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SOFT TİSSUE PAİNSOFT TİSSUE PAİN
Prof. Dr. Ece AYDOĞ Prof. Dr. Ece AYDOĞ
Physical Medicine and Physical Medicine and RehabilitationRehabilitation
SOFT TİSSUESOFT TİSSUE
LigamentLigament TendonTendon MuscleMuscle CartilageCartilage FasciaFascia SynoviumSynovium Articular cartilageArticular cartilage Adipose tissueAdipose tissue Intervertebral discIntervertebral disc
MechanismMechanism
Soft tissues are susceptible to failure Soft tissues are susceptible to failure under conditions of stress and strain.under conditions of stress and strain.
The most common mechanism of The most common mechanism of injury include:injury include:– acute traumaacute trauma; sudden overloading; sudden overloading– repetetive overuserepetetive overuse or overload; or overload;
Acute injuriesAcute injuries Sudden onsetSudden onset Classic Classic
inflammatory inflammatory reactionreaction
ResolutionResolution
Chronic injuriesChronic injuries Insidious onset of Insidious onset of
pain pain Less intense Less intense
inflammationinflammation Progressive Progressive
functional functional impairmentsimpairments
Tendency toward Tendency toward reinjuryreinjury
soft tissue healingsoft tissue healing
Cellular response to injuryCellular response to injury Repair and regeneration; immature Repair and regeneration; immature
collagen is laid downcollagen is laid down Scar remodeling; continue for yearsScar remodeling; continue for years
Succesful healing of soft tissuesSuccesful healing of soft tissues
Type of injuryType of injury AgeAge VascularityVascularity NutritionNutrition Genetic and hormonal factorsGenetic and hormonal factors Activity levelActivity level
Overuse InjuriesOveruse Injuries
Intrinsic variablesIntrinsic variables
AgeAge Flexibility imbalanceFlexibility imbalance Muscle imbalance/weaknessMuscle imbalance/weakness Anatomic malalignmentAnatomic malalignment Genetic predispositionGenetic predisposition
Ekstrinsic variablesEkstrinsic variables Training errors/poor Training errors/poor
techniquetechnique Enviromental factorsEnviromental factors Equipment factorsEquipment factors
Ligament sprainsLigament sprainsFirst DegreeFirst Degree
Signs and SymptomsSigns and Symptoms Minimal pain and Minimal pain and
swellingswelling No ligamentous No ligamentous
instabilityinstability Minimal localized Minimal localized
tendernesstenderness
Functional Functional ImplicationsImplications
No significant loss No significant loss of functionof function
Bracing often Bracing often unnecessaryunnecessary
Rapid return to Rapid return to activityactivity
Ligament sprainsLigament sprainsSecond DegreeSecond Degree
Signs and SymptomsSigns and Symptoms Significant pain Significant pain
and swellingand swelling Subtle structural Subtle structural
instabilityinstability Occasional joint Occasional joint
effusioneffusion
Functional Functional ImplicationsImplications
Protective bracing Protective bracing indicatedindicated
Significant activity Significant activity limitationslimitations
Susceptible to Susceptible to recurrencerecurrence
Ligament sprainsLigament sprainsThird DegreeThird Degree
Signs and SymptomsSigns and Symptoms Marked swelling Marked swelling
and hemarthrosisand hemarthrosis Structural Structural
instabilityinstability
Functional Functional ImplicationsImplications
Immobilization Immobilization indicatedindicated
Surgery may be Surgery may be requiredrequired
Prolonged Prolonged functional functional limitationlimitation
Tendon InjuriesTendon Injuries Paratenonitis or/Paratenonitis or/ TenosynovitisTenosynovitis
TendinitisTendinitis
TendinosisTendinosis
InflammationInflammation of the paratenon of the paratenon withwith
associated pain, swelling, andassociated pain, swelling, and
tendernesstenderness
Inflammation of the tendon Inflammation of the tendon withwith
associated vascular distruption andassociated vascular distruption and
inflammationinflammation
Intratendinous athrophy andIntratendinous athrophy and
degenerationdegeneration with a with a relative absencerelative absence
of inflammationof inflammation; a palpable nodule; a palpable nodule
may be present over tendonmay be present over tendon
Tendon InjuriesTendon Injuries
Paratenonitis with Paratenonitis with tendinosistendinosis
Partial or complet Partial or complet rupturerupture
Acute inflammationAcute inflammation
superimposed onsuperimposed on
chronic tendinitischronic tendinitis
Acute inflammation isAcute inflammation is
often superimposed onoften superimposed on
chronic inflammationchronic inflammation
with tendinosiswith tendinosis
Tendon Injuries: Functional ScaleTendon Injuries: Functional Scale
GradeGrade11
22
33
44
55
SymptomsSymptomsPain after exercise, subsiding within 24 hoursPain after exercise, subsiding within 24 hours
Minimal discomfort with exercise, withoutMinimal discomfort with exercise, without
activity limitationactivity limitation
Pain that interferes with exercisePain that interferes with exercise
