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Mark A. Merrick and Nicole M. McBrier

Context:

Acute musculoskeletal-injury management largely focuses on inhibiting secondary injury, although the data describing secondary injury and the timeline for its progression are sparse.

Objective:

To describe the timeline and early progression of secondary injury in skeletal muscle over the first 5 h after blunt trauma.

Design:

A controlled laboratory study with 2 independent variables (injury status and postinjury time point) in a 2 × 21 factorial.

Setting:

University research laboratory.

Subjects:

168 male Sprague Dawley rats (250 to 275 g).

Interventions:

Uniform blunt-contusion injury was caused to the right triceps surae using a drop-weight method; the contralateral limb served as an uninjured control. Both triceps surae were excised and flash frozen at 21 intervals across 5 h postinjury (8 animals, each 15 min).

Main Outcome Measures:

Cytochrome-c oxidase activity via reduction of triphenyltetrazolium chloride (TTC) to triphenyl-formazan.

Results:

There was an interaction effect (P = .041) between and main effects for both injury status (P < .0005) and postinjury time point (P = .038). In the first 30 min after injury, uninjured tissues did not differ from injured tissues, and both displayed TTC reduction rates in the vicinity of 7.1 ± 0.94 μg · mg−1 · h−1. Statistical differences between uninjured and injured tissues became evident starting at 30 min. TTC reduction for uninjured tissues did not change, but injured tissues declined in a roughly linear fashion across the entire 5-h period to 4.8 ± 1.04 μg · mg−1 · h−1.

Conclusions:

Cytochrome-c oxidase activity, an indicator of oxidative phosphorylation and mitochondrial viability, is diminished by events that follow muscle trauma. Loss of this enzymatic activity becomes statistically evident at 30 min postinjury and continues linearly for at least 5 h. This suggests that secondary injury is a slowly developing problem of more than 5 h duration. A window of opportunity for intervention may lie somewhere within the first 30 min after injury.

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Justin H. Rigby and Shaylene B. Dye

A variety of cryotherapy systems may be used to cool tissues immediately after an injury. The purpose our study was to examine the effect of a 30-min application of various cryotherapy devices on skin temperatures and compression. A crossover-designed study performed in a university research laboratory was conducted. Each treatment condition was applied to the lateral ankle for 30 min on different days. HyperIce’s colder temperatures over the lateral ankle (p < .0001) would make it the treatment choice for immediate care of ankle lateral ligament injuries, but is limited due its size for larger injuries.

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Brian W. Wiese, Kevin Miller, and Eduardo Godoy

A 19-year-old African-American male Division I collegiate American football player with no prior history of shoulder injury presented with right shoulder pain after making a tackle during a game. He was initially diagnosed with a rotator cuff strain with potential underlying labral pathology. Subsequent magnetic resonance imaging arthrogram showed no labral tearing, though a Buford complex was identified. A Buford complex is a normal anatomical labral variant where the anterior labrum is absent and the middle glenohumeral ligament is “cord-like” in structure. This case was managed conservatively since surgical intervention is only recommended if there is a secondary pathology to the shoulder (e.g., type II superior labrum anterior to posterior [SLAP] lesions). Clinicians should be aware of Buford complexes because they can predispose athletes to secondary injuries and can be managed successfully with a conservative rehabilitation approach in the absence of secondary pathology.

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Tricia Majewski-Schrage and Kelli Snyder

Clinical Scenario:

Managing edema after trauma or injury is a primary concern for health care professionals, as it is theorized that delaying the removal of edema will increase secondary injury and result in a longer recovery period. The inflammatory process generates a series of events, starting with bleeding and ultimately leading to fluid accumulation in intercellular spaces and the formation of edema. Once edema is formed, the lymphatic system plays a tremendous role in removing excess interstitial fluid and returning the fluid to the circulatory system. Therefore, rehabilitation specialists ought to use therapies that enhance the uptake of edema via the lymphatic system to manage edema; however, the modalities commonly used are ice, compression, and elevation. Modalities such as these may be effective at preventing swelling but present limited evidence to suggest that the function of the lymphatic system is enhanced. Manual lymphatic drainage (MLD) is a manual therapy technique that assists the lymphatic system function by promoting variations in interstitial pressures by applying light pressure using different hand movements.

