Soft Tissue Healing

What is Soft Tissue?

• Skin
• Ligaments – connects bones at joints
• Tendons – attaches muscle to bone
• Fascia – dense connective tissue
• Skeletal Muscle – usually attached to bone
and moves parts of the skeleton
• So, tissue that has not hardened into bone and
cartilage
 What are the Type of Injuries?
• Sprain ligaments are • Intramuscular hematoma
commonly caused by is confined to the muscle
indirect impact, over- compartment which fills
stretching (twisting) up with blood. Is more
• Muscle strains – painful and restrictive of
pulling action, over ROM
stretching, rupture or • Intermuscular hematoma
direct trauma / is when the blood
overuse. Includes escapes through the
tendons fascia and so becomes
• Contusions (bruise) – distributed, thus bruising
 Soft Tissue Healing from Injury
• Healing is a natural restorative response to injury.
• systemic process has got 04 overlapping classic phases:
haemostasis / inflammatory / proliferation / maturation or
remodelling phases.
• Platelets play a crucial role in clot formation during
haemostasis, inflammatory cells debride injured tissue during
the inflammatory phase.
• Epithelialisation, fibroplasias, and angiogenesis occurs during
the proliferative phase. Meanwhile, granulation tissue forms
and the wound begins to contract.
• Maturation phase, collagen forms tight cross links to other
collagen and protein molecules, increasing the tensile strength
of the scar.
 Early vs cellular phase

• 1. Inflammatory phase (0-6days)

 Acute and chronic

• 2. Proliferative phase
 Fibroplasia and granulation tissue formation
 Epithelialization
 Fibroplasia
 Angiogenesis
 Contraction

3. Remodelling phases (3 to 4weeks to 3 months or more)

 1. Inflammatory phase (0-6days
• The acute phase involves three mechanisms that act to stop blood loss
from the wound:

• 1). Local vasoconstriction occurs, lasting a few seconds to as long as 10

min. Larger constrict due to the influence of serotonin and
catecholamines released from platelets. The resulting reduction in the
volume of blood flow in the region promotes increased blood viscosity or
resistance to the flow, which further reduces blood loss at the injury site.

2). The platelet reaction provokes clotting as individual cells irreversibly

combine with each other and with fibrin to form a mechanical plug that
occludes the end of a ruptured blood vessel. The platelets also produce
of chemical mediators in the inflammatory phase: serotonin, adrenaline,
noradrenaline, and histamine. Also ATP is use for energy in the healing
process.
• 3). Fibrinogen molecules are converted into fibrin for
clot formation through two different pathways.
Following vasoconstriction, vasodilation is brought
on by a local axon reflex and approximately 20
proteins that normally circulate in the blood in
inactive form become active to promote variety of
activities essential for healing.

• Phagocytosis- is the activation of neutrophils and

macrophages to rid the injured site debris and
infectious agents. As the blood flows to the injured
area slows, these cells are redistributed to the
periphery, where they begin to adhere to the
endothelial lining.
• Mast cells and basophils are also stimulated to
release histamine, further promoting vasodilatation.
• Bradykinin also promotes vasodilation and increase
blood vessel wall permeability, contributing to the
formation of tissue exudates
• .The acute inflammatory response is of relatively
brief duration and involves activities that generate
exudates- plasma like fluid that exudes out of tissue
or its capillaries and is composed of protein and
granular leukocytes (white blood cells).
• In the Chronic inflammatory response is of
prolonged duration and involves the presence of
nongranular leukocytes and the production of scar
 02. Proliferative phase
• Formation of granulation tissue is a central
event during the proliferative phase. Its
formation occurs 3-5 days following injury and
overlaps with the preceding inflammatory
phase. Granulation tissue includes
inflammatory cells, fibroblasts, and
neovasculature in a matrix of fibronectin,
collagen, glycosaminoglycans, and
proteoglycans.
 A. Epithelialisation

• Epithelialisation is the formation of epithelium over a

denuded surface. It involves the migration of cells at the
wound edges over a distance of less than 1 mm, from one
side of the incision to the other. Incisional wounds are
epithelialized within 24-48 hours after injury. This
epithelial layer provides a seal between the underlying
wound and the environment.
• The process begins within hours of tissue injury.
Epidermal cells at the wound edges undergo structural
changes, allowing them to detach from their connections
to other epidermal cells and to their basement
membrane.
• When epithelialisation is complete, the epidermal cell
assumes its original form.
 B. Fibroplasia

Fibroplasia is the process of forming fibrous tissue.

