The Soft Tissues

Trauma and Sports Injuries

G. R. McLatchie, C. M. E. Lennox

• Publisher: Butterworth-Heinemann
• Year: 2013
• ISBN:
  9781483280073
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

The Soft Tissues: Trauma and Sports Injuries focuses on the diagnosis, treatment, and rehabilitation of soft tissue injuries. The publication first offers information on the incidence, nature, and economic effects of soft tissue injury and the anatomy of soft tissues. Discussions focus on economic effects and burden on health care service, nature of soft tissue lesions, muscles, tendons, ligaments, and the skin. The manuscript also examines skin injuries and wound healing and muscle injuries. The text takes a look at the management of the acutely injured joint, tendon injuries with special reference to the hand, and cold injuries. Topics include open flexor tendon injuries of the hand, closed extensor tendon injuries, insertional tendinitis, cold and muscle injury, prevention of cold injury, and cold and the increased risk of accidents. The manuscript also surveys the imaging of soft tissues; physiological testing in sport performance; effect of ultrasound on the biology of soft tissue repair; and injuries to the head, spine, lower and upper limbs, and the eyes. The publication is a vital reference for sports medicine specialists and readers interested in soft tissue injuries.

Part I

General Principles

1

Incidence, nature and economic effects of soft tissue injury

A.O. Adebajo and B.L. Hazelman

Publisher Summary

This chapter gives an overview of incidence, nature, and economic effects of soft tissue injury. Soft tissue injuries, although commonly overlooked in the planning and provision of health care, are disorders of major and increasing importance. While soft tissue problems are rarely associated with mortality, there is a high morbidity from these lesions. A large proportion of local causes of soft tissue rheumatism are related to chronic repetitive low-grade trauma and excessive and unaccustomed use. These factors may also cause partial interruption of the blood supply resulting in incomplete attempts at healing and degeneration, which render these tissues more vulnerable in the middle-aged and the elderly in whom these lesions predominate. Collagen is the basic framework of all soft tissues. Once a tear occurs within the collagen bundles, the defect is replaced by haphazard, loose connective tissue formed in the blood clot, which initially fills the torn area. Thus, the intrinsic structural strength may be reduced significantly, leading to impaired power, mobility, skill, and eventually to further damage.

Introduction

Soft tissue injuries, although commonly overlooked in the planning and provision of health care, are disorders of major and increasing importance. Fortunately there has been an increase in interest with regard to these lesions concomitant with an increase in our understanding of these disorders.

Soft tissue rheumatism includes lesions of tendons and the tenoperiosteal junction, and the development of the unifying concept of the local enthesopathies is a recent finding marking progress in the field of soft tissue rheumatism. The primary forms of these conditions are unassociated with arthritis or connective tissue diseases. Some of these disorders are regional, including sports-related and occupational soft tissue rheumatism problems, whereas others are generalized such as the fibromyalgia syndrome. In general laboratory and roentgenographic examination findings are normal.

Whilst soft tissue problems are rarely associated with mortality there is a high morbidity from these lesions. Since these patients seldom come to surgery, the opportunity to study their pathology has hitherto been infrequent and consequently poorly understood. Recently however much attention is being focused on the histology and biochemistry of tendon (Chard et al., 1985, 1987; Webster and Burry, 1982). A large proportion of local causes of soft tissue rheumatism are related to chronic repetitive low-grade trauma and excessive and unaccustomed use (both at work and at play). These factors may also cause partial interruption of the blood supply resulting in incomplete attempts at healing and degeneration, which render these tissues more vulnerable in the middle-aged and the elderly in whom these lesions predominate. Since the vascular supply to adult tendon is poor, healing of these lesions is slow. Poor tendon repair and degeneration would appear to explain the chronicity of tendon lesions. In vivo work has suggested that tendon healing after damage involves the reaction of surrounding tissue and adhesion without participation of the tendon tissue itself (Moushe et al., 1984). Other studies have revealed that tendons are capable of responding to injury, although it does appear that most actively dividing cells are derived from the superficial part of the tendon. Chard et al. (1987) have shown that the majority of cells obtained from tendon that are capable of replication in vitro are derived from the superficial layer of tendon (epithelium).

Growth characteristics of the cell lines have been established by investigating DNA synthesis using thymidine incorporation in response to stimulation by fetal calf serum. No significant reduction in growth response with increasing age was found.

