood is contained within the immediate area of the muscle by an intact muscle sheath. After an injury producing bleeding, tension within the muscle increases; the bleeding soon stops and haematoma formation is completed within two hours. It remains friable for two to three days during which time there is danger of further bleeding if more trauma occurs.
If the muscle sheath is torn then the extravasated blood seeps into the space between muscle in the fascial planes. The resulting haematoma is more diffuse and bleeding continues longer as tension does not build up. The extravasated blood tracks under influence of gravity distally and shows a discolouration beneath the skin.
It is difficult to separate inter- and intramuscular haematoma as they show very similar signs in the first 48 hours or so. After this time they can be differentiated. The characteristics of an intermuscular haematoma are:
1. Disappearance, or drastic reduction, of swelling at 48-72 hours; followed by
2. Reappearance of stronger muscular contraction.
3. Evidence of tracking of blood as the bruising shows some distance from the primary lesion.
4. Pain is moderate only.
RESOLUTION OF HAEMATOMA
Organisadon of the haematoma occurs because removal of the blood and exudate is impaired by damage to the blood and lymph vessels, especially the arterioles and the venules. Compression of the veins by congestion, and lack of muscular action in the muscle fascial pump due to pain and spasm, impairs reabsorption and allows organisatiort tO occur.
Recovery and repair
Repair involves two processes, the formation of connective tissue and the regeneration of muscle tissue.
The tissue is infiltrated by macrophages which are converted into fibroblasts; together with existing fibroblasts these undergo mitosis because of inactivation of the inhibitory enzymes present in healthy tissues. The fibroblasts secrete procollagen, a precursor of collagen which with the fibrocytes forms scar tissue which, as it matures, strengthens and shortens.
MUSCLE TISSUE (Allbrook, 1980)
Skeletal muscle is able to regenerate and in so doing will close a gap providing it is not too large. Muscle fibres grow at the rate of 1.0-1.Smm per day and need a smooth interface along which to grow. Usually this is impaired by the proliferation offibroblasts and collagen forming too much scar tissue to allow regeneration to occur, and the defect is usually too large. It has been shown that after minor damage
due to pressure there is rapid recovery and within 24 hours after iniury damaged fibres cannot be distinguished from the undamaged.
The cycle of events following severe damage to fibres with associated haematoma is muscle fibre necrosis, phagocytosis and regeneration.
Much of the research work has been performed on animals, and in 1966 Allbrook et al noted that . . . 'it would appear that in clinical cases activity is an important factor in speedy and effective muscle recovery. Active joint and muscle movements provide a suitable environment for muscle and soft tissue regeneration'.
Further work is needed to determine if the repair process can be enhanced and a suitable environment for repair produced by using low frequency electrical stimulation, e.g. fa'radic type currents. There is evidence to show that trophic changes occur when muscles are stimulated electrically (Hudlicka et al, 1980).
The major problem following laceration and repair of a flexor t6ndon is that functional recovery is hindered by the formation of adhesions which restrict tendon excursion. Potenza (1962) showed that adhesions to repaired tendons occur at each point where the physical integrity of the tendon is disrupted. Excision of the synovial sheath following tendon repair appears to have no adverse effect on the healing process nor on the functional result but if the bony floor of the digital tunnel is damaged through removal of the flexor tendon and disturbing the vincula brevia then extensive adhesions form. Matthews and Richards (1976) demonstrated that adhesions tend to form in the presence of a combination of suturing the tendon, removing the digital theca and immobilisation. (See also Matthews (1979) and Potenza (1980).)
When flexor tendons are divided within the flexor digital sheath there is proliferation of fibroblasts and vascular elements of the surrounding tissues which are damaged at the time of injury. At the same time resting tenocytes are transformed into tenoblasts within the cut ends of the tendon. Repair is then effected by the proliferation of these cells and the synthesis of new collagen fibres (Matthews and Richards, 1974). The initial collagen is laid down at right angles to the long axis of the repaired tendon. In 18-21 days the collagen is re-aligned and in response to tension lies parallel to the long axis. During this time the synovial sheath regenerates. Within 21-25 days there is enough collagen deposited to allow gradual active movement
and unrestricted use can be allowed after five weeks; at 128 days the wound is completely matured and it would be difficult to identify the scar histologically (Potenza, 1980).
The optimum time to commence active mobilisation of a repaired digital tendon is 23-25 days when the scar tissue is sufficiently strong to withstand stress.
