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Decreased blood flow...Flexing...How much and how often?

Posted by Glenn X on 8/06/01 at hrmin (055642)

I've heard that blood flow to tendons and ligaments (and fascia?) is less than that to muscles, which has the consequence of extending the healing time of connective tissues.

I also understand that when exercising muscles, it helps to fatique them slightly, and then give them a couple of days to recover before working them again. I assume in those two days they repair themselves (depending on the degree of fatiguing). And over time this process adds strength.

Does it then make sense to VERY moderately fatigue tendons, ligaments, and fascia material, maybe through tensioning, ART, myofascial release and the like -- and then give those tissues time to heal, only more time than we might with muscles, before 'fatiguing' them again? And given the decreased blood flow and extended repairing time, how much more time might we be talking about? I am assuming it's possible to 'exercise' connective tissues without tearing them, thereby strengthening them.

Maybe the simpler question is, how much less blood flow is there to connective tissue than to muscles? Half? Ten percent?

Maybe too a companion question is, how often should we intelligently stretch calf muscles to gain flexibility there? Every 48 hours? Daily? Three times daily?

(I'm home from work today and have an excess of thinking time).

Re: Decreased blood flow...Flexing...How much and how often?

Ed Davis, DPM on 8/06/01 at hrmin (055655)

Glenn:

I am not aware of accurate anatomical statistics in comparing blood flow to muscles, tendons and ligaments. Will see if the other docs have some stats on this. Muscle tissue is very rich in blood flow so my best guestimate is that tendons would have about 25% of the flow of muscle tissue and ligaments about 15%. Blood flow is one determinant of tissue repair and recovery but the most accurate measure would be the rate of cell division (mitosis) in a particular tissue. Nerve tissue is notoriously slow in this regard.

An important factor to look at is the type of load be placed on a tissue. Use of a lighter load would require less recovery time--possibly no recovery time under certain circumstances. An interesting illustration of this is a relatively new technique called the Ilazarov technique. The Ilazarov technique involves the placement of pins (external fixation device) across a healing area of fracture. The pins protrude throught the skin and a distraction (stretching) force is placed across the area of fracture. The goal is to elongate the area of fracture healing such that greater length is added to a fracture in which there was bone loss, that is, a fracture that would leave a limb potentially permanently short. We generally think that immobilization and compression are needed to heal bones and that is usually the case. Nevertheless, after a certain amount of compression has allowed partial healing, the immature bone bridging the fracture site can be stretched very slowly to gain the needed length. It is a difficult and time consuming procedure. The distraction or stretching force is light but relatively constant. The process of bone building is influenced by the external force applied. (Laws of Wolfe and Davis--not me)

Ligaments and tendons can be lengthened using external force applied over a long period of time. The 'right' amount of force should allow the many parallel fibers that make up ligament or tendon re-align themselves and, as the tissue repairs, the new tissue placement will be influenced by such forces to form in an elongated fashion. Too strong of a force, that is, a force of sufficient magnitude that causes the body to percieve tissue damage is occurring may cause the opposite to occur-tissue 'reinforcing' the tendon or ligament in an attempt to tighten it.
Ed

Re: Decreased blood flow...Flexing...How much and how often?

Glenn X on 8/07/01 at hrmin (055803)

Dr. Ed. This strikes a major chord with me, and ought to be up there with required PF reading.

Perhaps the chief challenge of being treated for PF is acclimating to a new time dimension. Meaning, we are so used to healing other parts of our body in here-to-fore predictable windows of time that we have enormous difficulty realizing and accepting that this particular type injury will take much longer. For simplicity's sake, if we use the 15 percent reduced-blood-flow figure, a 'familiar' muscle strain that might take 15 days to get over, might translate to a PF strain that takes 100 days to get over (15 divided by 0.15). And that's if it's caught in the early stages, and treated properly.

I realize this is crude in concept, but I recall with certainty that when I was first diagnosed with PF, I did not hear nor did I understand how different an injury this was, and hence failed to take it seriously. Probably most patients who respond to conservative care somehow get this early on, but I didn't, and proceeded on my merry way doing most activities so long as they were pain-tolerable. I did understand there was less blood flow, but not knowing how much less, and the consequences of that, helped me brush off the importance of that piece of knowledge. The difference between 15 and 100 days would have gotten my attention, and reinforced my patience.