Pain interfering with activities Pain interfering with activities
Rest pain that interfering with sleepRest pain that interfering with sleep
Muscular InjuriesMuscular Injuries
ContusionsContusions StrainsStrains AvulsionsAvulsions Delayed-onset muscle soreness Delayed-onset muscle soreness
(DOMS)(DOMS)
Muscular InjuriesMuscular Injuries Contusions:Contusions:Mild, moderate, severeMild, moderate, severe
– Soft tissue swellingSoft tissue swelling– Motion restrictionMotion restriction– Functional impairmentFunctional impairment
Strains:Strains:– result from result from overstreching or peak contractionoverstreching or peak contraction of the musculotendinous of the musculotendinous
unit, paticularly unit, paticularly during eccentric muscular contractionsduring eccentric muscular contractions– tend to occur more commonly at the tend to occur more commonly at the musculotendinous junctionmusculotendinous junction– The The injured muscle generatesinjured muscle generates reduced peak tensile loads and reduced peak tensile loads and
contractile forces, contractile forces, up to 50 % of its strengthup to 50 % of its strength– Contractile forces begin to recover as soon as Contractile forces begin to recover as soon as 1 week after1 week after an acute an acute
strainstrain– There is often There is often prolongedprolonged and sometimes and sometimes permanent losspermanent loss of complete of complete
contractile abilitycontractile ability– Premature return to activity may increase the risk for further injuryPremature return to activity may increase the risk for further injury
AvulsionsAvulsions Delayed-onset muscle soreness Delayed-onset muscle soreness (DOMS)(DOMS)
DOMSDOMS
occurs within the first 24 to 48 hours after occurs within the first 24 to 48 hours after an intense bout of exercise (often an intense bout of exercise (often repeated eccentric muscular contractions)repeated eccentric muscular contractions)
both inflammatory and metabolic both inflammatory and metabolic mechanismmechanism
self limitingself limiting occasionaly requires activity modification occasionaly requires activity modification
and antiinflammatory medicationand antiinflammatory medication
Rehabilitation of Soft-Tissue Rehabilitation of Soft-Tissue InjuriesInjuries
Prescribe activity-spesific trainingPrescribe activity-spesific training Correct functional deficienciesCorrect functional deficiencies Improve strength, flexibility, general Improve strength, flexibility, general
conditioningconditioning Address structural deficiencies Address structural deficiencies Promote healingPromote healing Control pain and inflammationControl pain and inflammation Establish correct diagnosisEstablish correct diagnosis
BursitisBursitis Subacromial Subacromial
(subdeltoid) bursitis:(subdeltoid) bursitis: Close relationship between Close relationship between
the subacromial bursa and the subacromial bursa and rotator cuffrotator cuff
Frequently used when Frequently used when describing the pathology of describing the pathology of impingementimpingement
Reactive phenomenaReactive phenomena
Acute traumatic bursitisAcute traumatic bursitis
Olecranon bursitisOlecranon bursitis Recurren elbow Recurren elbow traumatrauma:work :work
or leisure activitiesor leisure activities
InflammationInflammation; gout, RA; gout, RA
InfectionInfection
Treatment:Treatment:– AspirationAspiration– Rest, elbow protection and Rest, elbow protection and
NSAII drugsNSAII drugs– Corticosteroid injection (RA Corticosteroid injection (RA
and gout)and gout)– Antibiotic therapy for Antibiotic therapy for
infectioninfection– SurgerySurgery
Trochanteric bursitisTrochanteric bursitis Most common cause of pain Most common cause of pain
about the hip regionabout the hip region
Pain decreases at rest, Pain decreases at rest, worse at nigth, especially worse at nigth, especially lying on the affected sidelying on the affected side
Treatment:Treatment:– RestRest– Abductor and iliotibial band Abductor and iliotibial band
strechingstreching– NSAİDsNSAİDs– Infiltration of a local Infiltration of a local
anesthetics and anesthetics and corticosteroidscorticosteroids
– SurgerySurgery
Prepatellar bursitisPrepatellar bursitis
"housemaid's "housemaid's knee"knee"
Anserine bursitisAnserine bursitis
Overuse of the hamstringsOveruse of the hamstrings, , especially in especially in athletes(runners) with tight athletes(runners) with tight hamstrings is a common hamstrings is a common cause of goosefootcause of goosefoot
TraumaTrauma OsteoarthritisOsteoarthritis
Treatment:Treatment:– reducing Inflammation reducing Inflammation – hamstring stretcheshamstring stretches – quadriceps quadriceps
strengtheningstrengthening– InjectionInjection– surgerysurgery
Biceps Biceps tenosynovitisi:tenosynovitisi:
Yergason's supination sign
Speed test
Treatment:– rest, analgesics, rest, analgesics,
NSAIDs, and local NSAIDs, and local injection of injection of glucocorticoids. glucocorticoids.
