Musculoskeletal Injury Management

Aka: Musculoskeletal Injury Management, Physical Therapy Prescription, Physical Therapy, Physiotherapy, Physical Rehabilitation

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II. Approach: Neuromuscular Re-education

  1. Biofeedback with electrode sensors, focused on increasing or decreasing specific Muscle recruitment
  2. Indications
    1. Postoperative recovery
    2. Fall Prevention
    3. Gait retraining (e.g. Cerebral Palsy)
    4. Maladaptive sensory processing (e.g. balance retraining after Ankle Sprain)
    5. Sports-Injury prevention (e.g. ACL Rupture prevention in female athletes)

III. Approach: Therapeutic Exercise

  1. Systematic approach to planned and specific Exercises, Postures and movements
  2. Isometric Exercise
    1. Muscle contracts but maintains a constant length (e.g. weight held in a fixed position)
    2. Indications
      1. Early phases of rehabilitation
      2. Limited joint mobility
      3. Core Muscle and joint stabilization
  3. Slow Resistance Training
    1. Performed with a tolerable load (e.g. weight or band resistance) for a set number of repetitions
    2. Starts with slow concentric phase held for 3 seconds
      1. Muscle contracts while shortening (e.g. biceps flexion)
    3. Finish with slow eccentric phase held for 3 seconds
      1. Muscle contracts while lengthening (e.g. biceps extension)
    4. Efficacy
      1. Greater strength improvement than with either concentric or Eccentric Exercise alone
  4. Kinetic Chain
    1. Closed kinetic chain
      1. Proximal extremity moves with a fixed distal segment (e.g. push-ups, leg press)
      2. Indications: Multi-joint Exercises with the loading of large Muscle groups
        1. Functional motion
        2. Sport-specific movement
    2. Open kinetic chain
      1. Distal extremity moves in relation to the proximal extremity (e.g. upper extremity free-weight lifting)
      2. Indications: Isolated, single-joint, single-Muscle group Exercises
        1. Early rehabilitation
        2. Isolated Muscle group strengthening
      3. Open chain, low load Exercises may be combined with venous Blood Flow restriction therapy (see below)
        1. Consider in extremity injuries or in postoperative recovery from ACL injury, knee replacement
        2. Tourniquet applied to limit venous return during repeated low load open chain Exercises
        3. Do NOT apply too tight as to restrict arterial inflow
  5. Range of Motion Exercises
    1. Move a joint passively or actively in planes of normal motion
    2. Start early and continue throughout rehabilitation
    3. Limit pain on motion to <5/10
  6. Stretching
    1. Static Stretching
      1. Soft tissue lengthened beyond slack length (but without movement)
      2. Decreases acute and chronic Muscle tendon stiffness and improves flexibility
      3. May have a negative effect on performance
    2. Dynamic Stretching
      1. Repeated, unloaded motion without resistance, and without a static phase
    3. Proprioceptive Neuromuscular Facilitation
      1. Improves longterm flexibility
      2. Combination
        1. Static Stretching AND
        2. Submaximal to maximal Isometric Muscle Contraction AND
        3. Followed by Stretching once relaxed

IV. Approach: Adjunctive Treatments and Modalities

  1. Transcutaneous electrical nerve stimulation (TENS)
    1. Generates an Action Potential in nerve tissue, triggering a Muscle Contraction or altering Sensation
    2. Indications
      1. Postoperative strengthing and Muscle activation
      2. Neuropathic pain management
  2. Ultrasound
    1. Superficial soft tissue warmed by high frequency sound waves
    2. May reduce short-term pain in Muscle spasm or strain
    3. May promote cellular-level tissue healing
  3. Medication Delivery
    1. Iontophoresis
      1. Ionically charged medications delivered to deeper tissues via electric current
    2. Phonopheresis
      1. Medications delivered to deeper tissues via Ultrasound
  4. Spinal Traction
    1. Spine immobilized above/below target region and distracted for a set time period to decompress nerve roots
    2. Indicated in lumbar or Cervical Radiculopathy
  5. Blood Flow Restriction Therapy
    1. See open kinetic chain above
    2. Consider in extremity injuries or in postoperative recovery from ACL injury, knee replacement
    3. Tourniquet applied to limit venous return
      1. Pneumatic cuff inflated to 80% of limb Occlusion pressure
      2. Do NOT apply too tight as to restrict arterial inflow
    4. Repeated low load open chain Exercises
      1. Limit resistance to 20-30% of One Repetition Maximum
      2. Perform 15-30 repetitions under venous Occlusion
    5. Complications (rare)
      1. Rhabdomyolysis
      2. Deep Vein Thrombosis
      3. Nerve injury

