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Does Physical Therapy Help After an Acute Injury, or Should I Immobilize my Joint with a Brace ?

It can be difficult to think of your body as being made up of billions of individual cells each with its own nutrition needs, and more importantly, its own life cycle that eventually ends up in death. Think back to basic biology and you may recall that a group of cells with the same function make up a tissue, tissues make up an organ, and organs make up an organism. That is what the human being is, after all, an organism made up of living, breathing, and yes, dying cells.

One of the ways a cell can die is due to trauma. An injury to a cell can be in the form of impact as well as a lack of oxygen. Regardless, once a cell dies there is a remarkable cascade of events that the body arranges to remove the dead cell and regenerate a new cell in its place. There are 3 general phases of healing that occur after the tissue is damaged: inflammatory, proliferation, and maturation. Even before the inflammatory phase begins, the body attempts to stop any bleeding with clot formation within seconds of the trauma. The inflammatory phase then occurs about 24 hours later and can last about 10 days, however, the effects of the swelling can be felt even 3 weeks later. Once the inflammatory phase progresses past 50 to 60%, the body begins to create new granulation tissue or healthy cells that will repair the wound. This proliferation phase lasts about 6 weeks and is concluded with the tendon and ligament wound closure (3 to 5 weeks after injury). Finally, the maturation phase begins and the new fibroblasts and scar tissue increases their strength and is aligned according to the direction of the stress applied to that body region. The scar tissue remains stretchable for 8 to 10 weeks and is usually complete by 6 to 12 months.

Once this process is understood, it may no longer seem odd that a traumatic injury to the muscle, tendons, ligaments, or bones seem to take a long time. The body must move through these 3 phases of healing and each phase can last differing amounts depending on the surface area and depth of the injury. Furthermore, each time the tissue is subjected to excessive forces it is re-injured and must begin the process of inflammation once again. Therefore, it may seem obvious to some that an injured body part should be immobilized to prevent further damage, however, this is not correct. It is a fundamental physiological observation that immobilization has detrimental effects on collagen formation following an injury. For example, collagen fibres do not increase and are not laid down in the ground substance along the lines of stress which seem to contribute to decreased range of motion, and there is a decrease in hyaluronic acid and glycosaminoglycans (GAGs) which leads to weakening of the proteoglycans.
Proteoglycans are protein chains that synthesize the fibroblasts, and fibroblasts are what create new collagen which is needed to resist the strain of the tissue with increased stress.

Collagen requires a force of 5 to 15 kg/mm squared to cause the 6 to 8% stretching that results in failure point. Lower forces can cause irreversible damage, however, the collagen will not fail until it surpasses the ultimate stress point as described in the tissue-strain curve. The damaged tissue can cause irritability of the overall condition and your physical therapist will adjust the treatment to suit your state of reactivity. High reactivity usually results in pain being felt even before the joint restriction, whereas moderate reactivity will yield pain at the restricted point. High reactivity should be treated with oscillations while moderate reactivity can be addressed by adding a stretch between the joint oscillations. Regardless of the reactivity level, all components of the RICE (rest, ice, compression and elevation) contribute to decreasing cell destruction and further bleeding and damage, leading to faster healing time.

Palpation of injured tissue is usually met with moist, warm, edematic, chemical, and guarding due to tenderness of the acute condition. A chronic condition usually presents with shiny, dry, smooth, and cool skin, and it is always beneficial to compare side to side. The science of how joint mobilization helps to reduce pain is primarily the activation of the Golgi-tendon organ-like nerve endings or type 3 mechanoreceptors that are found in the ligaments and superficial layers of the joint capsule (except in the anterior and posterior longitudinal spinous ligaments and the interspinous ligaments). Activation of the sensory organs results in reflex inhibition of the muscle and improve the image of the body part in the somatosensory homunculus which prevents secondary (central) sensitization or chronic pain. In addition to inhibiting the collagen growth, immobilization causes death to the mechanoreceptors which can be reversed with repetitions, stabilizations, and mobilizations of the joint leading to improvement in pain.

Ligament tears can be painful and stable (grade 1) painful and unstable (grade 2) or painless and unstable (grade 3). Similarly, a contractile injury can be strong and painful (minor lesion) weak and painful (gross lesion warrants and x-ray), weak and painless (neurological or complete rupture) or all painful (highly irritable or central sensitization of the nervous system). It is therefore important to have the patient perform active movements followed by passive and resisted movements. Pain with repetitions may indicate a vascular problem.

In short, physical therapy can be highly beneficial following an acute injury, to facilitate healthy collagen fibre synthesis, prevent scar tissue formation, prevent loss of ROM, and prevent mechanoreceptor death. A thorough history and examination are necessary to properly identify the cause of your pain. Remember, trauma to a muscle or joint can occur as a result of repetitive movements, also known and microtrauma and repetitive injury. The symptoms may be the same although the mechanism will be different. Examining posture, measuring ROM and strength, and analysis of gait should be routine at any physical therapy facility, and it is part of what makes Therapy SPOT – Bellaire the facility of choice in the Greater Houston Area for physicians and their families members. Let us help you today and call 832-588-3552 to arrange your no-cost consultation.

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