Bass (1969) describes an injury to a joint as having three potential effects; (a) on ligaments only, (b) to the joint producing a synovitis and effusion, and (c) a combination of (a) and (b).
Injuries to ligaments are conventionally described as sprains and are classified in three degrees of severity. These injuries are caused by overstretching at the extreme of the range and are either acute or chronic; most acute lesions will occur in the lower limb or the spine. The medial ligaments of the ankle are damaged during eversion and the lateral ligament by inversion. Damage to the collateral ligaments at the knee occurs during rotary stress on a flexed knee or by a person falling over an outstretched leg, the medial ligament being the one most commonly affected.
GRADE I: FIRST DEGREE (MINOR SPRAIN)
With a Grade I sprain there will be minimal damage with some pain and tenderness at the site of injury. Swelling will be slight and there will be some loss of function. The differential test is to put the ligament at stretch and thus a knowledge of functional anatomy is essential to the physiotherapist.
Treatment: Ice, followed by the application of a Tubigrip bandage, crpe bandage or other type of support, and limitation of use for the first 24 hours. If the injury is to a lower limb ligament then the patient may be allowed to walk but to do little else with the injury during this time. Early commencement of static muscle contractions is desirable gor two reasons: first, the blood flow is maintained and the swelling reduced; second, developing strong muscles will develop strong ligaments (Inglemark, 1957).
GRADE II: SECOND DEGREE (SEVERE SPRAIN)
A greater force is required to produce this level of iniury: many more fibres are involved or a ligament may be partially detached from its attachment. The patient should be assessed medically or (in certain clinics/departments) by an experienced physiotherapist. Swelling is considerable but takes time to develop. Pain and tenderness are more acute. Movement is limited and, if in the lower limb, the patient is unable to bear body-weight even if the knee or ankle is kept stiff and straight. Function is very limited.
Immediate treatment: This involves the use of ice, compression and elevation if appropriate. To reduce pain the doctor may inject a local anaesthetic but activity must be restricted until later when the effects have worn off.
GRADE III: THIRD DEGREE (COMPLETE RUPTURE)
With a Grade III sprain there is rapid onset of effusion, very considerable pain and tenderness, the join, is unstable and there is complete loss of function. This must be assessed medically as the ligament rupture may result in displacement.
Treatment: First aid treatment involves the use of ice and compression with splinting and rest. If the ligament is displaced it is repaired surgically and the limb put in plaster of Paris for six to eight weeks. If it is not displaced plaster of Paris is applied to the limb and retained for six to eight weeks.
Static exercise must be started at once and all non-affected areas must be exercised. After about a week isometric movement can be attempted inside the plaster cast. For a lower limb injury weight- bearing is restricted and the patient is instructed in the use of sticks. When the splint is removed tissue mobility is encouraged and ultrasound, transverse frictions, and hydrotherapy are used. Effusion is controlled by the use of piessure bandaging correctly applied. At the appropriate time the patient joins classwork in the gymnasium.
Cyriax (1978) stated that this term should be abandoned as it is a symptom common to many disorders; it is not a diagnosis. Wiles (1959) said very much the same, especially in the chronic sense. Synovitis is an inflammation of the synovial membrane due for example to trauma, chondromalacia, loose bodies, arthritis, tubercu- Iosis, syphilis or haemophilia. Depending on the site it will mean that there is also damage to ligaments around the joint. The extent of trauma will decide the degree of synovitis; within the knee the menisci, cruciate or collateral ligaments may be involved. If all three are involved the description 'unhappy triad' has been applied O'Donahue, 1970).
Dislocation will damage the synovial membrane, so will 'nipping' of the membrane between the bony ends, even though it is thought that this is not possible. Direct blows will certainly damage. In some patients arthritis may lead to acute synovial rupture. Typically, synovitis is seen in the vigorous person who attempts to carry on despite the effusion.
SIGNS AND SYMPTOMS
There is characteristic swelling which has taken some time to develop. The joint area will be hot and red and the swelling will fluctuate on palpation. Pain may be present over the injured structure but more often there will be a feeling of tension or pressure due to the swelling. "the joint will be held in a relaxed position away from the extremes. Muscle atrophy will occur rapidly especially when the knee joint is involved.
In a synovial rupture of the knee the patient typically describes
getting up from a chair, going upstairs or circuit training, such as step-uPs or stride jumps, and feels a sudden pain at the back of the knee which rapidly swells, spreading into the calf causing an increase in girth of 5-7.5cm (2-3in) after several hours. The synovial fluid is irritating and leads to an inflamed oedematous leg. Homan's sign is positive and the condition is often mis-diagnosed as deep vein thrombosis. The signs of synovids arc similar to those of a haemarthrosis (blood within the joint).