What's even more helpful is the discussion on lengthening. If bones can lengthen, clearly tendons and ligaments can, particularly under the particulars of your last paragraph. Hence the working of night splints -- and added insight into what proper stretching routines we need to incorporate: more frequent (maybe hourly), more prolonged in the hold (maybe five minutes), less strain (perhaps just to the point of tension). Just guesses at this point, but it's something else to go after.

Thanks for the informative post.

Re: Decreased blood flow...Flexing...How much and how often?

Ed Davis, DPM on 8/06/01 at hrmin (055655)

Glenn:

I am not aware of accurate anatomical statistics in comparing blood flow to muscles, tendons and ligaments. Will see if the other docs have some stats on this. Muscle tissue is very rich in blood flow so my best guestimate is that tendons would have about 25% of the flow of muscle tissue and ligaments about 15%. Blood flow is one determinant of tissue repair and recovery but the most accurate measure would be the rate of cell division (mitosis) in a particular tissue. Nerve tissue is notoriously slow in this regard.

An important factor to look at is the type of load be placed on a tissue. Use of a lighter load would require less recovery time--possibly no recovery time under certain circumstances. An interesting illustration of this is a relatively new technique called the Ilazarov technique. The Ilazarov technique involves the placement of pins (external fixation device) across a healing area of fracture. The pins protrude throught the skin and a distraction (stretching) force is placed across the area of fracture. The goal is to elongate the area of fracture healing such that greater length is added to a fracture in which there was bone loss, that is, a fracture that would leave a limb potentially permanently short. We generally think that immobilization and compression are needed to heal bones and that is usually the case. Nevertheless, after a certain amount of compression has allowed partial healing, the immature bone bridging the fracture site can be stretched very slowly to gain the needed length. It is a difficult and time consuming procedure. The distraction or stretching force is light but relatively constant. The process of bone building is influenced by the external force applied. (Laws of Wolfe and Davis--not me)

Ligaments and tendons can be lengthened using external force applied over a long period of time. The 'right' amount of force should allow the many parallel fibers that make up ligament or tendon re-align themselves and, as the tissue repairs, the new tissue placement will be influenced by such forces to form in an elongated fashion. Too strong of a force, that is, a force of sufficient magnitude that causes the body to percieve tissue damage is occurring may cause the opposite to occur-tissue 'reinforcing' the tendon or ligament in an attempt to tighten it.
Ed

Re: Decreased blood flow...Flexing...How much and how often?

Glenn X on 8/07/01 at hrmin (055803)

Dr. Ed. This strikes a major chord with me, and ought to be up there with required PF reading.

Perhaps the chief challenge of being treated for PF is acclimating to a new time dimension. Meaning, we are so used to healing other parts of our body in here-to-fore predictable windows of time that we have enormous difficulty realizing and accepting that this particular type injury will take much longer. For simplicity's sake, if we use the 15 percent reduced-blood-flow figure, a 'familiar' muscle strain that might take 15 days to get over, might translate to a PF strain that takes 100 days to get over (15 divided by 0.15). And that's if it's caught in the early stages, and treated properly.

I realize this is crude in concept, but I recall with certainty that when I was first diagnosed with PF, I did not hear nor did I understand how different an injury this was, and hence failed to take it seriously. Probably most patients who respond to conservative care somehow get this early on, but I didn't, and proceeded on my merry way doing most activities so long as they were pain-tolerable. I did understand there was less blood flow, but not knowing how much less, and the consequences of that, helped me brush off the importance of that piece of knowledge. The difference between 15 and 100 days would have gotten my attention, and reinforced my patience.

What's even more helpful is the discussion on lengthening. If bones can lengthen, clearly tendons and ligaments can, particularly under the particulars of your last paragraph. Hence the working of night splints -- and added insight into what proper stretching routines we need to incorporate: more frequent (maybe hourly), more prolonged in the hold (maybe five minutes), less strain (perhaps just to the point of tension). Just guesses at this point, but it's something else to go after.

Thanks for the informative post.