• The fibroblast is a critical component of
granulation tissue. Fibroblasts are responsible
for the production of collagen, elastin,
fibronectin, glycosaminoglycans, and proteases
Fibroblasts grow in the wound as the number of
inflammation cells decrease.

• Fibroplasia begins 3-5 days after injury and may

last as long as 14 days. Skin fibroblasts and
mesenchymal cells differentiate to perform
migratory and contractile capabilities.
 C. Angiogenesis

• The macrophage is essential to the stimulation of angiogenesis and

produces macrophage-derived angiogenic factor in response to low
tissue oxygenation. This factor functions as a chemoattractant for
endothelial cells. Basic fibroblast growth factor secreted by the
macrophage and vascular endothelial growth factor secreted by
the epidermal cell are also important to angiogenesis.
• Angiogenesis results in greater blood flow to the wound and,
consequently, increased perfusion of healing factors. Angiogenesis
ceases as the demand for new blood vessels ceases.
• Contraction
• Contraction results in a decrease in wound size, appreciated from
end to end along an incision; a 2-cm incision may measure 1.8 cm
after contraction. Depends on the degree of tissue laxity and shape
of the wound.
03. Maturation and remodeling(WEEKS TO
MONTHS)
• The ultimate endpoint following remodeling
depends on the tissue type. This phase is focused on
increasing cellular organisation of the collagen
fibers.
• healing, in contrast, involves fiber alignment and
contraction to reduce the wound size and to
reestablish tissue strength. Complete recovery of
original tissue strength is rarely obtained in
secondary healing because repaired tissue remains
less organized than noninjured tissue, which results
in scar formation.
 The Healing Process
• The healing process after a muscle injury:
• This classification is based on a treatment
protocol . But is not indifferent from other
classifications. It is possible that some phases
overlap, dependable on the individual
response to healing and the type of injury. Not
every patient undergoes all phases to achieve
a full rehabilitation
• 1. PHASE 1: Acute phase: ( 1 to 7 days)
In this phase treatment exists out of the RICE-
method. This method exists of Rest, Ice,
Compression and Elevation. The main goal of
this method is to minimize inflammation and
pain. During the treatment with ice, a flexion
and extension exercises are important but
must be pain free (to prevent further injury).
• 2. PHASE 2: Subacute phase: (Day 3 to < 3
weeks)
This phase starts when signs of inflammation
begin to reduce. Inflammation signs are heat,
swelling, redness and pain. Muscle action is
important to prevent muscle atrophy. When the
patient has a full range of motion without any
pain during this movement, concentric strength
exercises can be done. When there is pain, the
intensity must be immediately decreased.
• 3. PHASE 3: Remodeling phase: ( 1 to 6
weeks )
In this phase, the patient can begin with
stretching exercises to avoid a decrease in
flexibility of the hamstrings. Eccentric
strengthening exercises can also be done in
this stage. These exercises are heavier than
concentric exercises. Therefore it is important
that the muscle is already regenerated
because otherwise, reinjury is possible.
• 4. PHASE 4: Functional phase: ( 2 weeks to 6
months)
The main goal in this stage is to return to sport
without a reinjury. To accomplish this goal, the
patients need to increase their strength,
endurance, speed, agility, flexibility and
proprioception until the normal values of
patient. Sport specific activities are the best
indicators for a patient who returns to his
sport.
• 5. PHASE 5: Return to competition phase: ( 3 weeks
to 6 months)
When a patient returns to the competition, it is
important that he can avoid a reinjury. Only when
the patient has a full range of motion, strength,
coordination and psychological readiness, he is
allowed to return to competition. A study reveals
that a program consisting of progressive agility a
trunk stabilization is effective in promoting return to
sports and in preventing for reinjury. This program
turned out to be less risky for acute reinjury than
isolated stretching and strengthening exercises. [2]