What is ligament repair like?

I want to cover more of the healing process of what the legal world refers to as soft tissue injuries.  This was such a new term for me years ago when I started working on medical legal cases.  It seemed that all an adjuster had to say was this is a soft tissue injury and this should just be known to all that there really isn’t an injury. It seemed that soft tissue injuries by attorneys were to be avoid at all cost and that a real case needed more than just soft tissue. 

This phrase soft tissue used to drive me crazy, and I had no idea what they meant.  I think the brain is a very soft tissue of the human body.  I also think the eyes, heart, and other organ systems are soft.  I think I may have solved the origin of the term soft tissue injury or at least a place I see this term in the medical legal area.  The AMA’s Guides to the Evaluation of permanent Impairment has separate categories of injuries in the spine.  The first category is soft tissue and non specific conditions.  This category covers “Non-specific chronic, or chronic recurrent pain also known as chronic sprain/strain, symptomatic degenerative disc disease, facet joint pain, chronic whiplash, etc.” end quote. 

This soft tissue category allows for a 0-3% whole person impairment rating.  The next category is motion segment lesions and this covers disc herniations and or AOMSI.  The motion segment lesions allow for a 0-30% whole person impairment rating.

The next category is pseudoarthrosis which is unsuccessful fusion.  This category only applies to spinal surgeries with failed fusion.   This category allows from 4-30% whole person impairment ratings. 

The next category is spinal stenosis or narrowing of the spine and allows for a 0-30% whole person impairment rating. 

The next category is fractures/dislocations of the spine.  This allows for a 0-30% whole person impairment rating. 

The last category is postoperative complications.   These need to be non-neurological  and allows for a 25-30% whole person impairment rating.  This is seen with quote “deep spinal wound infection requiring chronic suppressive antibiotics or chronic osteomyelitis” end quote. 

This shows the lack of seriousness so called soft tissue injuries have in regards to impairment ratings.  All other categories allow for up to 30% impairment rating and the soft tissue category allows for up to 3% impairment rating.  Keep in mind if the so called soft tissue or strain/sprain injuries are serious enough to alter the motion segment integrity then the patient has alteration of motion segment integrity or AOMSI and this allows for up to 30%. 

Why would soft tissue injuries of a strain/sprain or damage to ligaments and muscles if bad enough qualify for up to 30% whole body impairment rating?  We covered what the AOMSI means in prior podcasts, but remember AOMSI shows complete and sudden failure of ligaments where nearly all the ligaments were transected at that level. 

If soft tissue injuries were so irrelevant as it seems when talking to attorneys and adjusters then why would a patient qualify for up to 3% whole body impairment rating?  That is admission of a permanent injury that will never make a full recovery.  We have talked in prior podcasts about the healing or remodeling process of ligaments and the loss of the ligament reflexive control of muscles.  These so called soft tissue injuries are significant and permanent. 

I want to discuss the research article Tendon and Ligament: development, Repai and Disease by Samuel Tozer and Delphine Duprez in the Birth Defects Research Journal 2005.  This article talks a lot about embryonic development of tendons and ligaments.  They discuss how ligaments and tendons come from the same progenitor cells and how similar these structures are.  They reported that there is no extra cellular matrix component of the tendon ligament architecture that can be used to distinguish tendon from ligament and they are differentiated by their spatial orientation to the properties of ligaments or tendons. 

As interesting as embryonic formation of ligaments can be they also talk about tendon and ligament repair, which seems more relevant to our podcast.  They reported that tendon and ligaments are common clinical problems that are damaged by injuries.  They state that quote “No treatment currently exists to restore an injured tendon or ligament to its normal condition” end quote.  Think about that statement for a minute.  There are no treatments that exist to restore and injured tendon or ligament to its normal condition.  That is a great discerption of a permanent injury.  This so called soft tissue injury has no treatment to restore to normal condition. 

We talked in prior podcasts about how important ligaments are in the reflexive control of muscles.  This process is not restored once there is damage to the ligaments.  The Hauser study that we went over in prior podcasts showed how inferior ligament healing is.  That was the study they compared finding management of ligament damage to the search for the Holy Grail. 

Today’s study showed that quote “tendons and ligaments heal at a slower rate than other connective tissue” end quote.  They reported that this is due to the hypocelluar composition of these tissues and showed that there is only 5% cell in the composition of the tissues. 

Today’s study then went on to discuss different treatment options for ligaments and tendonds, but reported quote “there is no actual technique that leads to a complete tendon ligament recovery after an injury” end quote. 

Every time I have a patient with ligament damage after an injury I think about how serious of an injury this is.  There is no technique or treatment that can restore the ligament to pre-injury status.  We get up to 10-20% of the viscoelastic properties of a healthy ligament.  We get fat cells, blood vessels, inflammatory pockets and scar tissue forming inside of the ligaments.  We lose the reflexive control ligaments have on muscles which will inhibit muscle relaxation and activation.  This means that while lying in bed when the muscles should relax they will spasm and when we need the muscles to work they won’t respond. 

These are the types of patients I see all the time in my office.  I hear the same story every week.  I will have a new patient come in and I will ask them when did your neck start bothering you.  They respond with ever since my car accident years ago the neck has never been the same.  These injuries are significant and in my opinion should qualify for more than the 3% allowed in the AMA guides. 

Think of how important this information is when it comes to talking about soft tissue injuries.  I hope adjusters and attorneys will understand that the term soft tissue sucks.  The term soft tissue and its connotation of not a serious injury and will just get better needs to go.  If we are talking about ligament damage it is a serious permanent injury. 

Real World

For today’s real world example, I want to go over general spinal injuries and not specific examples.  When it comes to spinal ligament damage, I can think of 3 categories.  You have 2 objective and 1 mostly subjective type of ligament damage.  The worst damage to ligaments qualifies as AOMSI which we have covered in past podcasts.  AOMSI is seen on motion x-rays with 11 degrees change in angular motion and 3.5 or 20% translation of vertebra.  This is complete damage to the ligaments and in the AMA impairment rating guides is given significant impairments. 

The second objective spinal ligament damage was discussed in the podcast that we had Melody on with us.  This is seen with motion x-rays and when we don’t have AOMSI, but we have 7 degrees or more change in angular motion or .6mm translation at any level compared to C2-3.  This shows what I call sub-catastrophic ligament damage.   This is a powerful objective verification of ligament damage. 

The third category is when there is no specific objective evidence of ligament damage.  These cases are seen when we have a mechanism of injury consistent with ligament damage.  A motor vehicle collision with onset of spinal pain is consistent with ligament damage.  Palpation testing shows hypertonicity or muscle tension while at rest indicates potential ligament damage.  A decrease in range of motion indicates ligament damage.  Ongoing symptoms that do not resolve with treatment indicate ligament damage.  On this type of patient I am convinced they have a level of ligament damage. 

These cases would be harder to take to trial give the lack of visible objective data, but these are serious permanent injuries.  They typically qualify for a 1-3% whole body impairment rating.  These are the patients that have ongoing pain for the rest of their lives and will continue care for years. 

As seen in the literature chiropractic care of moving the affected joint is helpful management of these symptoms.  It is frustrating to see the lack of progress made on these patients.  It can be very annoying when I hear an attorney tell me the adjuster on the case won’t give any value to the injuries because it is just a soft tissue injury.  That is why it is our job to explain what type of injury the patient has and how serious it is.   Don’t argue soft tissue or not soft tissue.  Lets argue what the injury is and what it means to the patient and what the future of the injury will be.  Remember today’s study showed that quote :there is no actual technique that leads to complete tendon ligament recovery after injury” end quote.