Ligamentous injury & rehabilitation – Our anatomy was WRONG…therefore our approaches were WRONG
Before Jaap van der Wal’s incredible research on the composition of ligamentous structure, and its relationship to the surrounding fascial and contractile/muscular substances, similar conclusions could have been drawn from older histological research. Said research acted as a major contributor to many of the P.A.I.L’s (Progressive Angular Isometric Loading)™ rehabilitation protocols utilized by Functional Range Release™ practitioners.
Ligaments had long been thought to have two primary roles: the passive guidance of bone position during normal joint function, and passive joint stabilization. In addition to these functions, it was then discussed that the ligament also has a potential role as a proprioceptor in that nerves within ligaments were discovered to have sensory end organs capable of producing feed back information to the CNS which could then alter/improve muscular response and function (see Brand, 1989).
However, as noted by van der Wal (2009) “The architecture of the connective tissue, including structures such as fasciae, sheaths, and membranes, is more important for understanding functional meaning than is more traditional anatomy, whose anatomical dissection method neglects and denies the continuity of the connective tissue as integrating matrix of the body.” The author is referring to the common dissection methods which historically have artificially separated anatomy into individual structure, for example the “MCL,” by way of sharp scalpel dissection…ignoring, and removing the tissue that connects and binds each structure together, the fascia (capsule, retenaculum, etc). This is also not a new concept. As noted by Frank (1996) in Zachazewski’s text (Athletic Injuries and Rehabilitation) regarding ligamentous structure specifically, “Not all ligaments, however, have easily distinguishable fibers, at least not without considerable fine dissection. The removal of surrounding tissues or surface layers of ligaments during their anatomic dissection has never been thought to have any particular significance, since these tissues are believed to be nonligamentous. However, these obscuring surface layers may, in fact, be a very important component of the ligament.”
What does this continuity mean to the manual therapist in terms of ligamentous injury, treatment, and rehabilitation? As further noted by van der Wal (2009), the continuity of structure creates continuums between contractile (muscular) and “non-contractile” structure like ligaments and fascia (I use parenthesis because recent literature has demonstrated the ability of fascia to contract…thus making it a ‘contractile’ substance). Thus the stability across a joint is not reliant on passive or active components as individual entities,
but rather a continuum of all tissue components working as one. “An architectural description of the muscular and connective tissue organized in series with each other to enable the transmission of forces over these dynamic entities is more appropriate than is the classical concept of “passive” force-guiding structures such as ligaments organized in parallel to actively force-transmitting structures such as muscles with tendons (van der Wal, 2009).” Thus, rehabilitation across a joint can, and should involve progressively passively loading the historically considered ‘passive structures’ like ligaments, as well as in combination with active structure (muscle).
By ‘passive’ loading I am referring to progressively loading the joint in such a way that the joint is being stressed into the position that caused the injury….this is NOT a typo…during the second phase of healing which involves the production of scar matrix, mild loading of the injured tissues will promote tissue production as well as influence collagen alignment. Again, this is not a new concept that “very low cyclic loads on a ligament scar will promote scar proliferation and material remodelling, thus making the scar stronger and stiffer structurally” (Frank, 1984). We do this passively to actually ‘gap’ the joint. In addition to this, we must utilize ‘active’ loading by using progressive active loading of contractile tissues (ie. P.A.I.L.’s™), this will ensure that we are strengthening all of the tissues crossing the joint as a continuum (muscle-fascia/capsule-ligament-fascia/capsule-muscle) contributing to the joints stability.