5.4 - Injury and Healing 2

Question 1

What is soft tissue made up of?

Answer 1

Type I collagen

Question 2

What are ligaments?

Answer 2

• connect bone to bone
• restricts joint motion
• stability and proprioception

Question 3

What are tendons?

Answer 3

• connect muscle to bone
• transmits forces

Question 4

What can cause ligament and tendon injuries?

Answer 4

• pivoting forces
• eccentric contraction
• trauma
• laceration
• avulsion injury - when small piece of bone attached to a tendon/ligament gets pulled away from the main part of the bone
• injuries are often sports related

Question 5

What is a grade I tear?

Answer 5

• slight incomplete tear
• no notable joint instability
• integrity intact

Question 6

What is a grade II tear?

Answer 6

• moderate/severe incomplete tear
• some joint instability
• one ligament may be completely torn

Question 7

What is a grade III tear?

Answer 7

• complete tearing of one or more ligaments
• obvious instability
• surgery may be required

Question 8

How do ligaments and tendons heal?

Answer 8

1. bleeding - over the first few hours, inflamed
2. inflammation - hours to months
3. proliferation - days to months
4. remodelling - weeks to months

• maximum strength recovery at >6 months
• may never fully recover full tensile strength

Question 9

What are the components of the knee?

Answer 9

• bones - patella, tibia, fibula, femur
• muscles - quadriceps, hamstring
• ligaments - anterior cruciate ligament (ACL), lateral collateral ligament (LCL), medial collateral ligament (MCL), posterior cruciate ligament (PCL), patellar ligament
• cartilage - articular cartilage, meniscus

Question 10

What is the role of the ACL?

Answer 10

• gives knee joint stability
• rotational stability - back to forth movement of lower leg
• proprioception
• ACL is an oblique ligament running from front to back of knee

Question 11

What symptoms can arise due to an ACL tear?

Answer 11

• difficulty running
• instability (with twisting/pivot movement)

Question 12

What different examinations can you do to test for an ACL tear?

Answer 12

• Lachmann’s test - bring tibia forward, high level of movement is pathological
• anterior drawer - knee bent at 90 degrees, move tibia anteriorly, moves a lot if torn ACL
• pivot shift - ‘locked’ knee on bending if torn ACL, might hear a click, can damage meniscus/cartilage

Question 13

What is the acronym for short term management of a torn ACL?

Answer 13

• P - protect
• R - rest
• I - ice
• C - compress
• E - elevate

Question 14

What are the factors affecting tissue healing?

Answer 14

Mechanical environment:

• movement
• forces

Biological environment:

• blood supply
• immune function
• infection
• nutrition

Question 15

What do we need to consider when thinking about management of tendon/ligament tears?

Answer 15

Need to consider the patient:

• functional demands
• patient factors
• compliance - how likely they are to listen

Question 16

Things to think about specifically when it comes to management of an ACL tear?

Answer 16

• how old?
• symptoms - pain or giving way? instability? locking?
• activity level
• has physio been tried?
• other structures involved? meniscus
• indications for ACL reconstruction
• graft choice - autograft (from hamstring/patellar tendon), allograft, synthetic

Question 17

What are different methods for long term management of an ACL tear?

Answer 17

• non operative: brace - ACL does not heal well but some muscles can compensate in some cases
• operative - repair and replace

Question 18

Which tendon is likely to be injured if a squash player did not warm up before a match, felt severe pain in ankle when reaching back, loud snap sound and feeling of being shot in back of the ankle?

Answer 18

Achilles tendon

Question 19

What are the risk factors for a ruptured Achilles tendon?

Answer 19

• male, 30-50 years (in this case 35)
• anabolic steroid use
• fluroquinolone - antibiotic that increases risk
• ‘weekend warrior’ - participates in activity only in their spare time

Question 20

What muscles insert into the Achilles tendon?

Answer 20

• M. gastrocnemius (biventer muscle of the calf)
• M. soleus

Question 21

What is the function of the Achilles tendon?

Answer 21

Plantarflexion

Question 22

What would you find when examining a patient with a ruptured Achilles tendon?

Answer 22

• difficulty walking / limp
• unable to perform heel raises (standing on tiptoes)
• thickening, tenderness and swelling on the affected side
• when prone with feet off the end of couch, the affected side is held in dorsiflexion
• Simmonds Calf Squeeze Test - patient lies face down with feet hanging off edge of bed, positive result = no movement of foot (normally plantarflexion) on squeezing the corresponding calf = ruptured Achilles tendon

Question 23

What are management options for a ruptured Achilles tendon?

Answer 23

Operative:

• open vs percutaneous
• primary repair
• augmentation of repair

Non-operative:

• functional bracing
• gradual removal of wedges to plantigrade
• casting

Rehabilitation:

• range of motion
• strength
• proprioception

Question 24

What must be considered when thinking about management of a ruptured Achilles tendon?

Answer 24

• functional demands
• patient factors
• injury factors - based on USS/MRI, acute/chronic

Question 25

What are complications that can occur due to an operation?

Answer 25

General (early/late):

• DVT (deep vein thrombosis)
• infection
• prolonged immobility (UTI, chest infections, sores)

Specific:

• neurovascular injury - sural nerve
• tendon re-rupture
• local infection
• ankle stiffness
• pressure sores from plaster/boot
• reduced strength