UNDERSTANDING SOFT TISSUE INJURIES
When I look back over the last 20 plus years of being involved in Athletic Injuries I would say the most common thing I alleviate is “fear”. The fear of, “Is this injury career ending?” or “Is this injury going to take me out for the season”, or “Is this a simple injury?”. I hope that this article will answer some of those questions.
I have often thought of authoring a book and calling it “1001 Ways On: How – Not – To – Do - It”. If, as health-care providers, we would simply preface our statement with, “Based on our current research ….” or, “Based on my personal experience …” we would probably gain a lot more respect. Instead, we suffer the continual embarrassment of acting like authorities and having new technology prove otherwise. With this in mind, I would like to share this article entitled, “Understanding Soft-Tissue Injuries”. This is based on both my personal experience as a sports chiropractor for the last 20 years, of which the last 4 years spent as Director of Doll Repair /chiropractor for the Los Angeles Derby Dolls.
Since there is about as much controversy over the understanding and treatment of the body as there is in present day politics, I will do my best to stay within the areas of agreement between all disciplines. Please keep in mind that we are talking about most people and the “atypical” patient can and does walk into our office on a daily basis.
In understanding the mechanics and healing process involved with soft tissue injuries, I think it best to start with defining soft vs. hard tissue injuries. The easiest way to make this distinction is hard tissue is bone. Everything else is soft tissue. This includes, muscle, tendon (attaches muscle to bone), connective tissue (cartilage, ligaments (attaches bone to bone), fascia, joint capsules), bursas, arteries, veins and capillaries, organs and brain. Some injuries to the soft tissue will heal faster than others such as minor bruises or “track rashes” as they mostly affect the outer or superficial layers of the skin and its blood supply, or simple muscular strains, as both these areas are rich in blood supply. Other injuries may take quite some time to heal such as, more complex strain’s to the muscle in which there is a partial or complete tear, or damage to the ligaments and other connective tissues where there is a relatively poor blood supply.
When it comes to muscle and ligaments, we have classified damage into 3 categories based on the extent of damage. We call this damage a sprain, a strain, or both a sprain/strain. A “sprain” is an overstretching or tearing of the ligament, whereas a “strain” is an overstretching or tearing of muscle and/or tendon. We can however, “strain” a muscle through overuse or what we call a “repetitive trauma”. This is why it is important to have an understanding of exercise workouts and how to avoid overusing a muscle or muscle group. The three classifications of the sprain/strain component are as follows: Grade I: Is a “simple” sprain/strain, and usually is an overstretching or what we refer to as a “fraying” of the muscle fibers. Grade II: is a more complex sprain/strain. This involves a partial tearing of the muscle and/or ligament. Grade III: is the most complex sprain/strain. This involves the complete tearing of the muscle and/or ligament. In all three cases of sprain’s there will also be accompanying tearing of little arteries, veins and capillaries which will cause bleeding to occur in the area. Many times this will show up as bruising or discoloration in the area of the injury. The bleeding is an important part of the healing process as it is what will form the “scab” or blood clot to knit the tear back together.
Speaking of blood clots, this might be a good time to address another type of injury commonly seen with Roller Derby athletes; the ever-popular “hematoma”. The bruise that elevates like someone placed anywhere from a golf ball to a grapefruit under your skin. Most the time these go away with time, massage, heat and ultrasound, but sometimes if they are not treated properly they can harden and calcify in the muscle creating a painful condition we call Myositis Ossificans. Roughly translated, this means inflamed muscle tissue which is turning to bone. We will talk about this condition and the treatment for it in an upcoming article.
Regardless of the injury, whether it is hard or soft tissue, the following three stages of healing must occur in order to achieve full recovery. The first stage is known as the “Inflammatory” stage. Inflammation is defined as, “redness, heat and edema (swelling)”. The inflammatory stage usually lasts 2-3 days or 48-72 hours and usually has the following characteristics: Redness, Heat, Swelling, Decreased Movement or Ability to Contract the Muscle, Discoloration around the Injury, and, of course, Pain. As previously mentioned, with any injury, there is the tearing of blood vessels/capillaries. During the first 24 hours the blood vessels are closing off the bleeding to the area and forming a “clot” or “callus” around the injured tissue. This process is necessary for the “knitting” of the injured tissue. It begins the next phase known as the “Repair” phase.
In the Repair phase, new blood vessels are being created. The same tissue as the original tissue is being reproduced, and collagen fibers, aka scar tissue, are being laid down across the injury in all directions. Unfortunately, with muscle, the repaired area loses some or all of its elasticity (stretch). There are various forms of soft tissue therapies that address this. Many of which can return a great deal of the stretch back to the muscle. The repair phase usually starts within 48 hours of the injury and can last up to 6 weeks depending on the extent of the injured area.
The last phase of the healing process is known as the “Remodeling” phase. The collagen fibers have stopped being laid down or are minimally being laid down. This is when the newly formed tissue has the ability to start strengthening. As the increased demands or stress loads are placed on the repaired tissue, the fibers will start to align themselves for maximum strength. There are several theories as to how to maximize this. Cyriax, an orthopedist in the 1930’s, came up with what we call “transverse” or “cross” friction massage. This technique breaks down the fibers of the scar tissue in all directions. Most myofascial release techniques tend to go only in the direction of the fibers. Their understanding is, one is tacking down the fibers in the direction of the original fibers and breaking down the other more binding fibers. I personally, use my intuition and may use either cross fiber or aligned fiber approach. I do feel that regardless of the approach, it is crucial to stretch the muscle after it has been worked on. The stretching will help lay down the fibers to determine the maximum tensile strength of the fiber.
The athlete usually starts some type of rehabilitation program during the repair phase. This consists of range of motion, resisted range of motion, balance, neuro-muscular re-education (band work/ball work), stretching. In general, the athlete prepares for the re-entry into their training and sport. This is dependent on several factors: pain, severity of injury and of course if there is a doctor-involved doctor’s advice. By the time the athlete is through with the Remodeling phase they are ready to start the Re-Entry to Training period.