Ligament and tendon damage from Immobilization syndrome

In this article, we review various aspects of short and long-term immobilization of an injured joint, specifically the damage to the tendons and cartilage. Immobilization syndrome has been implicated in being a developmental cause of long-term chronic joint pain.

If you have questions about immobilization syndrome you can get help and information from our Caring Medical staff.

Immobilization, or stress deprivation, is a term to describe casting, splinting, taping, or other means of limiting movement to an injured area of the body. Immobilization is part of the RICE therapy which involves rest, ice, compression, and elevation.

Immobilization syndrome refers to the results of short-term as well as long-term immobilization, the symptoms of which are: very stiff joints, muscle atrophy, joint degeneration, and chronic pain.

Immobilization syndrome is a painful component of conditions such as Complex Regional Pain Syndrome, osteoarthritis, and frozen shoulder, also known as adhesive capsulitis.

Immobilization, or stress deprivation, is a term to describe casting, splinting, taping or other means of limiting movement to an injured area of the body

Immobilization can be detrimental to ligament healing and should not be done casually, though it is sometimes necessary under medical supervision. In our office, it may be used early in the treatment course for more severe cases of instability. Immobilization is generally discouraged for most cases because it can cause the following changes:

proliferation of fatty connective tissue within the joint
cartilage damage and necrosis
scar tissue formation and articular cartilage tears
increased randomness of the collagen fibers within the ligaments and connective tissues
ligament weakening with a decreased resistance to stretch.

When bone replaces cartilage in immobilized knees

A study from hospital and university researchers in Canada published in the journal Bone made some concerning discoveries. Here is what they said:

Lost joint range of motion (ROM) is common in chronic osteoarthritis, alters regional weight-bearing across the articular surfaces, and contributes to loss of cartilage and bone alterations. In prolonged immobilization bone replaces cartilage and the effects are irreversible.
In this animal study, eleven rat knees were rigidly-immobilized in 32 weeks
- Immobilized cartilage had increased collagen I content (scar tissue)
- Articular cartilage was thinner
- Severity of osteoarthritis increased as measured by Mankin scores
- The trabecular bone plate area (the spongy bone at the end of long bones like the thigh and shin bones) at the front and back of the shin showed bone loss, but not in the middle.
- Chondral vascular ingrowth was seen in the subchondral bone. This means that blood supply was increased to the bone as the cartilage and outer bone was was dying. The center of the knee joint was being fortified as we see in the fact that bone loss was not seen in the center of the top of the tibia bone.
In summary: Bony replacement characterizes articular cartilage degeneration of knees immobilized for 32 weeks in the anterior, non-weight bearing region of the tibia. Replacement of cartilage by bone may have been mediated by chondral vascularization, suggesting irreversible changes. These findings stress the importance of weight-bearing and joint motion to maintain cartilage structure.(1)

When bone and tendon are weakened in immobilized knees

Research lead by the University of Iowa made these findings published in the Journal of bone and joint surgery:

Immobilization had a significant detrimental effect on the bone-tendon complex.
At two weeks there was a significant decrease in the mechanical properties of the native tendon, but the immobilized, native tendon remained significantly stronger than the repaired and immobilized tendon.
However, four weeks of immobilization led to a significant loss of strength of the bone-tendon complex in the native tendon, such that it was significantly weaker than the repaired and immobilized tendon.
Surgeons who manage patients with immobilization should be aware of the changes at the bone-tendon complex.(2)

Patients should also be made aware of these detrimental changes.

Tendons and ligaments need to move, that is how they repair themselves. Concerning is research like this published by Japanese researchers at Hokkaido University Graduate School of Medicine which found that complete stress deprivation/immobilization of the patellar tendon induces fibroblast apoptosis – the death of cells that produce reparative collagen in tendons – within 24 hours of casting.(3)

Immobilization and the elderly

Immobilization syndrome is not limited to younger patients healing an injury. Inactivity is another, one that can particularly affect the elderly. For example, an activity as simple as walking can nourish the joints in the hips and the knees. Inactivity, on the other hand, can lead to a vicious spiral of disuse, no nourishment to the hip and knee joints, cartilage degeneration, and pain, which leads to even less movement and makes the likelihood of starting an activity even slimmer, resulting in a downward spiral of joint deterioration and pain.

Not surprisingly, it has been shown that the more a specific joint is exercised, the stronger the bone-ligament and bone-tendon complexes become. Exercise specifically helps strengthen the fibro-osseous junction, which is where the ligament/tendon and bone attach to each other, and which, incidentally, is the area where Prolotherapy treatments are administered. Controlled activity and stretching are therefore an important part not only of healing an injury but also of preventing injuries.

Movement and gentle range-of-motion exercises improve blood flow to the affected area, removing debris. If movement of the joint is painful, isometric exercises, which involve contracting a muscle without moving the affected joint, would be recommended. This is why the RICE treatment protocol typically used for soft tissue injuries, where R stands for rest and E for elevation, which “spell” immobilization, is so detrimental to healing. Ligaments too are especially sensitive to immobility.

If you suffer from back pain please see our article Ligament laxity and spinal instability, for a general discussion on the damaging effects of weakened ligaments on joint stability please see our article Joint Instability to Osteoarthritis to Degenerative joint disease.

Although immobilization syndrome can be the result of any one of a number of other conditions, injuries are the most common. If this is the case, Prolotherapy to the injured area will strengthen the weakened and/or injured ligaments and tendons and even cause cartilage regeneration.

Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction – where ligaments and tendons attach to the bone, an area rich in sensory nerves. What’s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent.

If you have questions about immobilization syndrome you can get help and information from our Caring Medical staff.

1 Campbell TM, Reilly K, Laneuville O, Uhthoff H, Trudel G. Bone replaces articular cartilage in the rat knee joint after prolonged immobilization. Bone. 2018 Jan 1;106:42-51. [Google Scholar]

2 Hettrich CM, Gasinu S, Beamer BS, Fox A, Ying O, Deng XH, Rodeo SA. The effect of immobilization on the native and repaired tendon-to-bone interface. J Bone Joint Surg Am. 2013 May 15;95(10):925-30. doi: 10.2106/JBJS.K.01329. [Google Scholar]

3 Kawabata H, Katsura T, Kondo E, Kitamura N, Miyatake S, Tanabe Y, Setoguchi T, Komiya S, Yasuda K. Stress deprivation from the patellar tendon induces apoptosis of fibroblasts in vivo with activation of mitogen-activated protein kinases. J Biomech. 2009 Nov 13;42(15):2611-5. [Google Scholar]

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