Musculoskeletal Disorders
■ Strain: Overstretching, overexertion, overuse of soft tissue: tends to be less severe than a sprain, occurs from slight trauma or unaccustomed repeated trauma of a minor degree. This term is frequently used to refer specifically to some degree of disruption of the musculotendinous unit.
■ Sprain: Severe stress, stretch, or tear of soft tissues, such as joint capsule, ligament, tendon, or muscle. This term is frequently used to refer specifically to injury of a ligament and is graded as first- (mild), second- (moderate), or third- (severe) degree sprain.
■ Muscle/tendon rupture or tear: If a rupture or tear is partial, pain is experienced in the region of the breach when the muscle is stretched or when it contracts against resistance.
■ Grade 1 (first-degree). Mild pain at the time of injury or within the first 24 hours. Mild swelling, local tenderness, and pain occur when the tissue is stressed.
■ Grade 2 (second-degree). Moderate pain that requires stopping the activity. Stress and palpation of the tissue greatly increase the pain. When the injury is to ligaments, some of the fibers are torn, resulting in some increased joint mobility.
■ Grade 3 (third-degree). Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with severe pain. Stress to the tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint.
Management During the Acute Stage
Tissue Response: Inflammation
The inflammatory stage involves cellular, vascular, and chemical responses in the tissue. During the first 48 hours after insult to soft tissue, vascular changes predominate. Exudation of cells and solutes from the blood vessels takes place, and clot formation occurs. During this period, neutralization of the chemical irritants or noxious stimuli, phagocytosis (cleaning up of dead tissue), early fibroblastic activity, and formation of new capillary beds begin. These physiological processes serve as a protective mechanism as well as a stimulus for subsequent healing and repair. Usually this stage lasts 4 to 6 days unless the insult is perpetuated.
Management During the Sub-acute Stage
Tissue Response: Proliferation, Repair, and Healing
During the second to fourth days after tissue injury, the inflammation begins to decrease; the clot starts resolving; and repair of the injured site begins. This usually lasts an additional 10 to 17 days (14 to 21 days after the onset of injury) but may last up to 6 weeks. The synthesis and deposition of collagen characterize this stage. During this stage of healing, the immature connective tissue that is produced is thin and unorganized. I
Initiation of Active Exercises
- Multiple-angle, submaximal isometric exercises. – Muscles should be placed in the shortened or relaxed position so the new scar is not pulled from the breached site. Resting position for the joint may be the most comfortable position. The intensity of contraction should be kept below the perception of pain.
- Active range of motion exercises. Active range of motion (AROM) activities in pain-free ranges are used to develop control of the motion. May use and incorporate diagonal motions. Do not stress beyond the ability of the involved or weakened muscles to participate in the motion.
- Muscular endurance exercises. Exercises for muscle endurance are emphasized during the subacute phase, because slow-twitch muscle fibers are the first to atrophy when there is joint swelling, trauma, or immobilization. Initially, use only active ROM, with emphasis on control. Later during the healing phase, low-intensity, high-repetition exercise with light resistance is used rather than high-intensity resistance. Be certain that the patient is using correct movement patterns without substitution and is informed of the importance of stopping the exercise or activity when the involved muscle fatigues or involved tissue develops symptoms.
- Protected weight-bearing exercises. Partial weight bearing within the tolerance of the healing tissues may be used early to load the region in a controlled manner and stimulate stabilizing co-contractions in the muscles.
Initiation and Progression of Stretching
- Warm the tissues. – Modalities
- Muscle relaxation techniques. – Hold-relax
- Joint mobilization/manipulation. –
- Stretching techniques – Passive stretching techniques, self- stretching, and prolonged mechanical stretching are used
- Massage – Cross-fiber massage
Management During the Chronic Stage
- Progression of Stretching – Stretching of any restricting contractures or adhesions should
be specific to the tissue involved so long as no signs of increased irritation persist beyond 24 hours. - Progression of Exercises for Muscle Performance: Developing Neuromuscular Control, Strength, and Endurance –
- Progress exercises from isolated, unidirectional, simple movements to complex patterns and multidirectional movements requiring coordination with all muscles functioning for the desired activity.
- Progress strengthening exercises to simulate specific demands including both weight-bearing and nonweight bearing (closed- and open-chain) and both eccentric and concentric contractions.