Supraspinatus tendinitis Supraspinatus tendinitis (painful arc syndrome):(painful arc syndrome):
often associated with often associated with shoulder impingement syndrome. .
inflammation of the inflammation of the supraspinatus/rotator supraspinatus/rotator cuff tendon and/or the cuff tendon and/or the contiguous contiguous peritendinous soft peritendinous soft tissuestissues
Supraspinatus tendinitisSupraspinatus tendinitis
injury, overuse, or injury, overuse, or with aging as the with aging as the tendon loses elasticity tendon loses elasticity
TreatmentTreatment– relieve pain and reduce relieve pain and reduce
inflammationinflammation– flexibility training and flexibility training and
strengthening exercisesstrengthening exercises– injectioninjection
Infrapatellar tendinitisInfrapatellar tendinitisJumpers KneeJumpers Knee
Overuse injuryOveruse injury and is often and is often associated with jumpingassociated with jumping
Tenderness at the tibial Tenderness at the tibial tubercletubercle or at the or at the inferior inferior pole of the patellapole of the patella
Rupture of the patella Rupture of the patella tendontendon usually occurs in usually occurs in patients younger than 40 patients younger than 40 years old and is associated years old and is associated with chronic patella with chronic patella tendinitistendinitis– Patients usually present Patients usually present
with with anterior knee painanterior knee pain and the and the inability to extend inability to extend the knee.the knee.
Aschilles TendinitisAschilles Tendinitis The Achilles tendon is The Achilles tendon is
the largest tendon in the largest tendon in the human body the human body
The The most frequentlymost frequently ruptured ruptured tendontendon
Achilles tendonitisAchilles tendonitis, a , a common common overuse overuse injuryinjury and and inflammationinflammation of the of the tendon. tendon.
EnthesopatiesEnthesopaties
Lateral epicondylitis Lateral epicondylitis ((tennis elbow):tennis elbow):
commonly caused by commonly caused by inflammation of the inflammation of the extensor carpi radialis extensor carpi radialis brevis tendonbrevis tendon at at
the outer edge of the the outer edge of the elbowelbow
caused by overusing caused by overusing the forearm extensor the forearm extensor muscles muscles
Medial Medial epicondylitis epicondylitis (Golfer elbow):(Golfer elbow):
Brachialis Brachialis Brachioradialis Brachioradialis Pronator teresPronator teres
Flexor carpi radialisFlexor carpi radialis– help to flex and help to flex and
pronate wrist and pronate wrist and fingersfingers
Overuse injuryOveruse injury
Lateral epicondylitisLateral epicondylitis Medial epicondylitis Medial epicondylitis
Treatment:Treatment:– ice, ice, – rest, rest, – NSAIDs, NSAIDs, – compression, compression, – streching, streching, – strength exercise,strength exercise,– corticosteroid corticosteroid
injection,injection,– surgery surgery
Myofascial Pain Syndrome (MPS)Myofascial Pain Syndrome (MPS)
Myofascial pain is a chronic condition that Myofascial pain is a chronic condition that affects the muscle and fasciaaffects the muscle and fascia– involve either a single muscle or a muscle involve either a single muscle or a muscle
group group
– pain usually originatespain usually originates in specific areas of the in specific areas of the body, called myofascial body, called myofascial trigger pointstrigger points (TrPs) (TrPs)
– these trigger points commonly develop these trigger points commonly develop throughout the body, typically where the fascia throughout the body, typically where the fascia comes into contact with a musclecomes into contact with a muscle
Myofascial Pain SyndromeMyofascial Pain Syndrome
– nonprogressive nonprogressive – nondegenerativenondegenerative– noninflammatorynoninflammatory
It is caused by the activation of one or more trigger It is caused by the activation of one or more trigger pointspoints
Majority of these people will not develop severe Majority of these people will not develop severe symptoms and will be able to continue on with their symptoms and will be able to continue on with their normal routinesnormal routines
