Factors and Stages of Healing

Layla has a grade II ankle sprain, which is a rupture of the ligament partially.  Grade II ankle sprain causes mild instability of the joint (Struijs et al., 2010). Layla’s current stage of healing is the proliferative stage because her weight bearing has increased and initial symptoms has improved over the last three weeks. She reports stiffness and tight feeling, which is due to (granulation tissue) scar tissue, swelling and limited range of motion.

Ligaments are organised dense fibrous connective tissue. Scar tissue is less organised and less mobile therefore weaker than normal the ligament (Hildebrand et al.,1998).

Immobilisation can cause stiffness in the joint leading to a decrease in range of motion therefore causing thickening of the synovial membrane (Kunz et al., 2014).

Growth factors and cytokines are released by Immune cells during the proliferative stage. The growth factors and cytokines initiates fibroblast to reconstruct the ligament tissue matrix. The new tissue matrix is less organised scar tissue with an increased number of blood vessels and inflammatory cells, resulting as swelling.

(Hauser, 2013).

There are four stages of healing are, bleeding and clotting, inflammation, proliferation and remodelling.  The key events in the proliferative phase are; fibroblast migration, angiogenesis, formation of granulation tissue, epithelialisation and wound contraction. (Schultz et al., 2011).

The surrounding tissue are stimulated by the fibroblast to proliferate for three days following the injury (Velnar et al., 2009).

As a response to mediators the fibroblast migrate into the wound (Schultz et al., 2011).

Factors such as transforming growth factor beta one (TGF-β) and platelet-derived growth factor (PDGF) attract fibroblast as they migrate in the wound. Both PDGF and TGF-β regulate fibroblast activity. PDGF stimulates fibroblast functions. TGF-β regulates extracellular matrix deposition and induces the synthesis of collagen (Schultz et al., 2011; Watson, 2008).

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Fibroblast in the matrix are active and higher in number compared to fibroblast in regular dermis, which are inactive and sparsely arranged. Fibroblast change their morphology and produce protease enzyme, in order to make a path for movement from extracellular matrix to the site of the wound. Once the fibroblast fully migrate into the matrix, they begin to proliferate and synthesise collagen (Schultz et al., 2011).

Collagen provides a rigid network facilitating further healing.  Collagen impacts integrity and strength to all tissues, as support for the formation of the wound matrix (Velnar et al., 2009). Type IV collagen is produced as a part of the basement membrane when there is damage to the skin. Type V collagen is deposited around cells providing structural support (Watson, 2008). Collagen molecules attach together head to tail and side by side forming collagen fibrils, form into large bundles.

Angiogenesis is the production of new blood vessels to replace existing damaged vessels therefore restoring circulation (Adair, 2011; Schultz et al., 2011).

Angiogenesis is initiated by multiple stimuli and involves capillary budding and the disruption of basement membrane of the venule at a point next to the stimulus. Endothelial cells migrate towards the stimulus as a group of cells surrounded by a provisional matrix. Individual sprouts link to form capillary loops. Existing vessels within the wound space form cross-connections, leading to a developed blood supply within the granulation tissue (Watson, 2008). Granulation tissue acts as a temporary replacement for normal dermis. Granulation tissue eventually matures into a scar during the remodelling phase of healing. Granulation tissue has a dense network of blood vessels, higher cell density of fibroblast and macrophages and randomly organised collagen fibers (Schultz et al., 2011).

Epithelialisation is where epithelial cells surrounding the wound migrate into the wound. Cells in the deepest layer of the epidermis begin to proliferate adding more epithelial cells.

Wound contraction peaks around two weeks after injury. The wound contraction process involves the contractile ability of myofibroblast to pull the edges of the wound together. Myofibroblast are cells that have both fibroblast and smooth muscle properties. Collagen is held by actin filament in myofibroblast, until collagen position stabilised (Watson, 2008).

The extent and intensity of the objective assessment is based on the severity, irritability and nature (SIN) of the patients symptoms, in order to produce a suitable treatment plan (Baker., et al 2017).

Severity is defined as the degree or intensity of pain (Smart & Doody, 2006), measured by the visual analogue scale (VAS) pain scale. A pain score of 7-10 is high, 4-6 is mild and 1-3 is low (Tidy & Porter, 2013).

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Irritability is defined by how quickly pain comes on from aggravating activity and the length of time the pain takes to subside (Smart & Doody, 2006). Irritability is classified by being high, moderate and low (Baker., et al 2017).

High irritability – the activity causes an increase in pain instantly and takes a long period of time to subside. Moderate irritability – it takes longer for the pain to increase. Low irritability- the activity can be carried out for a long period before exacerbating the patient’s symptoms, which subside quickly after the activity is stop (Tidy & Porter, 2013).

The nature of the condition is based on whether the problem is worsening, improving or stabilised, the stage of healing and the pathologic process (Barakatt., et al 2009). In terms of layla’s condition it is improving.

To avoid exacerbating patients pain while maximising the patients mobility, the vigour of physical examination and exercise prescribed is limited based on the patients severity and irritability (Barakatt., et al 2009).

Layla describes her pain as mild severity and low irritability. For the objective assessment this means that her pain takes longer to come on therefore more thorough objective assessment can be carried out, as her pain is well-tolerated.

Aggravating factors are movements that increase a patient’s symptoms. The specific movements that bring on the symptoms need to be recognised in order to indicate how irritable the condition is, along with the ease of reproducing the patient’s symptoms in the objective assessment (Petty 2000).

Layla reports sitting down for an hour aggravates her ankle, therefore in the objective she will be constantly moving during the assessment in order to prevent any aggravation. Laya has mild asthma and uses a salbutamol inhaler before exercise, however she will not be doing any vigorous activity in the objective assessment. Layla has no history of rheumatoid arthritis, no heart problems, no fits or faints and does not take any anticoagulants therefore she has no underlying health condition which would increase her symptoms.


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  • Hildebrand, K. A., & Frank, C. B. (1998). Scar formation and ligament healing. Canadian journal of surgery. Journal canadien de chirurgie, 41(6), 425-9.
  • Hauser, R. (2013). Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics. The Open Rehabilitation Journal, 6(1), 1-20. doi: 10.2174/1874943701306010001
  • Kunz, R. I., Coradini, J. G., Silva, L. I., Bertolini, G. R., Brancalhão, R. M., & Ribeiro, L. F. (2014). Effects of immobilization and remobilization on the ankle joint in Wistar rats. Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas, 47(10), 842-9.
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  • Smart, K., & Doody, C. (2006). Mechanisms-based clinical reasoning of pain by experienced musculoskeletal physiotherapists. Physiotherapy, 92(3), 171-178. doi: 10.1016/j.physio.2006.04.004
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