Soft Tissue Injuries

By Caitlin Lukacs

Most DCs would list soft-tissue injury treatment as a major component of their practices. But what exactly does such treatment entail? Soft-tissue injury covers a large variety of health issues, from over-use or repetitive-motion injuries to acute traumas such as ankle sprains. Because of the range of problems that are categorized as soft-tissue injuries, there are also a variety of treatments that can be used to care for them.

What Makes a Soft-tissue Injury?
There are two main types of soft-tissue injuries: focal lesions and global lesions, according to Michael Schneider, DC, PhD, assistant professor in the University of Pittsburgh’s School of Health and Rehabilitation Sciences and postgraduate faculty member at several prominent chiropractic colleges. Focal lesions are localized to one tissue area. An example of a focal lesion is tennis elbow. “Tennis elbow consists of very discrete pain in a particular area—not the entire arm,” Dr. Schneider explains. There are three types of tissue affected by focal lesions: muscle, tendon and fascia.

Another way to describe the three types of focal lesions, according to Gregory Doerr, DC, CCSP, head physician at the Bergen Chiropractic and Sports Rehabilitation Center, is structural, neurologicallymediated and microcirculatory. Structural issues include tendinopathy and ligament sprains. Neurologically- mediated issues consist of problems such as scapular dyskinesia. Microcirculatory issues include edema and inflammation caused by acute injuries.

Global lesions are a weakness or tightness in an entire muscle. An example is a tight hamstring.

How Does a Soft-tissue Injury Occur?
“Typically, soft-tissue injuries are caused by an overuse problem—repetitive motion—or an acute trauma,” explains Vincent DeBono, DC, CSCS, vice president for academic services at National University of Health Sciences. “Over-use injuries are relative,” he continues. “For example, postural deficits such as upper-cross syndrome may result in an over-use injury to the muscles that are correcting for the postural syndrome—the muscles are accommodating a biomechanical defect.” In other words, over-use injuries can occur when a muscle is used for an activity that it was not meant to be doing.

According to Dr. Schneider, the type of soft-tissue injury you’ll see depends on the patient population you treat. If you treat mostly athletes, you’ll probably see lots of over-use injuries and fascial problems, but if you treat mostly seniors or young children, it’s not very likely that you’ll see over-use injuries. Instead, acute trauma injuries are more common.

Are Soft-tissue Injuries Preventable?
“We’d love to be able to prevent soft-tissue injuries, but the reality is there is no way to do that. Accidents happen; no matter how much exercise you do. However, there are things we can do to help our patients reduce the likelihood of an injury,” says Dr. Doerr.

“It’s all about living a healthy lifestyle,” explains Dr. DeBono. “If you’re not getting regular exercise, proper rest and a balanced diet, you’re definitely going to be more prone to injury.” He goes on to explain that once your body sustains one injury it’s much more susceptible to future injuries or illness.

Dr. Doerr agrees, saying that proper conditioning and stabilization are key to protecting your body from injury. DCs are uniquely equipped to discuss healthful lifestyles with their patients— they can make exercise recommendations, give nutrition advice and even comment on healthful sleep habits.

How Are Soft-tissue Injuries Treated?
First and foremost, you always perform an evaluation, says Warren Hammer, DC, DABCO, and soft-tissue expert, who practices in Norwalk, Conn. For most soft-tissue injuries, you want to perform a standard active, passive and resistive testing of the area. Active testing determines the range of motion of an area, while passive testing or stretching, differentiates the passive tissues involved— ligaments, capsules or fascia. Resistive muscle testing confirms the muscle and/ or tendon involvement. “In order to properly treat a soft-tissue injury you need to know the specific part of the soft-tissue that is involved. Is it the ligament? Muscle? Tendon? Fascia? All of the above?” Often, the type of treatment depends on the specific area of involvement.

A common mistake in soft-tissue treatment is that doctors look only at the area that is experiencing pain, says Dr. Hammer. “Soft-tissue injuries are often a multifaceted problem. A chronic lower back problem could actually stem from a previous ankle sprain. If the earlier injury didn’t heal properly, it’s possible that the body is compensating for the injury and thus putting a strain on back muscles,” he explains. “That’s why it’s so important to look at the patient’s whole body.”

