JOINT CARE: Managing soft tissue injuries

Pam King gives her take on how pharmacists can help their patients to successfully manage musculoskeletal soft tissue injuries with timely advice on controlled physical activity and nutrition…

An ever-increasing emphasis is being placed on getting and staying fit and mobile, whatever your age, with good reason. Regular aerobic exercise (physical activity which gets the heart beating faster) helps patients to:

• Reduce or maintain body weight
• Reduce the risk of heart disease, strokes and diabetes
• Control blood sugar (helpful for diabetics)
• Maintain mobility and muscle strength, allowing daily activities to be undertaken more easily
• Improve mood, physical activity can be beneficial for everyone.

However, injuries sometimes happen during exercise or everyday life. Collectively, injuries to tendons, ligaments and/or skeletal muscle, are referred to as musculoskeletal soft tissue injuries. Post pandemic pharmacists are now the first port of call for many seeking to self-treat so it is important that information, advice and a wide range of treatment options are available.

While the precise incidence and prevalence of such disorders are difficult to define, they are known to be the most common rheumatic causes of sickness absences from work. Indeed, soft tissue complaints account for up to 59 per cent of new patient referrals to rheumatology practice and up to 15 per cent of consultations in primary care.

Ankle injuries are very common with an estimated incidence of one per 100,000 population per day. They account for about one in five of all sports related injuries. The majority of ankle injuries are moderate ligament sprains. With appropriate treatment the majority of patients should be able to return to normal activities within a few weeks.

Knee injuries can be particularly concerning, especially those affecting the anterior cruciate ligament, as they can cause lengthy absence from normal activities, such as work and physical exercise. The highest incidence of anterior cruciate ligament injuries is seen in young physically active people between 15 and 25 years of age. The incidence is three to five times higher in women than men.

Injury is commonly caused by rotation of the knee, and may be consequence of physical activities such as football, basketball and skiing. Tendinothies can result in appreciable morbidity and loss of productivity, representing a major socioeconomic burden.

Trigger finger, tennis elbow, Achilles’ tendinopathy, and rotator cuff lesions are some of the most common tendinopathies. It is interesting to note that more tennis elbows probably result from industrial work, gardening, or carpentry than from sport.

Pain and dysfunction are the main symptoms of tendinopathy, while clinical signs such as swelling or thickening of the tendon are variable. Musculoskeletal injuries can be classified according to the duration of symptoms.

Up to two weeks, symptoms may be described as acute, two to four weeks may be described as subacute, and if symptoms have been present for over six weeks, the condition may be described as chronic.

After acute injury, inflammation is the body’s method of limiting the amount of tissue damage and protecting against further insult. After the initial inflammatory response (usually within 24 hours), the inflammatory process becomes a healing process.

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. As new tissue is constructed, the original scar tissue is being dissolved.

The scar eventually decreases in size, and tissue remodeling occurs according to the specific demands placed on the healing tissues. Complete scar maturation may take up to one year.

For successful management of acute soft tissue injury factors promoting efficient optimal recovery should be maximized. 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.

Other factors that can affect the healing process are difficult to modify, but should still be factored into 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 fibres. A poor vascular supply may be an important factor in the chronic evolution of soft tissue injuries such as tendon disorders.

Successful management of acute musculoskeletal injury requires early recognition, identification of the cause(s), and treatment of any specific pathology. RICE Rest, ice, compression, elevation (RICE) is a mnemonic used to guide the early treatment after acute musculoskeletal injury.

However, the evidence base for this intervention is lacking and guidance on how to apply ice and/ or compression varies between sources. Thus, although widely accepted, there is little evidence for the effectiveness of this intervention, and even suggestion that it may be detrimental to recovery.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for analgesia and helping during recovery from acute musculoskeletal injury. Topical NSAID gels can also be effective, as in addition to their therapeutic effects they are useful for selfmassage. Local corticosteroids are used to reduce inflammation in patients with chronic tendinopathies, they have no role in the management of acute injuries.

There is scope for improvement in the management of acute musculoskeletal injury. As much soft tissue pathology represents a failure to repair tissue adequately after injury, improving the wound healing response seems an appropriate strategy for improving outcomes.

Potential targets that have been proposed to achieve this include transforming growth factor beta (TGF-β), which may promote regeneration of the tendon matrix structure and composition.

Traumeel is a 100 per cent natural treatment which has been shown to stimulate TGF-β production,16, and studies suggest that it has beneficial effects on the wound-healing process and may offer another treatment option available in pharmacy.

(Pam King is a marketing consultant at Bio Pathica.)