SOFT TISSUE TRAUMA

STRENGTHS n Awareness and knowledge of the therapist relating to the concept of injury & rehabilitation n Provision of clear instructions to patient e.g. what to do, and what not to do in line with tissue repair n Employment of suitable outcome measures

OPPORTUNITIES n Educate the patient with respect to SWOT n Enhance adherence by encouraging and motivating the patient n Encourage the patient to ask questions and provide relevant feed-back, particularly relating to symptoms n Introduce a home rehabilitation plan

Figure 4: SWOT analysis

Figure 5a: Swelling of calf

Figure 5b: Extensive bruising

Figure 5c: Severe loss of ROM

immobilisation following injury is necessary (7). In conjuction, PRICE is used to control inflammation, thus limit haemorrhaging, oedema, swelling, pain, and promote optimal healing (18, 19). Limiting inflammatory exudate reduces the amount of fibrin, and ultimately excessive scar tissue (20), while limiting adhesions and excessive crosslink formation. Unfortunately, for reasons already mentioned, the cyclist failed to implement early PRICE and immobilisation, thus failed to limit haemorrhaging and therefore lost the opportunity to promote optimal healing. Moreover, the damaged tissue was further provoked and the condition exacerbated, consequently, resulting in increased amounts of inflammatory exudate and fibrin. Potentially this leads to excessive scarring, adhesions, and cross-link formation resulting in functional losses in ROM. Clinically this was confirmed on examination at 10 days post-injury, also confirmed by the cyclist who reported that his condition had deteriorated since the accident.

Figure 6: effects of hydrostatic pressure

Protection

The immediate plan was to protect the injured limb, control pain and remove oedema. The limb would remain non-weight bearing for several days, before progressing to partial weight- bearing on achieving 90º flexion and full knee extension (13). To facilitate this the patient was issued with elbow crutches which included; fitting, safety and ambulation training, emphasis on normal gait pattern. Non-weightbearing mobilisation was encouraged in an attempt to minimise further loss of functional range.

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POTENTIAL WEAKNESSES n Poor patient education n Failure of the therapist to manage the situation n Lack of clear instructions to patient

THREATS n Poor adherence to rehabilitation plan n Too enthusiastic - doing too much too soon

Assisting oedema removal to restore normal tissue dynamics Control and removal of oedema, particularly associated with joint effusion, is considered a priority as it can impair proprioception and cause muscle inhibition (21). Airaksinen (23) and Airaksinen et al. (24) found intermittent pneumatic compression (IPC) reduced oedema and pain levels, increased mobility and thus promoted rehabilitation in posttraumatic conditions of the lower extremity. Therefore, with the injured limb elevated, 40 minutes of IPC followed by effleurage and petrissage massage were administered to assist oedema removal (25). Massage involved ‘down-the-line’ sequence lymphatic drainage, starting proximally with the thigh, followed by the calf and ankle (22). Massage consisted of both manual techniques and mechanical vibration - with vibration adding an extra dimension. As part of the home plan the patient was instructed to perform hydrotherapy sessions at the local swimming pool, ie. walking immersed up to his neck. Water immersion has been shown to reduce peripheral oedema due to the hydrostatic pressure of the water and resulting changes in circulation (26). It is important to note that since hydrostatic pressure increases with depth of immersion, the physiological and clinical benefits will vary with patient position (figure 6).

NONSTEROIDAL ANTI- INFLAMMATORY DRUGS (NSAIDS)

Although the use of NSAIDS is frequently cited in the management of acute soft tissue injuries, there is growing evidence of their detrimental effects on healing (9) of ligaments (27), tendons (28) and muscles (29). In view of the growing evidence against their efficacy, it was agreed NSAIDS would not be used.

PHASE II: SUBACUTE/ PROLIFERATION PHASE The proliferative phase is essentially the generation of repair material which involves the production of scar tissue (type III collagen), which commences after 2-3 days, reaching a peak at 2-3 weeks post-injury. There are two fundamental processes involved; fibroplasia (formation of collagen) and

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