V. Approach: Other Measures associated with Soft-Term Benefits

  1. Manual Therapy
    1. Joint and soft tissue mobilization
    2. High-velocity, low amplitude maneuvers (e.g. spine manipulation)
  2. Dry Needling and Trigger Point Injection
    1. Acupuncture
    2. Dry Needling
    3. Trigger Point Injection

VI. Management: General - 5R Approach

  1. Recognize Injury Stage (Chronicity) and Severity
  2. Reduce load on injured structures
    1. Activity modification
    2. Weight bearing limitations
    3. Restricted movement
    4. Complete extremity unloading
  3. Rehabilitation
    1. Rehabilitation Exercises appropriate for injury stage, pain and dysfunction (combined with reduced load)
    2. Stepwise strengthening program with progressive focused loading of injured tendon or Muscle group
    3. Start
      1. Range of motion Exercises
      2. Low-load Isometric Exercises
    4. Next
      1. Slow resistance Exercise with progressively increased load
    5. Next
      1. Functional and sport-specific Exercises
  4. Relieve
    1. Relieve factors that lead to tissue overload
      1. Expedites activity return
      2. Prevents future injury
    2. Targets
      1. Biomechanical abnormality
      2. Strength imbalance
      3. Inflexibility
      4. Training error
      5. Technique error
  5. Refer
    1. Consider referral in refractory cases to sports medicine or orthopedics
    2. Manage suboptimal adherence (50-70% of cases)
      1. Limit home Exercises to 3-5 Exercises
      2. Give a specific diagnosis
      3. Give detailed Exercise instructions
        1. Use visual resources (e.g. Bob and Brad Youtube videos, Macenzie Books)
        2. FITT instructions (frequency, intensity, time and type)
      4. Contributing factors
        1. Fear of pain
        2. Poor social support
        3. Low self efficacy
        4. Behavioral health issues
        5. Socioeconomic barriers
    3. Manage ongoing mechanical overload
      1. Consider whether rehabilitation plan is excessive in volume or intensity
      2. Consider other daily activities impacting recovery
      3. Review pain thresholds for performing Exercises and daily activities
      4. Encourage at least one day of recovery between days of strengthening Exercises
    4. Manage Insufficient progressive improvement
      1. Rehabilitation plans should be progressive
      2. Gradually increase repetitions, resistance and/or intensity in stages without causing overload
    5. Manage Inappropriate Exercise Prescriptions
      1. Therapeutic Exercises should incorporate strengthening
      2. Exercises should match the injury stage (e.g. avoid a too-early introduction of late-stage Exercises)
      3. Caution in excessive joint stress or loads in specific conditions

VII. Management: Acute Musculoskeletal Injury (first 72 hours after injury)

  1. See Acute Pain Management
  2. See Acute Pain Management in Children
  3. Home management
    1. Local Cold Therapy (as well as other RICE-M modalities)
    2. Gentle active range of motion
    3. Isometric Exercise
  4. Physical Therapy modalities (daily for 5 days)
    1. Electrical Muscle Stimulation
    2. Pulsed Ultrasound
    3. Gentle massage
  5. Therapeutic Goals
    1. Decrease swelling and pain
    2. Improve range of motion
    3. Speed healing

VIII. Management: Subacute Musculoskeletal Injury (3-14 days after injury)

  1. Home management
    1. Local Heat Therapy
    2. Active range of motion and Stretching
    3. Isotonic Exercise
  2. Physical Therapy modalities (three times weekly for 2 weeks)
    1. Electrical Muscle Stimulation
    2. Iontophoresis
    3. Massage and joint mobilization
  3. Therapeutic Goals
    1. Improve range of motion and function
    2. Improve Muscle tone

IX. Management: Chronic Musculoskeletal Injury (Beyond 2 weeks after injury)

  1. See Chronic Musculoskeletal Pain Management
  2. See Low Back Pain Management
  3. Home management
    1. Contrast Bath
    2. Muscle Strengthening and joint stabilization
    3. Active range of motion and Stretching
    4. Isotonic Exercise
  4. Physical Therapy modalities (twice weekly for 4 weeks)
    1. Continuous Ultrasound Therapy
    2. Transcutaneous electrical nerve stimulation (TENS)
    3. Myofascial release techniques
  5. Therapeutic Goals
    1. Normalize tissue length
    2. Normalize Activities of Daily Living

X. References

  1. Rand (2007) Am Fam Physician 76::1661-6 [PubMed]
  2. Do (2026) Am Fam Physician 114(3): 248-59 [PubMed]

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