Strain,sprain cramps
- 1. MUSCLE STRAIN & LIGAMENT SPRAIN -Dr. Krupal Modi(MPT) 3/9/2018
- 2. MUSCLE STRAIN/TEAR Types of muscle injuries: • Laceration- cut by external trauma • Contusion- compressive forces to muscle , contact sports • Strain- when muscle can not withstand excessive tensile forces placed on them and are therefore associated with eccentric muscle action.
- 3. • Muscles are strained or torn when some or all of the fibers fail to cope with the demands placed upon them. • Muscles that are commonly affected are the hamstrings, quadriceps and gastrocnemius; these muscles are all biarthrodial (cross two joints) and thus more vulnerable to injury. • A muscle is most likely to tear during sudden acceleration or deceleration(because muscle in lengthened state and contracting forcefully).
- 4. • When the muscle is strained the initial injury is usually associated with disruption of the distal myotendinous junction and fibres distal to this but still near the myotendinous junction. • Injuries to the musclebelly only occur with the application of very high forces. • The contractile elements are the first tissues to be disrupted; with the surrounding connective tissue not being damage until high forces are applied. PATHOPHYSIOLOGY
- 5. • The contractile elements are relative stiff in comparison to the surrounding connective tissue and hence become disrupted at lower forces than the surrounding connective tissue.
- 6. • Muscle strains are classified in three grades. • A grade I strain involves a small number of muscle fibers and causes localized pain but no loss of strength. • A grade II strain is a tear of a significant number of muscle fibers with associated pain and swelling. Pain is reproduced on muscle contraction. Strength is reduced and movement is limited by pain. • A grade III strain is a complete tear of the muscle. This is seen most frequently at the musculotendinous junction.
- 9. Healing • Muscles heal by a repair process that can be divided into two phases: • (1) the destruction/injury phase resulting in rupture and necrosis of the muscle fibres; and • (2) Repair and regeneration.
- 10. Destruction/injury phase • This phase results in damage to the vascular supply and as oxygen can no longer reach the cells, they die and release lysosome. • Excessive force to a musclefibre results in tearing of the sarcoplasm and the cells respond by forming a contraction band , creating a protective barrier. • Within 15 minutes of injury the damaged tissue consists of disrupted extracellular tissue and dead cells, platelets and plasma, which themselves release powerful enzymes such as thrombin thereby setting off an inflammatory cascade. • A haematoma is formed to fill the gap between ruptured muscle fibres.
- 11. • Clinically tissue inflammation presents as redness, heat, swelling and pain of the tissues. • The redness, heat and swelling are due to an increased blood flow and so blood within vascular beds in the area, with the swelling developing as a result of the increased local tissue pressure due to inflammatory exudates leaking into the interstitial space. • The pain is due to the initial damage to local nerves and irritation of nerves in the area from the inflammatory chemicals release by the damaged tissue.
- 12. Repair and regeneration phase • The regeneration process starts within 3–6 days following injury, reaching a peak between day 7 and 14. • After the initial injury, the inflammatory chemicals released from the injured tissues attract lymphocytes and macrophages to the area. • Macrophage phagocytosis of the necrotic material then occurs removing the debris.
- 13. • In response to injury satellite cells proliferate and differentiate into myoblasts and then become multinucleated myotubes. • These then fuse with parts of the muscle fibre that have survived the initial injury and attempt to breech the gap in the muscle.
- 14. • A number of factors predispose to muscle strains: • inadequate warm-up • insufficient joint range of motion • excessive muscle tightness • fatigue/overuse/inadequate recovery • muscle imbalance • previous injury • faulty technique/biomechanics • spinal dysfunction.
- 15. SIGNS AND SYMPTOMS • Pain • Muscle spasm • Muscle weakness • Swelling • cramp
- 16. Treatment of muscle injuries • It is frequently cited within the sports medicine literature that the initial treatment of musculoskeletal injuries should be rest, ice, compression and elevation (RICE). • However, this acrimony is likely to be more valid in the less metabolically active tissues such as ligament and bone. • Muscle with its capacity for rapid regeneration due to the nature of its constituent tissues requires a modified approach. This modification is based around the balance between absolute rest and the absolute level of loading to stimulate appropriately the rapidly developing tissues.
- 17. Rest and mobilisation • Early mobilisation, rather than immobilisation or complete rest, has been advocated . • Studies have shown early mobilisation aids with regeneration of muscle fibres. • The exact level of loading is difficult to judge, it must be sufficient to stimulate and challenge the developing tissues, but not so great that it causes tissue breakdown . • This includes early weight bearing to help promote scar tissue re-alignment and controlled running to reduce muscle inhibition.
- 18. • Immobilisation and poorly controlled early loading (low or high), have been shown to lead to the development of contracted scar tissue, which blocks the linking of myotubes across the injury, thereby stopping the formation of a functional contractile element, and the surrounding areas then become more susceptible to further injury.
