Permanency Issues and Ligament/Tendon Injuries The biology of soft tissue injury and permanent functional impairment
by Dr. William J. Owens, D.C., D.A.A.M.L.P.
The human body, as we are well aware, is a complex system of anatomical and physiological mechanics that continues to amaze and frustrate clinicians. I would venture to say the latter is more common when triaging and caring for the traumatically injured patient. Diagnostic dilemmas abound in trauma cases.
When it comes to determining bodily injury, causality and persistent functional loss, understanding the different anatomical structures involved and how they “wound-heal,” is the key to providing complete care to your patients. Notice that I did not write “heal;” in fact; I wrote “wound-heal.” Wound-healing is not the same as healing, and that important concept needs to be articulated in your examination and progress notes. Otherwise every patient that is injured would demonstrate normal range of motion and negative orthopedic testing after six weeks of care, which is not always the case. Why? Wound-healing indicates that, post-injury, the tissue will never again be the same, because one type of tissue (Type I Collagen) is replaced with granulation tissue. This has profound mechanical effects on the body and is the number one reason why persistent functional loss exists in the first place. All of us have been taught wound-healing principles in our professional educations, but how many of us actually put that knowledge to practical use in our offices? I had an opportunity through the Academy, to review a research paper that targeted the physiology behind ligament and tendon repair. This information had been published in 2005 and is some of the most current scientific information on ligament and tendon structure. This particular article was presented in the Birth Defects Research journal (Samuel Tozer and Delphine Duprez, 2005). In their quest to learn more about how ligaments and tendons develop and how to correct developmental errors, the authors reveal the similarities of ligaments and tendons. Structurally there is little difference between the tissue types. The authors described the internal make up of these specialized tissues, commenting on one important fact. “There is no ECM (Extracellular Matrix) components of the T/L (tendon/ligament) architecture that can be used to distinguish tendon from ligament or either from other connective tissue” (Tozer et al, pg230). They go on to state, “T/L injuries are common clinical problems” (Tozer et al, pg 231) and “No treatment currently exists to restore an injured tendon or ligament to its normal condition” (Tozer et al, pg230). The authors report that, “Wound healing comprises different stages such as inflammatory, proliferative, and remodeling phases” (Tozer et al, pg231). “The major issue is that although the phases are similar to other tissues, the T/L tissues heal at a slower rate than other connective tissue probably because of the dense and hypo cellular composition of these tissues, only 5% of the volume is occupied by cells”(Tozer et al, pg230). Can that be why muscle belly injury will heal far faster than tedious insertions? Is that why point tenderness over the par spinal muscles is reduced before range of motion is improved? When we are diagnosing anatomical structures injured as a result of a traumatic event, remember there are three types of tendon/ligament us injuries. These types include: 1: Grade I – Microscopic tearing of collagen fibers in the ligament/tendon. 2: Grade II – Significant macroscopic tearing of collagen fibers in the ligament/tendon. 3: Grade III – Complete tearing or rupture of the ligament or tendon resulting in significant joint instability. Grading these types of injuries is important since the amount of “wound-healing” directly influences the amount of scar tissue produced. If the trauma patient has decreased ranges of motion along with moderate tenderness and swelling, Grade II injury is present. If there is evidence of mild to moderate segmentation instability on flexion-extension radiographs, digital motion X-ray or X-ray digitization procedures, Grade II is present. It is only when significant macroscopic tearing exists that we see vertebral translation. Grade II ligament us tears take considerably longer to “wound-heal” and will result in permanent changes to the anatomical and functional structures of the joint complex. This is a permanent condition that needs regular supportive care to assist the patient in maintaining functional levels. Understanding of anatomical structures, how they are injured, and what happens when that injury is repaired is a complex clinical picture that is often overlooked. Chronic pain and supportive care is an important part of today’s medical-legal practice. Doctors of Chiropractic are in a unique situation to diagnose and care for these conditions. There are no other practitioners that touch their patients as often and consistently as chiropractors. Let’s put that to good use. Disclaimer: The following preview is provided for educational purposes only. It is not designed or intended to reproduce or replace the author’s work. Readers are encouraged to obtain full licensed versions of the full article as determined by Copyright Law. For information on how to obtain a licensed copy, please contact the Academy directly. In each issue, a clinical topic will be covered by the Academy, which is a national, non-profit organization, comprised of doctors and lawyers. The purpose of the organization is to provide its members with current research in trauma and spinal related topics, to keep the profession on the cutting edge of healthcare. Members may also sit for a Diplomat examination and be conferred a DAAMLP. The organization also offers support to the individual member’s practice. To learn more go to www.aamlp.org or call 716-228-3847.