Common soft tissue injuries
by Stephanie Roche, Archie Rachuene & Stephen Roche
- Classification of common soft tissue injuries.
- Management of common soft tissue injuries.
- Indications for referral and further investigation.
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:
- Acute soft tissue injuries (generally due to trauma, such as a sudden fall)
- Overuse injuries
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).
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.
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.
Acute trauma or sports injury. Pain, swelling and loss of function.
- Look: Swelling, bruising, deformity
- Feel: Warm inflamed joint, effusion
- Move: Limited range of motion (ROM)
Refer to specific chapters Neurovascular examination
Plain X-rays: first-line (refer to Ottawa ankle rules).
Common overuse injuries
Tendon inflammation as a result of repetitive micro trauma
Tendon degeneration in response to overuse.
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.
Common overuse injuries
- Assess and rule out serious injuries, limb-threatening injuries and complications, if present manage appropriately.
- Ice packs
- Limb elevation
- Analgesia and anti-inflammatory drugs
- Corticosteroids (oral and intra-articular injections)
Indications for referral for special investigations or further management
- Excessive bleeding
- Expanding haematoma
- Joint effusion (for example, knee haemarthrosis)
- Excessive swelling or compartment syndrome
- Associated neurovascular deficits
- Joint instability
- Loss of function
- Persistent pain or intermittent joint effusion
- Signs of infection (fever, effusion, sinuses)
Lohr KM. Bursitis. Medscape. 2018 [cited 29 May 2019]. Available from: https://emedicine.medscape.com/article/2145588-overview
Levy DB. Soft tissue knee injury clinical presentation. Medscape. 2016 [cited 29 May 2019]. Available from:https://emedicine.medscape.com/article/826792-clinical#b4
OrthoInfo. Sprains, strains and other soft tissue injuries [Internet]. 2015 [cited 28 May 2019]. Available from:https://orthoinfo.aaos.org/en/diseases--conditions/sprains-strains-and-other-soft-tissue-injuries/
An 18-year-old male presents with injury to his right knee following a tackle during a soccer match. He reports severe pain and loss of function. Clinical examination reveals massive knee effusion, bruising and reduced distal pulses. Plain x-rays are normal. Which of the following is the most appropriate action?
- Splint the limb and observe overnight in the emergency unit.
- Splint the limb, provide analgesia and discharge home.
- Splint the limb, provide analgesia and emergency referral for special investigations and review by a specialist (vascular surgeon and orthopaedic surgeon).
- Splint the limb and refer for specialist review at the next available clinic day.
- Analgesia, intra-articular steroids and splint.
Option (C) is correct. The patient might have had knee dislocation, which is now reduced but presenting with signs of vascular injury and internal knee injuries requiring emergency treatment. Other options fail to recognize the urgency of his condition.