- 19. Ice • Studies have shown that ice results in a significantly smaller haematoma and less inflammation in the initial stages of the injury. • Reducing tissue temperature results in vasoconstriction, thereby limiting the amount of bleeding in the area . • It also reduces the metabolic rate of the tissue and therefore reduces the demand for oxygen , decreasing the hypoxic damage. • 5–10 minutes in the initial stages and repeat every 60minutes within the first24–48hour to reduce the inflammatory effects.
- 20. Compression and elevation • Compression is an area where research is lacking, it has been stated that it results in a reduction in the severity of bleeding and swelling following an injury , though the only evidence often present in support of this theory is from studies involving ligament injuries. • A recent clinical study by Thorsson et al. (2007) utilising 40 athletes with calf injuries found compression resulted in no significant difference in reducing muscle haematoma, or speed of recovery of the injury using compression.
- 21. • Elevation is still one of the preferred and easiest methods of immediate management used in sports medicine for muscular injuries. • It simply relies on the use of gravity to promote venous return and lymphatic flow to drive swelling/oedema from the area. • It would appear that the greatest benefit that comes from compression and elevation is that it ensures that the athlete rests during the acute inflammatory phase of the first 72 hours following injury.
- 22. Strengthening exercise • Isometric exercise can begin after 2–5 days and should be performed within the limits of pain . • Frequency, duration and intensity are limited by the patients’pain. • Some therapists advocate three sets of 10 repetitions using 5–10 second holds to begin with at intensity within pain tolerance. • These then are undertaken at multiple angles, beginning in mid range then progressing to inner range (shortened position) then outer range (lengthened position).
- 23. • Once these can be undertaken in a pain-free manner throughout the available range, then isotonic exercises can commence. • Dynamic movement and isotonic contraction is then incorporated again starting in the strongest position (mid range, close to a 90◦ joint angle) progressing to and finishing in the functionally most relevant (outer range with eccentric and concentric contractions most often).
- 24. • There is preferential atrophy of type 1 muscle fibres with disuse. • Therefore, initially an endurance based programme should be used, (three sets of 15 repetitions at 40–60% of one repetition maximum) this would be progressed to strength (4–6 sets of 3–6 repetitions at 85– 95% of one repetition maximum and then power training (3–5 sets of 3-5 repetitions at 75–85% of one repetition maximum) or plyometrics depending on the specific requirements of the muscle.
- 25. Stretching • Passive stretching (at the end of available range) should be avoided for the first 72 hours as a minimal period, possibly the athlete should not stretch for the first 7–10 days following injury. • The reasons for this are twofold. • Firstly, the healing tissue is weak and intolerant of tensile loading and so is likely to be damaged by uncontrolled stretching. • The second reason is there is no physiological need in the early stages to stretch, as the scar does not beginning to shrink until around the tenth day post injury when fibroblasts begin to be converted to myofibroblasts and contract and draw the wound ends together.
- 26. • Prior to the tenth day post injury it would be more appropriate to take the muscle through its full available pain-free range without any attempt to force the muscle beyond this point. • Each stretch should be held at the end of available range within the limits of pain. Time, frequency, duration and intensity of stretch remain debateable in the literature. Some research suggests passive stretching should be held for a minimum of 15 seconds with 6–8 sets per day.
- 27. Electrotherapy • Pulsed shortwave diathermy is particularly helpful for enabling re-absorption of the muscular haematoma as it is particularly effective in more vascularised tissues such as skeletalmuscle. • It is thought to work at the cell membrane level, resulting in an ‘up regulation’ of cellular behaviour. This results in an improved rate of oedema dispersion,resolution of the inflammatory process and promotes a more rapid rate of fibrin fibre orientation and deposition of collagen.
- 28. • Therapeutic ultrasound • This is the use of high intensity soundswaves,which research has been shown can help recovery of tissues at a cellular level by increasing ion transport across cells and increasing metabolism within the cell and increasing fibroblastic and angiogenic activity.
- 29. • Muscle stimulation may prove a further useful electrotherapeutic adjunct for the treatment of muscle injuries. • It has been shown to decrease oedema, muscle inhibition and the rate of strength loss with inactivity . • However, muscle stimulation has not been shown to be useful in the regaining of strength in the injured athlete.
- 30. Summary key points of muscle healing and rehabilitation • RICE should be implement as soon as possible following acute injury. • Early mobilisation and weightbearing should also be encouraged • Stretching and strength exercises can start within pain-free range as soon as possible • Fitness and conditioning of the athlete should be incorporated within the early rehabilitation programme without compromising the injury • Specificity, and functional fitness are imperative to help return the athlete back to sport without recurrence.