However, about 14% of the population will develop However, about 14% of the population will develop a chronic form of the syndrome, resulting in a chronic form of the syndrome, resulting in persistent pain and discomfortpersistent pain and discomfort
Myofascial Pain SyndromeMyofascial Pain Syndrome
Myofascial pain disorder is very common in Myofascial pain disorder is very common in fibromyalgia sufferersfibromyalgia sufferers
It was once thought that myofascial pain It was once thought that myofascial pain syndrome was actually a kind of fibromyalgiasyndrome was actually a kind of fibromyalgia
However, this is now known not to be the caseHowever, this is now known not to be the case
It is possible to have both fibromyalgia and It is possible to have both fibromyalgia and chronic myofascial syndrome chronic myofascial syndrome
Aggravating FactorsAggravating Factors
Poor posturePoor posture and body mechanics and body mechanics
Repetitious exercisesRepetitious exercises or work or work Anything that restricts movement or Anything that restricts movement or decreases decreases
oxygen supply to the musclesoxygen supply to the muscles
PPerpetuating erpetuating FFactorsactors
Impaired sleepImpaired sleep Chewing gum Chewing gum Smoking cigarettesSmoking cigarettes Dental workDental work Exposure to organic chemicals or heavy metals Exposure to organic chemicals or heavy metals İnhalant and food allergiesİnhalant and food allergies Nutritional deficienciesNutritional deficiencies Metabolic and endocrine dysfunctionMetabolic and endocrine dysfunction Malabsorptive conditions in the gutMalabsorptive conditions in the gut Chronic infectionsChronic infections FibromyalgiaFibromyalgia Alcohol ingestionAlcohol ingestion Stress (physical and/or mental)Stress (physical and/or mental)
Signs and symptoms of myofascial Signs and symptoms of myofascial pain syndrome may include: pain syndrome may include:
Deep, aching pain in a Deep, aching pain in a musclemuscle
Pain that persists or Pain that persists or worsensworsens
Muscle stiffnessMuscle stiffness
Joint stiffness near the Joint stiffness near the affected muscleaffected muscle
Area of tension in the Area of tension in the
muscle that may feel muscle that may feel like a like a knot or tight spotknot or tight spot and may be particularly and may be particularly sensitive (“sensitive (“trigger" or trigger" or "tender" points"tender" points))
Other SymptomsOther Symptoms
FatiqueFatique AnxietyAnxiety StressStress Abnormal REM Abnormal REM
sleepsleep HeadacheHeadache Irritable bowel Irritable bowel
syndromesyndrome DepressionDepression
MPS Versus FMMPS Versus FM Some people believe that MPS and FM are not Some people believe that MPS and FM are not
entirely distinct entitiesentirely distinct entities
Both MPS and FM may fall under the umbrella of Both MPS and FM may fall under the umbrella of “Central Sensitivity Syndromes” (CSS) or “Central Sensitivity Syndromes” (CSS) or “Dysregulation Spectrum Syndrome” (DSS)“Dysregulation Spectrum Syndrome” (DSS)
Other conditions included under this umbrella are Other conditions included under this umbrella are migraine head-aches, tension headaches, migraine head-aches, tension headaches, temporomandibular pain syndrome, primary temporomandibular pain syndrome, primary dysmenorrhea, chronic fatigue syndrome, dysmenorrhea, chronic fatigue syndrome, irritable bowel syndrome, periodic limb irritable bowel syndrome, periodic limb movement disorder, restless leg syndromemovement disorder, restless leg syndrome
TreatmentTreatment
Multi-disciplinary approach Multi-disciplinary approach Essential to identify and eliminate or Essential to identify and eliminate or
correct perpetuating factorscorrect perpetuating factors
TreatmentTreatment
1-1-Physical therapy
– ""Stretch and spray"Stretch and spray" technique technique – MassageMassage therapy therapy
2-2-Trigger point injection
3-3-MedicationMedication is used to treat other is used to treat other conditions that often occur with conditions that often occur with myofascial pain, such as insomnia myofascial pain, such as insomnia and depression.and depression.
