9MUSCULOSKELETAL DISORDERS

After the initial inflammatory response (usually within 24 hours), the inflammatory process should move to inflammation resolution, with both proinflammatory and proresolution mediators present.[Demidova-Rice 2012] Damaged tissues are cleared by phagocytosis and the foundation is laid for new tissues. As phagocytosis is nearing completion (normally after several days), the proliferation phase of healing begins. Fibroblasts and granulocytes are drawn to the site of injury by growth factors, and new collagen is produced to replace the injured tissues.

Within a few days of trauma, a new network of capillaries is established to ensure that scar tissue is well vascularized.[Demidova-Rice 2012] As new tissue is constructed, the original scar tissue is being dissolved. The scar eventually decreases in size, and tissue remodeling occurs.

Factors affecting response to injury For successful management of acute soft tissue injury factors promoting efficient optimal recovery should be maximized.[Brumitt 2015] For example, early controlled activity is helpful, but excessive activity may impair recovery. Nutrition is also important, and an adequate intake of protein, energy, vitamins and minerals is required. Inflammation, while part of the healing process, can be deleterious if excessive. A proresolution environment should be promoted.

Other factors that can affect the healing process are difficult to modify, but should still be included in the management process to improve outcomes. For example, tissues take longer to heal with increasing age, partly as a result of morphological and biochemical changes in collagen and elastin fibers.[Speed 2006] A poor vascular supply may be an important factor in the chronic evolution of soft tissue injuries such as tendon disorders.

Endocrine disorders can also have an impact on healing. A poor healing response in diabetes is well recognized, and hypoestrogenism may be associated with an increased incidence of tendinosis.[Speed 2006]

Genetic factors are implicated in the etiology of many acute musculoskeletal soft tissue injuries.[Collins 2009] Common musculoskeletal soft tissue injuries for which a genetic contribution has been proposed include the Achilles tendon, rotator cuff tendons and cruciate ligaments.

Current treatment options Successful management of acute musculoskeletal injury requires early recognition, identification of the cause(s), and treatment of any specific pathology.[Speed 2006] The underlying paradigm is to control pain so that rehabilitation can proceed. Rehabilitation should be individualized, and may include progressive exercises to promote flexibility, proprioception, strength, speed, agility and stability.

Much of the management of musculoskeletal injury has developed based on clinical experience with too little research evidence.[MacAuley 2002, Orchard 2008] Consequently,