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Soft Tissue Injury and Repair Pt 2 - Coggle Diagram
Soft Tissue Injury and Repair Pt 2
Tendinitis vs Tendinosis:
Tendinitis: microscopic tear in MT junction
-attended by localized swelling and tenderness
tendinosis: degenerative process
-chronic irritation or inflammation
-occurs at tendon-bone interface
tendinitis and tendinosis differentiated by clinical exam
-hard to differentiate paratenonitis from tendinitis
paratenonitis refers to inflammation or thickening of paratenon (double layer of loose areolar tissue attached to outer connective tissue surface of tendons without synovial lining)
Tendinitis vs tendinosis treatment
Tendinitis:
-conservative
-reduce inflammatory process (NSAIDs, injection, ice rest, ionto)
Tendinosis:
-NSAIDs and injection not as effective
-eccentric program (10-12 weeks)
-may require surgical intervention to remove diseased tissue
Immobilization after soft tissue injury
-alters rate of biological remodeling
-results in increased density of cells (usually fibroblasts), presence of myofibroblasts, reduction in hyaluronic acid and chondroitin sulfate and 4-6% decrease in water content after 9 weeks of immobilization
-collagen degradation > synthesis, overall reduction in collagen
effect on stiffness and strength:
-9 weeks of immobilization results in 50% decrease in ultimate strength of MCL (in rabbits)
-contracture formation due to increase in cross-linking of collagen
-remodeled connective tissue is thicker and weaker (due to random alignment of collagen fibers)
effect of stress and motion on connective tissue repair after injury:
-scar tissue forms earlier, is well-oriented, not attended by adhesions
-exposure of scar tissue to physiologic tensile force results in more mature and stronger union of tendon and ligament
-articular cartilage involves greater amount of collagen, GAGs, less cellularity, and fewer joint adhesions when accompanied by modest joint movements
-US improves tensile strength of tenotomized achilles 2-4 days post-op (may be due to limiting inflammatory process and encouraging fibroplasia
-high volt ESTIM appears to augment protein synthesis and ultimate strength of tendon if applied early during stages of healing
Myositis ossificans: formation of heterotopic bone in soft tissue after contusion or trauma involving the muscle, connective tissue, blood vessels, and underlying periosteum
occurs most often in males 15-30 following contusion to thigh or fracture/dislocation of elbow
presence of undifferentiated cell (inducible osteogenic precursor cell) is activated by trauma differentiates into osteoblast
Precise mechanism by which trauma activates stem cell is elusive
tendon/ligament reconstruction
-most of research is in animal models
-patellar tendon autograft strongest on day it is implanted
-strength diminishes to <50% during first 4-8 weeks post-op
-slow transformation of collagen type and revascularization of graft -6 months post-op
-1 year post-op graft is reported to have 82% of its original strength
-clinical implications: protect graft early, encourage closed-chain axial loading activities (?) to minimize shear, emphasize max motor unit activation throughout rehab
location of tendon/ligament repair (mid-substance vs. insertional)
insertion site repairs heal faster than mid-substance
-primarily due to availability of adequate blood supply
-intra-articular vs.extra-articular environment-presence/absence of synovial linind/fluid which usually encourages healing
-distribution and level of fibroblast activity may play role
response of articular cartilage to chondroplasty (microfracture, abrasion, drilling, etc)
-used to stimulate tissue repair in articular cartilage defects
-perforations made in subchondral bone to produce "super clot"
-over 8 week period super clot heals with hybrid mixture of fibrocartilage and hyaline-like collagen (type 2)
-hybrid mixture thought to function better than fibrocartilage alone
-animal/human studies suggest it is durable enough to function like AC
evidence supporting AC repair
-chondrocyte cells harvested from patient and injected under periosteal flap covering AC defect
-2 year follow-ups indicate excellent results for those with femoral condyle transplants. most developed hyaline like cartilage in defect
-patellar lesion have not done as well potentially due to shear forces and non correction of underlying malalignment
-research is encouraging for focal defects, but not for generalized OA of joint
-AC exposed to electric and EM fields can lead to sustained upregulation of growth factors improving viability
-degrative enzymes in synovial fluid of OA joints not conducive to cell transfer
Growth factors involved with soft tissue healing
chemotactic factors
-prostaglandins, complement, platelet derived growth factor, angiokines
competence factors
-activate quiet cells, PDGF, prostaglandins
Progression factors
-stimulate cell growth such as IL-1 and somatomedins
Enhancing factors
-fibronectin and osteonectin
Factors that may aid in soft tissue repair
-PRP in soft tissue healing
-macrophage secreted myogenic factors in muscle repair
-chondrocyte growth factors and bone morphogenetic proteins in improving cartilage repair
effect of NSAIDs on muscle recovery
-short term (<1 week) may improve recovery -long term (>1 month) may decrease recovery
factors that affect allograft strength
-freezedrying reduces immunogenic response, by dec strength
->3 megarad dec strength
-2 megarad combined with ethylene oxide dec strength
-have slower and less predictable recovery than autografts