- 32. LIGAMENT SPRAINS • The stability of a joint is increased by the presence of a joint capsule of connective tissue, thickened at points of stress to form ligaments. • The ends of the ligament attach to bone. Ligament injuries range from mild injuries involving the tearing of only a few fibers to complete tears of the ligament, which may lead to instability of the joint. • Most common ???
- 33. Pathology • Pathological changes in ligaments may occur due to structural and functional failure. • Any strain to a ligament may cause a long-term joint instability. • Following a strain, ligaments do not heal by producing an identical tissue; instead, a scar tissue is formed. (The scar tissue presents with an uneven matrix, smaller in diameter collagen fibers, weaker collagen crosslinking and a limited creep.)
- 35. • The blood circulation is also affected with a long term reduction in blood circulation to the scar tissue. • Although scar tissue is formed relatively fast, there are still mechanical and chemical changes months and years after the injury, though it never has a normal appearance or function again, resulting in a high level of reoccurrences. • Ankle sprains, for example, reoccur in 73% of all athletes (Yeung et al. 1994). • As ligaments provide the proprioceptive sensory nerve supply to the central nervous system, any ligament injury may cause further problems in the neuromuscular system.
- 36. healing process • Following a strain injury, the gap within the ligament fills with blood to start the inflammation phase. • Fibroblasts proliferate, the ligaments revascularise and the gap becomes filled with scar tissue . • Fibroblasts start producing scar tissue made by type III collagen. This collagen-type material creates a rapid, disorganised structure with weaker cross links to fill the gap between the ligament’s edges quickly. • Followed is the long remodelling period, which can take months or even years as the matrix and collagen fibres are rearranged to have stronger bonds.
- 37. • Ligament injuries are divided into three grades. • A grade I sprain represents some stretched fibers but clinical testing reveals normal range of motion on stressing the ligament. • A grade II sprain involves a considerable proportion of the fibers and, therefore, stretching of the joint and stressing the ligament show increased laxity but a definite end point. • A grade III sprain is a complete tear of the ligament with excessive joint laxity and no firm end point. Although they are often painful conditions, grade III sprains can also be pain-free as sensory fibers are completely divided in the injury.
- 39. SIGNS AND SYMPTOMS • Pain • Swelling • Bruising • Joint instability • Not be able to move the joint
- 40. Treatment • The viewpoints of the main two treatments are 1) the immobility, long rest and braces versus 2) the sooner-than-later active treatment. • A systematic review finds no data to support any benefits from using braces in sprained ligament (Pietrosimone et al. 2008). • Another study found that early activity, rather than long immobility, would make the healing time shorter, more complete and that the ligaments would appear stronger.
- 41. MANAGEMENT • For grades I–II a non-operative active treatment approach is the most common and usually comprises rest(for a limited period),ice, compression and elevation (RICE), isometric and isotonic exercises and proprioceptive training. • RICE therapy (Rest, Ice, Compress, Elevate) for the first 24 to 48 hours. • 1. Rest the injured area (reduce regular exercise or activities as needed)
- 42. • 2. Ice the injured area, 20 minutes at a time, four to eight times a day (cold pack, ice bag, or plastic bag filled with crushed ice and wrapped in a towel can be used) • 3. Compress the injured area, using bandages, casts, boots, elastic wraps or splints to help reduce swelling. • 4. Elevate the injured area, above the level of the heart, to help decrease swelling while you are lying or sitting down.
- 43. Proprioceptive training • Proprioceptive training concentrates mostly on the lower limb, in particularly post sprain in the ankle joint. • To maintain the proprioceptive neural function by continuously using the joint in a challenged position. • It has been found that even the use of unsupervised, home proprioceptive exercises reduces the rate of reoccurance in atheletes. Example: balanced and coordination training performed on the wobble board, both as a treatment and preventative measurements.
- 44. • For grade I and II sprains, treatment aims to promote tissue healing, prevent joint stiffness, protect against further damage and strengthen muscle to provide additional joint stability. • The treatment of a grade III sprain may be either conservative or surgical.
- 45. PREVENTION • Although we cannot prevent all sprains and strains from occurring, there are some tips on how to avoid them: • Stretch before you workout with heavy items • Use proper footwear for the activity you are doing • Warm up adequately before activities
- 46. Summary key points of ligaments • Ligaments offer joints stability with sensory feedback to the central nervous system. • Ligaments’ blood supply is the limiting factor in many healing process of sprain. • Ligaments heal by the process of laying down scar tissue, which exhibits structurally different tissue organisation and is weaker compared to the original ligament.
- 47. • Most frequent treatment for grade I–II sprains are RICE, early mobilisation, isometric and isotonic strengthening exercise, neuromuscular rehabilitation and return to normal function as soon as possible. • For grade III injury, reconstructive surgery is an option.