Pain
Soft tissue pain and
physical therapy
Paul J Watson
Abstract
Soft tissue pain is one of the most common reasons for consulting a
physiotherapist. Physical therapy management of the condition in the
acute (injury) stage is focused on the management of inflammation to
reduce further damage and promote healing. Treatment soon after injury
and in the subacute stage focuses on functional rehabilitation to restore
normal strength and biomechanics to the injured part. Adjuncts to treat-
ment such as electrotherapies and acupuncture are often used but lack
rigorous scientific evidence. In patients with chronic pain arising from
soft tissues a rehabilitation approach that identifies barriers to normal
function, both physiological and psychological, is adopted. Although
pain reduction is one aim of management in chronic pain, treatment is
designed to restore function and achieve patient-valued goals, even if
complete pain relief is not achievable.
Keywords acute pain; chronic pain; physical therapy
The treatment of soft tissue pain, and in particular pain associ-
ated with muscular and ligamentous structures, forms most of
the work of the musculoskeletal physiotherapist.
Pain commonly arises from an injury to the structural integ-
rity of skin, fascia, muscle, tendon or ligament. These injuries
often follow trauma or may be due to the cumulative effects
of repeated microtrauma. Trauma may be external following a
blow to the body or may result from stressing a tissue beyond
its mechanical strength. About 5% of soft tissue injury is sus-
tained during a sporting activity but commonly occurs in normal
daily activities.1 Of course, such problems do not always occur in
isolation and are often accompanied by joint damage and pain;
however, this article concentrates on soft tissue.
A convenient way of considering physiotherapy treatment
is via the natural history of inflammation and injury and this
framework is used in this article. However, there are conditions
which do not fit easily into this framework, especially chronic
or recurrent pain problems and these will be considered later.
Chronic soft tissue pain often exists in the absence of obvious
injury or abnormal pathology or it may be pain that has per-
sisted beyond the time when healing might be expected to have
occurred.
At rest, deep soft tissue pain is often poorly localized and
muscle pain in particular is characterized by aching and cramping
Paul J Watson, FCSP, PhD, is Senior Lecturer in Pain Management and
Consultant Physiotherapist at University Hospitals NHS Trust, Leicester,
UK. His research interests are musculoskeletal pain and rehabilitation.
Q1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:1
pain, which may be referred to other tissues and structures. The
structures involved can be identified by movement and palpation
and an accurate diagnosis of the problem is essential in the acute
phase of the injury. Significant pain affects the motor control
systems, reducing movement through protective guarding and
reducing muscle strength over the affected joints.
It must be emphasized that physiotherapy is delivered as a
package, modalities are rarely delivered in isolation. Physiother-
apy treatment sessions most often combine a treatment modality
with education, advice and exercise. This has made physiother-
apy very difficult to evaluate in research terms because isolating
one element does not represent clinical practice.
Acute and subacute management
Diagnosis of the injury and its severity informs the future man-
agement. A sprain of a ligament may vary from first-degree
with minimal stretching, maintaining the structural integrity, to
third-degree or complete rupture. The diagnosis is made by the
observation of bruising, inflammation, ability/inability to move
the limb, joint looseness, laxity or instability. A muscle strain is
usually a non-contact injury that occurs after an over-stretch or
over-contraction. The key features of this are pain, muscle spasm
and loss of strength. The injury may range from the disruption
of a few muscle fibres (mild strain) to disruption of most of the
muscle, which may require surgery (severe).2
Repeated microtrauma occurs when an individual performs
activities that alone may not cause pain, but when repetitious
can result in inflammation (e.g. where a tendon is repeatedly
compressed on movement, such as against the carpal bone com-
plex when typing).
The aim of physiotherapy in the treatment of acute pain is to
manage the underlying inflammatory process to encourage heal-
ing and early restoration of function. First aid in the management
of soft tissue pain aims to decrease bleeding, prevent excessive
swelling and relieve pain. If possible the limb should be elevated
in the early stages to help reduce swelling.
Movement restriction is recommended in the very early stage
of an acute injury and this is achieved by the use of splints and
non-elastic strapping or bandaging. The latter also provides com-
pression to help reduce swelling, but must be applied carefully and
reviewed regularly to prevent further complications. Cold therapy
is applied immediately to reduce pain and swelling. In its simplest
form, cold therapy consists of ice alone, but there are a number of
sophisticated cold-therapy devices that can be incorporated into
splints to provide both cold therapy and compression. Ice may be
applied repeatedly for 12 weeks to keep swelling under control. It
is often applied after exercise in the early stages of rehabilitation.
Ice cools the tissue and lowers tissue metabolism in the immediate
stages after injury, it reduces hypoxic cell death and relieves pain
through reducing neuronal activity. Ice must be applied early, a
delay of 24 hours will reduce the effectiveness of ice therapy.3
Electrotherapies: a localized application of ultrasound is used
to accelerate healing. Although there is some evidence for the
up-regulation of cell activity and for improved protein synthesis
in vitro, the clinical evidence for the use of ultrasound is less
convincing. Pulsed shortwave therapy and low-intensity laser are
also used and have similar benefit claims but, again, the clini-
cal studies are weak. All these therapies have been shown to
27 2007 Elsevier Ltd. All rights reserved.