DIFFERENCE BETWEEN HAEMARTHROSIS AND SYNOVITIS
With haemarthrosis the swelling is generalised and occurs rapidly indicating that there is significant intra-articular injury. Less serious injury produces an effusion which is manifest by swelling occurring over a period of hours; the effusion is serous. The classic type of injury to a joint has been described as capsular sprain which can be identified with the Bass classification (Williams, 1964). Thus capsular sprain can involve the whole joint, a specific capsular structure or ligament either as partial or complete sprain.
Signs: Pain on certain movements and extremes associated with local spasm. Clinical instability will only be demonstrable in a complete tear and even then it may be difficult due to muscle spasm. Swelling is usually slight although in some cases gross superficial swelling may be present, e.g. in damage involving the fibular collateral ligament.
Ligament damage alone: The affected area is rested with a Robert Jones type compression bandage. Ice is useful to help reduce any swelling. Transverse frictions may be given to the site after insonadon with low power ultrasound for 3-5 minutes as the latter will have anaesthedsed the part. Graduated activity is begun at once and isometric action of muscles around the joint is essential.
Synovitis: Ice and compression with elevation as appropriate. Relative rest with specific instructions as to what can and cannot be done. If swelling persists for 48 hours, and if it interferes with mobility, then the joint may be aspirated. After aspiration the joint may be infiltrated with 25-50mg hydrocortisone which may be repeated if necessary. Other anti-inflammatory drugs such as phenylbutazone (Butazolidln) or ibuprofen (Brufen) may be prescribed. After aspiration isometric exercises should be encouraged progressing to a graduated exercise regime when the effusion has cleared. Where necessary weight- bearing must be reduced to a minimum.
HEALING OF LIGAMENTS
When there is a complete tear or a rupture of a ligament the ends. retract and the gap fills wxth blood, not because of bleeding from the ligament but from the damaged subcutaneous tissues. Eventually the clot organises by invasion from fibroblasts, collagen is laid down joining the ends within two weeks. There is insufficient strength to be fully functional until six to eight weeks have passed with restoration of collagenous continuity.
It has been reported that the unstressed length of ligaments is the same if allowed to heal without suturing a it is if the ligament is sutured (Potenza 1980). If, for example, the medial ligament at the right knee is stressed by pushing the thigh medially with the left hand and the leg is pulled laterally with the right hand the sutured ligament will not give or lengthen but the unsutured ligament will do so, the stretch depending on the amount of fibrous tissue between the ends. The suggestion is that for maximum stability of joints, esPecially in the young and in athletes, the damaged ligament should be sutured.
Combined synovitis and ligamentous damage
The synovitis is given priority of treatment.and the injured ligament is protected from further damage.
Bursae are membranous sacs lined with synovial membrane and sited so that they prevent friction or wear and tear of muscle and tendons as they pass over bone. They are of two sorts:
1. Normally occurring (true) bursae are found subitcromially, and at the elbow, knee and heel.
2. Adventitious bursae occur in response to new fnctlon on tendons over bone and can occur anywhere, e.g. hip, ischial tuberosity or at the medial side of the great toe.
The response to injury or disease of both 'types is the same, inflammation, which may be the result of mechanical irritation or bacterial infection.
The inflammation arises because of excessive pressure, friction or gouty deposit. The wall of the bursa becomes mildly inflamed as a result of unaccustomed activity, exercise or ill-fitting shoes. The sacs become filled with clear serous fluid and are not usually painful unless pressured, e.g. a bunion or calcaneal bursitis.
Treatment: Rest, perhaps in a sling for the upper limb and restricted weight-bearing for the lower limb. Short wave diathermy, ice or infra red irradiation as appropriate. Muscle strengthening if necessary (PNF is useful, using slow reversals); mobilising if there is any limitation in joint freedom. The doctor may inject hydrocortisone into the bursa; this requires reduced activity for two to three days afterwards. In intractable cases of chronic pain the bursa may be removed surgically.
This may be an acute infection with a pyogenic organism, or a chronic
infection with a low grade Organism such as tuberculosis.
Treatment: Rest; ppropriate antibiotics with surgical drainage or excision. If there is an operation then pre- and postoperative physiotherapy is indicated. Short wave diathermy and massage may be given to the scar but not to the bursa.