Complex Regional Pain Syndrome Complex Regional Pain Syndrome (CPRS)(CPRS)
Reflex Sympathetic Reflex Sympathetic Dystrophy (RSD)Dystrophy (RSD)
CausalgiaCausalgia Sudeck's AtrophySudeck's Atrophy
DefinitionDefinition
Chronic condition affecting the nerves and Chronic condition affecting the nerves and blood vessels of one or more extremitiesblood vessels of one or more extremities
Extremely unpleasant burning sensations, Extremely unpleasant burning sensations, swelling, sweating, color changes, and swelling, sweating, color changes, and other distressing symptomsother distressing symptoms
CRPS 1CRPS 1
(Reflex sympathetic dystrophy- RSD)(Reflex sympathetic dystrophy- RSD)– No nerve damage existsNo nerve damage exists
CRPS 2CRPS 2 (causalgia) (causalgia)– This produces similar symptoms after a nerve This produces similar symptoms after a nerve
injury has occurredinjury has occurred
CausesCauses
Not known:Not known:– overactivity of the sympathetic nervous overactivity of the sympathetic nervous
systemsystem
– inflammation inflammation
Risk FactorsRisk Factors
Trauma Fractures Fractures Lacerations Lacerations Burns Burns Frostbite Frostbite Surgery Surgery Penetrating injury Penetrating injury Crush injury Crush injury An injection into the muscle An injection into the muscle Blood draws Blood draws Diabetic neuropathy Diabetic neuropathy Multiple sclerosis Multiple sclerosis StrokeStroke
SymptomsSymptoms
Within Hours or Days After Injury:Within Hours or Days After Injury: Deep aching or burning pain, typically more severe than Deep aching or burning pain, typically more severe than
expected from the injury expected from the injury
Sensitivity to touch or even a light breeze Sensitivity to touch or even a light breeze
Swelling in the arm or leg Swelling in the arm or leg
Unusual sweating Unusual sweating
Excessively warm or cool skin Excessively warm or cool skin
Hair and nails changesHair and nails changes
SymptomsSymptoms
3-6 Months After Injury:3-6 Months After Injury: Burning pain moves to above and below the initial injury Burning pain moves to above and below the initial injury
Swelling in the arm or leg hardens Swelling in the arm or leg hardens
Muscle spasms or weakness develop Muscle spasms or weakness develop
Extremity becomes cold Extremity becomes cold
Hair growth slows Hair growth slows
Nails become brittle or crackNails become brittle or crack
Six Months or Later After Injury:Six Months or Later After Injury: A pale, blue, and/or shiny appearance to A pale, blue, and/or shiny appearance to
the skin the skin
Limited joint movement Limited joint movement
Muscle lossMuscle loss
DiagnosisDiagnosis
Medical historyMedical history X-rayX-ray Bone scanBone scan Nerve conduction studiesNerve conduction studies EMGEMG
TreatmentTreatment
BiofeedbackBiofeedback AcupunctureAcupuncture Physical therapyPhysical therapy Mirror box therapyMirror box therapy TENSTENS
MedicationMedication Sympathetic nerve Sympathetic nerve
block block Sympathectomy Sympathectomy Psychological Psychological
support support
MedicationMedication
Anti-inflammatory drugs/immunomodulators Anti-inflammatory drugs/immunomodulators Anticonvulsants/neuromodulators Anticonvulsants/neuromodulators Antidepressants/anxiolytics Antidepressants/anxiolytics Opioids Opioids N-methyl-D-aspartate (NMDA) receptor antagonists N-methyl-D-aspartate (NMDA) receptor antagonists Anti-hypertensives and alpha-adrenergic antagonists Anti-hypertensives and alpha-adrenergic antagonists Calcitonin Calcitonin Bisphosphonates Bisphosphonates Additional systemic drug treatment options Additional systemic drug treatment options Topical treatmentsTopical treatments
PreventionPrevention
Quick mobilization after surgery or injuryQuick mobilization after surgery or injury Early use of pain relievers after trauma Early use of pain relievers after trauma
Use of sympathetic nerve block after trauma Use of sympathetic nerve block after trauma
Desensitization techniques (if needed) Desensitization techniques (if needed)
Use of vitamin C —In a study, this was shown to Use of vitamin C —In a study, this was shown to reduce the risk of CRPS after a wrist fracture. reduce the risk of CRPS after a wrist fracture.