a ccelerate fibrin and collagen deposition but whether this leads
to earlier return to function is unclear.4
Low-level laser therapy is used in the subacute phase of
healing, and there have been many claims of success, but the
supporting research suffers from poor methodology and lack of
agreement about a therapeutic dose.4
One of the most widely prescribed electrotherapies is trans
cutaneous electrical nerve stimulation (TENS), and there is strong
animal and experimental evidence that this therapy has analgesic
effects if applied correctly. These effects are not always trans-
lated into the clinical field, although more recent reviews have
suggested that this therapy is of benefit.5 Interferential therapy is
similar to TENS and is widely used by physiotherapists, but it has
not been subject to robust clinical trials.
Exercise: immobilizing a part of the body leads to reduced
muscle strength in the short term and reduces muscle endurance,
tissue length, proprioceptive acuity and strength in the long term.
Following the immediate acute phase, depending on the sever-
ity of the injury, exercise is introduced. Early exercise following
injury maintains the extensibility of the injured tissue, and a graded
increase in activity promotes remodelling of soft tissues along the
lines of normal stress. Prolonged immobilization following injury
can lead to the deposition of connective tissue in a non-organized
arrangement that lacks strength, and could lead to further injury.
Introducing graded stress on tissues through exercise enhances
their strength and promotes remodelling in the direction of stress.
As the acute phase subsides the intensity of exercise increases.
Low-repetition high-resistance exercises increase strength, low-
resistance, high-repetition exercises increase endurance, and sus-
tained aerobic exercise improves cardiovascular function. Most
injuries will benefit from a combination of all three exercises,
particularly if the patient has restricted activity.6
Additional pain-relieving treatments include acupuncture and
electrical nerve stimulation and sometimes the two are com-
bined. Although widely used there remains little evidence that
acupuncture is effective in soft tissue pain.
Massage and other hands-on therapies may be used as part of
a treatment plan; however, there is no strong evidence for the use
of massage alone in the management of pain. In acute and sub-
acute conditions where inflammation is present massage can be
effective in reducing swelling and removing oedema. The effects
of massage are likely to be caused by stimulation of A-receptors,
the relaxation effect of the treatment itself, and increased levels
of serotonin and reduced levels of cortisol, both of which have a
modulatory effect on pain.7 Soft tissue manipulation techniques are
used to mobilize and break down adhesions within and between
tissues, which may limit movement and normal performance.
The management of chronic pain
Chronic pain is a complex multifactorial condition. The cause of the
pain in many cases may not be clearly identifiable and imaging or
examination findings often fail to fully explain the patients report
of pain and accompanying disability. This should not lead the clini-
cian into assuming that there is no treatable pathology, and a full
examination and the provision of adequate analgesia is essential.
The main aims of physiotherapy in chronic pain is to provide
pain relief where possible, focus on the restoration of normal
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:1
Pain
function and assist the patient to return to normal physical
activities, including going back to employment, through active
rehabilitation.
Barriers to successful rehabilitation include fear of activity
and reinjury, pain catastrophizing and low self-efficacy for physi-
cal function and pain control. The relative importance of these
barriers needs to be assessed early on, and interventions should
be designed to address them. These can range from simple clari-
fication of misguided interpretations of symptoms to systematic
cognitive restructuring; the latter is usually outwith the remit of
the physiotherapist.6
A rehabilitation programme should inform the patient of their
condition, challenge distorted beliefs about pain and disabil-
ity and encourage self-management. This is achieved through
a combination of education, exercise and behavioural experi
mentation. Patients are encouraged to set goals for increasing
physical activities (activity scheduling) and resume valued activ-
ities, which they have avoided or stopped because of the pain,
in a paced manner.6
Although physical exercise is an essential component of treat-
ment, there is little evidence to support the use of specific exer-
cise over general exercise regimens, which include stretching,
strengthening and cardiovascular exercise with an emphasis on
increasing daily physical activities.6 The patient is also taught
how to self-manage pain flare-ups that are likely to occur.
Electrotherapies, acupuncture and massage alone are generally
not recommended in chronic conditions but there has been little
research to investigate their utility as an adjunct to rehabilitation.
Outcomes
The outcomes of acute soft tissue injury are good if treatment is
prompt and rehabilitation is complete and comprehensive. The
longer pain persists or if the patient starts to manifest psycho-
social risk factors is indicative of poor outcome. However, if the
latter factor is addressed the outcomes may be improved. The
emphasis in chronic pain is functional rehabilitation and teaching
the patient to self-manage symptoms that are likely to persist.
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28 2007 Elsevier Ltd. All rights reserved.