- Progress trunk stabilization, postural control, and balanc exercises and combine with extremity motions for effective total body movement patterns.
- Teach proper body mechanics
- Return to High-Demand Activities
Patients who must return to activities with greater-thannormal demand, such as is required in sports participation and heavy work settings, are progressed further to more intense exercises including plyometrics, agility training, and skill development.- Develop exercise drills that simulate the work or sport activities using a controlled environment with specific, progressive resistance and plyometric drills. As the patient demonstrates capabilities, increase the repetitions and speed of the movement.
- Progress by changing the environment and introducing surprise and uncontrolled events into the activity.
The grades of ligament injuries (strains) can be related to the stress-strain curve.
Grade I—Microfailure: rupture of a few fibers in the lower part of the plastic range.
Grade II—Macrofailure: rupture of a greater number of fibers resulting in partial tear further into the plastic range.
Grade III—Complete rupture or tissue failure
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Ankle and Foot
Ligamentous Injuries: Nonoperative Management
After trauma, the ligaments of the ankle may be stressed or torn. The most common type of ankle sprain is caused by an inversion stress and can result in a partial or complete tear of the anterior talofibular (ATF) ligament and often the calcaneofibular (CF) ligament. The posterior talofibular (PTF) ligament, the strongest of the lateral ligaments, is torn only with massive inversion stresses. There is greater likelihood of an avulsion from or fracture of the medial malleolus with an eversion stress.
Acute Ankle Sprain: Management—
If possible, examine the ankle before joint effusion occurs. To minimize the swelling, use compression, elevation, and ice. The ankle should be immobilized in neutral or in slight dorsiflexion and eversion.
■ Use gentle joint mobilization techniques to maintain mobility and inhibit pain.
■ Educate the patient.
■ Teach the patient the importance of RICE (rest, ice, compression, and elevation), and instruct the patient to apply ice every 2 hours during the first 24 to 48 hours.
■ Teach partial weight bearing with crutches to decrease the stress of ambulation.34
■ Teach muscle-setting techniques and active toe curls to help maintain muscle integrity and assist with
circulation.
Ankle Sprain: Management— Controlled Motion Phase
■ As the acute symptoms subside, continue to provide protection for the involved ligament with a splint during weight bearing. Apply cross-fiber massage to the ligaments as tolerated.
■ Use grade II joint mobilization techniques to maintain mobility of the joint.
■ Teach the patient exercises to be done within tissue tolerance at least three times per day. Suggestions include:
- Nonweight-bearing AROM into dorsiflexion and plantarflexion, inversion and eversion, toe curls, and writing the alphabet in the air with the foot.
- Sitting with the heel on floor and scrunching paper or a
towel and picking up marbles with the toes.
■ If adhesions are developing in the healing ligament, have the patient actively move the foot in the direction opposite the line of pull of the ligament. For the anterior talofibular ligament, the motion is plantarflexion and inversion.
■ As swelling decreases and weight-bearing tolerance increases, progress to strengthening, endurance, and stabilization exercises; include isometric resistance to the peroneals, bicycle ergometry, and partial to full weight-bearing balance board exercises. Have the patient wear a brace or splint that restricts end-range motion to control the range and prevent excessive stress on the healing ligament.
Ankle Sprain: Management—Return to Function Phase
■ Progress strengthening exercises by adding elastic resistance to foot movements in long-sitting (open-chain) and sitting with the heel on the floor for partial weight bearing. Use isokinetic resistance if a unit is available.
■ Progress postural/stabilization and proprioceptive/balance training for ankle stability, coordination, and neuromuscular response with full weight-bearing activities.
■ Incorporate movement patterns, such as forward/ backward walking and cross-over side stepping with
elastic resistance secured around the unaffected lower extremity.
■ Utilize an unstable surface, such as a BOSU® or BAPS® board.
■ Depending on the final goals of rehabilitation, train the ankle with weight-bearing activities, such as walking, jogging, jumping, hopping, and running, and with agility activities, such as controlled twisting, turning, and lateral weight shifting.
■ When the patient is involved in sports activities, the ankle should be splinted, taped, or wrapped, and proper shoes should be worn to protect the ligament from reinjury
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