When a therapist considers a patient’s rehab program several factors must be addressed. Beyond looking at individual strength levels and activity levels desired we must consider the severity of injury. We specify our programs to appropriately stress the injured tissue.
Tendons and ligaments should be treated in the same manner by considering the mechanics of injury, adaptation to activity, and healing response during rehabilitation. Mechanical loading of a tendon/ligament can create injury with a single high load strain or repetitive loading or misuse injuries. The single high load strain can result in sprains, partial tears or ruptures which are more prevalent in ligaments, as muscle will rarely contract hard enough to tear a tendon. Achilles and patellar tendon ruptures are usually a result of muscle forces in combination with external forces. In repetitive strain situations the tissue injury begins with micro damage, which if created too quickly cannot be repaired fast enough. This results in pain, swelling and degradation of the tendon/ligaments mechanical properties. When this cycle continues, it can create a progressive degradation and make the tissue more susceptible to traumatic overload injuries. Tensile load is dictated by increased length of tissue stretched by percentage. A 1.5%-3.0% tensile load is common in normal activities, however without this stimulation the tissue will weaken, and with increasing the tensile load tendon strength will improve. Injury is created usually with over 10% tensile loads.
After a soft tissue injury the tendon/ligament will go through a typical soft tissue healing process. Inflammation 3-7 days, proliferation 2-3 weeks followed by remodeling after 2-3 weeks and up to more than one year, all in overlapping stages. Through the remodeling phase, the tissue fibers increase cross-links and align in the direction of tensile load. It is critical that the rehabilitation program provide adequate stress in a program of progressive loading that avoids inflammation. We must avoid over stress that can impede the healing process and cause scar tissue to form. The paradox of functional tissue training comes in balancing between sufficient loading to guide the healing process and overzealous loading that continues inflammation and tissue degradation. We minimize inflammation with early mobilization and PROM-AAROM program. This may be increased as the tissue progresses into the remodeling phase by progressive AROM, isometric and eccentric exercises followed by high repetition progressive exercises including CKC with proprioceptive and perturbation activities assisting in return to normal upper level activities.
Careful management of exercise type and intensity relative to the particular tendon or ligament injury, as well as awareness of the phase of recovery the tissue has reached is the key in progressing the patient. Optimal management will produce minimal pain and increased speed of healing, providing improved patient satisfaction.
About the Author:
Ross Hutchinson, PT, CSCS, has been actively involved in Colorado physical therapy since 1991.
You can contact Ross at his Arvada, Colorado office.