Initial light microscopy analysis of normal rotator cuff tendons (Chard et al., 1989) suggests a general thickening of blood vessels, fewer tendon fibroblasts, increased mucopolysaccharide and increased calcification with increasing age. Attention has been drawn to the unifying concept of the enthesopathies, suggesting that local ischaemia is the common denominator in their causation. The enthesis is always at risk because the working muscle takes up most of the blood at the expense of the tendon and insertion. Other contributory factors include overstressing, microtraumati-zation, muscular hypertonus and excessive cooling. Endogenous factors such as impaired vascularization, metabolic disorders, endocrine disorders, trophic disorders, toxic damage and even psychological factors may also influence damage to the enthesis. Those tendons without sheaths are better supplied with blood than tendons in sheaths and studies of dynamic in vivo blood flow in these regions may yield valuable information.

Collagen is the basic framework of all soft tissues. Once a tear occurs within the collagen bundles, the defect is replaced by haphazard, loose connective tissue formed in the blood clot which initially fills the torn area. Thus the intrinsic structural strength may be reduced significantly, leading to impaired power, mobility, skill and eventually to further damage.

Recent interest has centred on the role of prostaglandin synthesis and release in response to soft tissue injury due to either trauma or overuse. After injury a prostaglandin ‘cascade’ occurs as a secondary event. Prostaglandins may act synergistically with other inflammatory mediators such as histamine, serotonin and bradykinin to potentiate both swelling and pain. Muscle injuries are associated with bleeding to a greater or lesser degree and interstitial haematomas produce marked pain and loss of function. Muscle regeneration is a slow process. Strains affect muscles; with minor strains, only fibre damage occurs and the muscle sheath is left intact. With more severe strains a partial or complete rupture of fibres and sheath is present. A sprain is an overstretch injury of a ligament. It may affect only a few fibres, or complete or partial tears of tendons may occur. Each tendon is surrounded by a paratenor and, in sites where movement occurs around bone, is further enclosed in a fibrous sheath. Most tendon injuries are due to overuse. In tendinitis and peritendinitis, either the tendon or its sheath becomes inflamed and swollen. Tendovaginitis occurs in sites where there is no synovial sheath such as the anterior tibial tendons as they traverse the front of the ankle joint. The sheath becomes inflamed and there is crepitus and pain on movement (tendovaginitis crepitans). Bursae are found where tendons or muscles move over bony prominences. They may also be subcutaneous and can become acutely inflamed.

Soft tissue injuries due to sport are in essence acute or severe forms of the soft tissue disorders seen in non-sportsmen. The increasing popularity of sport is evidenced by the sight of joggers in the streets and the increasing popularity of marathon runs, gymnasia and fitness training. The last General Household Survey conducted in the UK in 1985 showed that the highest involvement in at least one outdoor sport, excluding rambling, was by full-time students (41%), falling off after this generally young age group, with a continuing greater involvement by professional (27%) than unskilled manual workers (9%). The last decade has seen a dramatic increase in the number of participants in sport. Folsom et al. (1985) state that the proportion of Americans taking regular exercise has more than doubled since 1961. As in the UK, the professional groups participate more and this more vocal group is likely to insist on proper health provision for their sports injuries.

This increase in participation has occurred for several reasons. Firstly there is a general awareness that regular exercise is related to good health. Secondly there is broader acceptance of the ‘sport for all’ concept promoted by successive governments, especially in the USA and Germany but also in the UK, with regular aerobic exercise being advocated as a major component of health promotion and disease prevention for all age groups, from children to the elderly. Unfortunately there is a high level of neuroticism amongst some people with injuries. Even Hippocrates recognized this problem and stated that ‘all parts of the body which have a function, if used in moderation and exercised in labours in which each is accustomed, become thereby healthy, well-developed and age more slowly, but if unused and left idle they become liable to disease, defective in growth and age quickly’. The overstepping of Hippocrates’s suggestion of moderation in exercise, and thus sports appropriate to the individual, leads not to health but to injury, most frequently involving the soft tissues.

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Table of contents

• Cover image
• Title page
• Table of Contents
• Dedication
• Copyright
• Contributors
• Foreword
• Preface
• Acknowledgements
• Part I: General Principles
• Part II: Diagnostic Methods and Problems in Practice
• Part III: Sports Injuries
• Index