Chapter 2

Tissue Behavior, Injury, Healing,

and treatment
Overview

 A wide range of external and internal

forces are either generated or resisted
by the human body during the course
of daily activities
 Biological tissues must demonstrate
the ability to withstand excessive or
repetitive stresses if musculoskeletal
health is to be maintained
Stress
 The capacity of a tissue to withstand stress
is dependent on a number of factors:
– Age
– The proteoglycan and collagen content of the
tissue
– The ability of the tissue to undergo adaptive
change
– The speed at which the adaptive change must
occur
Terminology
 Kinetics - the study of forces that arise as
motions change
 Mass - the quantity of matter composing a
body
 Inertia - the resistance to action or to
change
 Force - a vector quantity, with magnitude,
direction and point of application to a body
Terminology
 Load - the type of force applied
 Stress - the force per unit area that
develops on the cross section of a structure
in response to an externally applied load
 Strain - the deformation that develops
within a structure in response to externally
applied loads
 Hysteresis - the difference in the behavior
of a tissue when it is being loaded versus
unloaded
Load-deformation curve

 The load-deformation curve, or stress-

strain curve, of a structure depicts the
relationship between the amount of
force applied to a structure and the
structure’s response in terms of
deformation or acceleration
Load-deformation curve

 The shape and position of the load-

deformation curve depends on a
number of factors:
– Stiffness
– Viscoelasticity
– Age
– Exercise
Musculoskeletal stress

 Macrotrauma - an acute stress

(loading) that occurs when a single
force is large enough to cause injury
of biological tissues
 Microtrauma - a repetitive stress that
in of itself is insufficient to damage the
tissue, causes injury when repeated
over a period of time
Collagen
 Collagen fibers have a wavy or folded
appearance at rest (slack)
 When a force lengthens the collagen fibers
this slack is taken up
 This slack is called the tissue’s crimp
 Crimp is different for each type of
connective tissue and this provides each of
these tissues with different viscoelastic
properties
Articular cartilage

 Articular cartilage is a viscoelastic

structure with a very high tensile
strength and is resistant to
compressive and shearing forces
 Articular cartilage has the ability to
undergo large deformations while still
being able to return to its original
shape and dimension
Articular cartilage

 Damage to articular cartilage may

result from microtrauma
(degeneration), macrotrauma, or an
inflammatory process
– Degeneration: osteoarthritis
 Primary and secondary
– Inflammation: Rheumatoid arthritis
Ligament

 Fibrous bands of dense connective

tissue that connect bone to bone and
which behave as a viscoelastic
structures when exposed to stress
 Ligament injuries are called sprains
Sprains

 Ligament injuries may be graded by

severity:
– Grade I - painful, but do not have
swelling or instability
– Grade II - marked swelling, and pain.
Mild ligament laxity and joint instability
– Grade III - complete disruption of the
ligament with gross instability and laxity
Tendon

 Connects muscle to bone

 The causes of a tendon injury center
around microtrauma to the tendon
tissue due to repetitive mechanical
loading from external factors, or
macrotrauma
Tendinitis

 The term tendinitis implies an

inflammatory reaction to a tendon
injury - a microscopic tearing and
inflammation of the tendon tissue,
commonly resulting from tissue fatigue
rather than direct trauma
Tenosynovitis

 Tenosynovitis/tenovaginitis, peritendinitis,
and paratenonitis, indicate an
inflammatory disorder of tissues
surrounding the tendon such as the tendon
sheath – usually the result of a repetitive
friction of the tendon and its sheath
Tendinosis

 The term tendinosis refers to a

degenerative process of the tendon.
 Characterized by the presence of
dense populations of fibroblasts,
vascular hyperplasia, and disorganized
collagen
Bone

 Bone is a solid with elastic properties

 Bone is stiffer and stronger than other
tissues at higher strain levels
 Bone is better able to withstand
compressive forces than tensile or
torsional forces
Bone

 Wolff’s law - forces applied to bone,

including muscle contractions and
weight bearing can alter bone the
internal and external configuration of
bone through adaptation to these
stresses
Bone
 If the adaptations of bone to stress do not
occur fast enough, the bone is resorbed
faster than it is replaced, and bone strength
is compromised
 Causes of decreased adaptation include:
– An increase in the applied load
– An increase in the number of applied stresses
– A decrease in the size of the surface area over
which the load is applied
Musculoskeletal Injuries

 Injuries to the soft tissues can be

classified as primary or secondary:
– Primary injuries can be self-inflicted,
caused by another individual or entity, or
caused by the environment
 Acute
 Chronic

 Acute on chronic
Musculoskeletal Injuries

 Secondary injuries are essentially the

inflammatory response that occurs
with the primary injury
Muscle tissue
 Muscle injury can result from:
– Excessive strain
– Excessive tension
– Contusions
– Lacerations
– Thermal stress
– Myotoxic agents (local anesthetics, excessive use
of corticosteroids, snake and bee venoms)
Hematoma
 Contusion to a muscle belly
 Two types:
– Intramuscular: associated with a muscle
strain or bruise. The size of the
hematoma is limited by the muscle fascia
– Intermuscular. This type of hematoma
develops if the muscle fascia is ruptured
and the extravasated blood spreads into
the interfascial and interstitial spaces
Muscle strains
 Often graded according to severity:
– I: involves a tear of a few muscle fibers with
minor swelling and discomfort. Associated with
no or minimal loss of strength and restriction of
movement
– II: Greater damage of the muscle and clear loss
of strength and some loss of function
– III: Involves a tear extending across the whole
muscle belly. Characterized by severe pain or
loss of function
Wound healing
 Fortunately, the majority of soft tissue
injuries heal without complication in a
predictable series of events
 However, healing abnormalities can occur.
These abnormalities can be due to such
complications as:
– Infection
– Compromised circulation
– Neuropathy
Wound healing