Focused Clinical Question:

Does MLD improve patient- and disease-oriented outcomes for patients with orthopedic injuries?

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Brent A. Baker

Clinical Scenario:

Even though chronological aging is an inevitable phenomenological consequence occurring in every living organism, it is biological aging that may be the most significant factor challenging our quality of life. Development of functional limitations, resulting from improper maintenance and restoration of various organ systems, ultimately leads to reduced health and independence. Skeletal muscle is an organ system that, when challenged, is often injured in response to varying stimuli. Overt muscle-strain injury can be traumatic, clinically diagnosable, properly managed, and a remarkably common event, yet our contemporary understanding of how age and environmental stressors affect the initial and subsequent induction of injury and how the biological processes resulting from this event are modifiable and, eventually, lead to functional restoration and healing of skeletal muscle and adjacent tissues is presently unclear. Even though the secondary injury response to and recovery from "contraction-induced" skeletal-muscle injury are impaired with aging, there is no scientific consensus as to the exact mechanism responsible for this event. Given the multitude of investigative approaches, particular consideration given to the appropriateness of the muscle-injury model, or research paradigm, is critical so that outcomes may be physiologically relevant and translational. In this case, methods implementing stretch-shortening contractions, the most common form of muscle movements used by all mammals during physical movement, work, and activity, are highlighted.

Clinical Relevance:

Understanding the fundamental evidence regarding how aging influences the responsivity of skeletal muscle to strain injury is vital for informing how clinicians approach and implement preventive strategies, as well as therapeutic interventions. From a practical perspective, maintaining or improving the overall health and tissue quality of skeletal muscle as one ages will positively affect skeletal muscle’s safety threshold and responsivity, which may reduce incidence of injury, improve recovery time, and lessen overall fiscal burdens.

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Translational Science: An Opportunity for Rehabilitation Scientists Thomas H. Kelly * Carl G. Mattacola * 11 2010 19 4 369 379 10.1123/jsr.19.4.369 Original Research Reports Progression of Secondary Injury After Musculoskeletal Trauma—A Window of Opportunity? Mark A. Merrick * Nicole M. McBrier * 11

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Cordial M. Gillette and Mark A. Merrick

secondary injury through lowering the metabolic rate, microcirculatory changes, and granulocyte activity. 1 , 6 – 8 Although cryotherapy is accepted in clinical practice as a key component in the treatment of musculoskeletal injuries, evidence is lacking to provide specific guidelines concerning treatment

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Tyler A. Beauregard, Jade Vaile, Lucas Whitney, Mark Merrick, and Valerie Moody

, Rankin JM , Andres FA , Hinman CL . A preliminary examination of cryotherapy and secondary injury in skeletal muscle . Med Sci Sports Exerc . 1999 ; 31 ( 11 ): 1516 – 1521 . PubMed ID: 10589851 doi:10.1097/00005768-199911000-00004 10.1097/00005768-199911000-00004 10589851 4. Deal DN

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Caroline Lisee, Tom Birchmeier, Arthur Yan, Brent Geers, Kaitlin O’Hagan, Callum Davis, and Christopher Kuenze

Due to the health care and financial burdens associated with anterior cruciate ligament (ACL) injury, clinicians and researchers have attempted to identify high-risk biomechanical characteristics that play a role in ACL tears to provide specific targets for both primary and secondary injury

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Caroline Lisee, Lindsay Slater, Jay Hertel, and Joe M. Hart

throughout the rehabilitation process after ACLR, patients continue to demonstrate difficulties returning to previous levels of activity 5 and are at increased risk of secondary injury. 6 , 7 These challenges are heightened in females and athletes at higher levels of competition. 5 , 8 Athletes at higher