Common soft tissue injuries

by Stephanie Roche, Archie Rachuene & Stephen Roche

---

Background

Soft tissue injuries are very common, particularly in patients who are active and involved in sports but can also occur as a result of trauma or repetitive everyday activities. They can broadly be divided into two categories: acute and overuse injuries. The following lists common examples of each:

1. Acute soft tissue injuries (generally due to trauma, such as a sudden fall)
1. Sprain
2. Strain
3. Contusions
2. Overuse injuries
1. Tendinitis
2. Bursitis

Acute injuries

Sprain

A sprain can be defined as a stretch, tear or both, in a ligament.

The most commonly affected joints are the ankles, wrists and knees (see the relevant chapters for more information, for example, ACL tears of the knee). Clinical features include pain of varying severity, bruising and inflammation (swelling, erythema, warmth).

Strain

A strain involves stretching, tearing or both, of the muscle, tendon or both. Contrastingly, these injuries typically affect the posterior thigh (hamstring), feet and back. Clinical features include pain, signs of inflammation and muscle spasm, weakness or cramping sensations.

Contusion

A contusion occurs due to a blunt force injury, which causes crushing of the underlying connective tissue and muscle and damage to local blood vessels. Management is supportive, as above.

Clinical evaluation

History

Acute trauma or sports injury. Pain, swelling and loss of function.

Examination

• Look: Swelling, bruising, deformity
• Feel: Warm inflamed joint, effusion
• Move: Limited range of motion (ROM)

Special tests

Refer to specific chapters Neurovascular examination

Investigations

Plain X-rays: first-line (refer to Ottawa ankle rules).

Common overuse injuries

Tendinitis (acute)

Tendon inflammation as a result of repetitive micro trauma

Tendinosis (chronic)

Tendon degeneration in response to overuse.

Bursitis

Bursitis is inflammation of the bursa. Bursae are fluid-filled sacs lined with synovium which reduce friction between adjacent tissues that slide past each other during normal movement (such as tendons, ligaments and bone). Clinical features of bursitis include pain (worsened with movement), swelling, erythema and decreased range of motion. Knowledge of anatomy is essential to identify the affected soft tissue structure. The sites of commonly affected bursae should be palpated to exclude bursitis in patients presenting with joint or limb pain.

Joint	Tendinosis	Bursitis
Shoulder	Rotator cuff tendinopathy Biceps tendinitis/tendinosis	Subacromial bursitis Scapulothoracic bursitis (medial scapula pain/winging scapula)
Elbow	Lateral epicondylitis (tennis elbow) Medial epicondylitis (golfer’s elbow)	Olecranon (rule out gout and infections)
Knee	Popliteus tendinopathy Iliotibial band syndrome Patellar tendinopathy	Pre-patellar bursitis (rule out infection)
Ankle	Achilles tendinopathy, Rupture	Calcaneal and retrocalcaneal bursitis

Common overuse injuries

Management

• Assess and rule out serious injuries, limb-threatening injuries and complications, if present manage appropriately.
• Joint/immobilisation/splint.
• Ice packs
• Compression
• Limb elevation
• Analgesia and anti-inflammatory drugs
• Corticosteroids (oral and intra-articular injections)

Indications for referral for special investigations or further management

Acute

• Excessive bleeding
• Expanding haematoma
• Joint effusion (for example, knee haemarthrosis)
• Excessive swelling or compartment syndrome
• Associated neurovascular deficits

Chronic

• Joint instability
• Loss of function
• Persistent pain or intermittent joint effusion
• Signs of infection (fever, effusion, sinuses)