 Three main phases:

– Inflammatory
– Proliferative
– Remodeling
Inflammatory phase

 The reaction that occurs immediately

after wounding includes a series of
defensive events that involves the
recognition of a pathogen and the
mounting of a reaction against it. This
reaction involves both coagulation and
inflammation
Inflammatory phase
 Coagulation. Apart from an initial period of
vasoconstriction lasting for 5-10 minutes,
tissue injury causes vasodilation, the
disruption of blood vessels and
extravasation of blood constituents,
including platelets
 The main functions of the exudate are to:
– Provide cells capable of tissue reconstruction
– Dilute microbial toxins
– Remove contaminants present in the wound
Inflammatory phase
 Inflammation. Inflammation is mediated by
chemotactic substances, including
anaphylatoxins, which attract neutrophils
and monocytes
– Neutrophils are white blood cells that bind to
microorganisms, internalize them, and kill them
– Monocytes are white blood cells that develop
into macrophages, and provide immunological
defences against many infectious organisms
Inflammatory phase

 The complete removal of the wound

debris marks the end of the
inflammatory process
 This stage can last from 1-6 days to
longer than 6 months
 Common causes for a persistent chronic
inflammatory response include:
– Infectious agents
– Persistent viruses
– Hypertrophic scarring
– Poor blood supply
– Edema
– Repeated direct trauma
– Excessive tension at the wound site
– Hypersensitivity reactions
Inflammatory phase
 Clinically, during the inflammatory phase
there is pain:
– At rest
– With active motion
– When specific stress is applied to the injured
structure
 The pain, if severe enough, can result in
muscle guarding, and a loss of function.
Proliferative phase

 Characteristic changes during this

phase include:
– Capillary growth
– Granulation tissue formation
– Fibroblast proliferation with collagen
synthesis and increased macrophage and
mast cell activity
Proliferative phase

 This phase lasts from 5 to 15 days,

and often up to 10 weeks depending
on the type of tissue, and the extent
of damage.
Remodeling phase

 The remodeling phase of wound

healing involves a conversion of the
initial healing tissue to scar tissue
 This lengthy phase of contraction,
tissue remodeling and increasing
tensile strength in the wound lasts for
up to a year
Remodeling phase
 Imbalances in collagen synthesis and
degradation during this phase of healing
may result in hypertrophic scarring or keloid
formation
 If left untreated, the scar formed is less
than 20% of its original size
 Scarring that occurs parallel to the line of
force of a structure is less vulnerable to re-
injury than a scar, which is perpendicular to
those lines of force
Muscle healing
 The capacity of muscle for regeneration is
based primarily upon the type and extent of
injury
 Broadly speaking, there are three phases in
the healing process of an injured muscle:
– The destruction phase
– The repair phase
– The remodeling phase
Ligament and tendon
healing
 Healing of ligaments and tendons
generally can be broken down into
four overlapping phases:
– I. Hemorrhagic
– II. Inflammatory
– III. Proliferation
– IV. Remodeling and maturation
Articular cartilage healing

 The capacity of articular cartilage for

repair is limited
 The repair response of articular
cartilage varies with the depth of the
injury
Articular cartilage healing

 Injuries of the articular cartilage that

do not penetrate the subchondral
bone become necrotic and do not heal
 These lesions usually progress to the
degeneration of the articular surface
Articular cartilage healing
 Injuries that penetrate the
subchondral bone undergo repair due
to access to the bone’s blood supply
 These repairs are usually characterized
as:
– Fibrous
– Fibrocartilaginous
– Hyaline-like cartilaginous
Bone healing

 The striking feature of bone healing,

compared to healing in other tissues,
is that repair is by the original tissue,
not scar tissue
 Bone healing involves a combination of
intramembranous and endochondral
ossification
Bone healing

 In classic histologic terms, fracture

healing has been divided into two
broad phases:
– Primary fracture healing
– Secondary fracture healing
Bone healing

 Primary healing involves a direct

attempt by the cortex to reestablish
itself once it has become interrupted
 Bone on one side of the cortex must
unite with bone on the other side of
the cortex to reestablish mechanical
continuity
Bone healing

 Secondary healing involves responses

in the periosteum and external soft
tissues with the subsequent formation
of a callus
 The majority of fractures heal by
secondary fracture healing
Immobilization

 Continuous immobilization of
connective and skeletal muscle tissues
can cause some undesirable
consequences to the tissues of the
musculoskeletal system
Immobilization

 The undesirable consequences

include:
– Cartilage degeneration
– A decrease in the mechanical and
structural properties of ligaments
– A decrease in bone density
– Weakness or atrophy of muscles