The fascial system requires particular attention, according to Dr. Hammer, because it is the main connective, softtissue component in the body. Injuries in the fascia can be determined using both passive and resistive testing techniques, such as fascial manipulation.©

Once you’ve isolated the injured tissue many different treatment methods are available. “For focal lesions, you’ll focus on techniques such as ART,® Graston® and NIMMO® care,” says Dr. Schneider, “while rehabilitation exercises treat global weaknesses and coordination problems.” Focal techniques should always be followed up by rehab methods.

Dr. Schneider breaks the focal treatment options into four categories.

  1. Static pressure (for example, NIMMO® care) – find trigger-points, and press on them and hold until the muscle knot releases.
  2. Dynamic pressure (for example, transverse friction massage or Graston®) - pressure with movement. Sometimes called gliding or stripping.
  3. Focal stretching (for example, muscle energy or post-isometric technique)
  4. Combination of 1-3 (for example, ART®)

Treatment for global lesions consists of rehabilitative exercise. For example, with a patient who is suffering from a tight hamstring, you’ll want to inhibit the overactive muscle (hamstring) using static stretching and post-isometric stretching . This patient most likely has a weakness in the opposite muscle as well, meaning that you’ll want to facilitate muscle activity there. The best option would be to contract against resistance through strength training.

Dr. DeBono agrees that different types of injuries require varied treatments. He prefers to start with light soft-tissue techniques as well as kinesiology taping. “The body responds to mechanical signals, and taping is one of the mechanisms with which we can sustain this input,” he explains. There are three main effects of taping, he says: increasing fluid flow during the acute phase of care, promoting repair of damaged tissue during the repair phase and assisting in neuromuscular adaptations during the functional rehabilitation phase.

PTs vs. DCs
According to Dr. Schneider, it’s common for patients to wonder about the difference between chiropractic techniques and physical therapy methods. “There is definitely an overlap of the care provided by DCs and that provided by PTs, but the biggest difference I’ve found is that PTs tend to look at the global dysfunctions while DCs focus on focal injuries.”

Theoretically, this should give DCs an advantage, says Dr. Schneider. “You have to treat the focal lesions first—often with hands-on manipulative techniques—and then most DCs are skilled in global treatments as well—exercise, nutrition counseling, etc.—so we should be able to treat a patient during their entire recovery.”

Soft-tissue injury treatment is a great example of an area in which DCs and PTs could work together says Dr. Schneider. A DC could treat the focal lesion (his or her forte) and then refer the patient to a PT for global treatment. The opposite is true as well. A PT could refer a patient to a DC for focal lesion treatment and then treat the global issue.

Is More Education or Training Needed?
Experts agree that while soft-tissue techniques are covered in general chiropractic education, additional training is recommended. “The schools teach the basic sciences and anatomy, as well as introductory clinical decision-making, but it’s impossible to teach everything in the short time they have with students,” says Dr. Doerr. “The introductory courses in school expose students to the techniques, but it’s beneficial for them to attend classes/seminars on the particular methods that work best for their patients.” He recommends finding courses through the particular treatment websites.

Dr. Schneider suggests contacting ACA’s Sports or Rehabilitation Councils to find educational programming. “Learning soft-tissue techniques requires a level of skill that is analogous to manipulation, which means that DCs need to recognize that a lot of additional training is needed to become proficient,” he adds.

Dr. Hammer believes that the techniques taught in post-graduate courses should be incorporated into the general chiropractic curriculum. “A majority of DCs who wish to practice soft-tissue treatment do partake in continuing education. To me, this says that they do not feel adequately trained without some sort of additional schooling,” he says.

“Continuing education is particularly helpful for DCs who have been out of school for a long time,” says Dr. DeBono. “Soft-tissue methods have changed significantly in the last several years, and it’s good to keep up to date. For example, DCs look at patients differently today. It’s not just an ankle sprain: We look at the patient as a whole body and identify aberrant postures and mechanical problems related to the ankle injury.”

Published in the August 2012 ACA News.