Are we talking Kleenex here? Some soft, 2 ply tissue providing luxurious and elevated care? Perhaps this is some sort of gentle new whacky treatment method supposedly helping with severe chronic pain.
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What is Soft Tissue?
Whenever you feel pain in the musculoskeletal (MSK) system, unless you have broken a bone, chances are it’s because of something wrong with the soft tissue. Injuries such as tendon tears, ligament sprains, or muscle strains all fall under soft tissue injuries. Soft tissue is defined by Merriam-Webster as “tissue (such as tendon, muscle, skin, fat, and fascia) that typically connects, supports, or surrounds bone and internal organs”.
Types of Soft Tissue
The types of soft tissue are as follows:
Tendons – tissue which connects muscle to bone. These are the elastic energy storing tissues and act as springs to propel the body.
Muscle – tissue connected mostly from bone to bone through the tendon. These are the contractile soft tissue.
Ligaments – tissue which connects bone to bone and ensures that movement is restricted. Without this tissue, bones can derail from their proper position – joint subluxation or joint dislocation.
Fascia – tissue which forms a network, interconnecting and separating layers of muscle, different muscles, and other internal organs.
Fat – tissue which stores energy, insulates and cushions the body.
Skin – tissue that lines the body surface.
Basic Categories of Tissue
For those who are aware of basic physiology, you may be confused as soft tissue doesn’t fall into normal categorization of tissue. All the tissues that make up the human body are categorized into four basic types: epithelial, connective, muscle and nervous tissue (Medline Plus 2021). So, what type of tissue is soft tissue then if it’s not one of these four? It’s a mix of all these basic types of tissue:
1. Epithelial tissue – skin is a type of epithelial tissue
2. Connective tissue – ligaments, tendons, fascia, fat are all types of connective tissue
3. Muscle tissue – skeletal muscle is a type of muscle tissue
4. Nervous tissue – lower motor neuron nerves, although not a soft tissue has much of an interface with soft tissue
The reason why some health disciplines such as physiotherapy categorizes soft tissue as a type of tissue is to differentiate it from the skeletal system and internal organs. With this differentiation, we are able to conceptualize methods of massage, stretching, and strengthening targeting this adaptable and malleable soft tissue, something which can’t be done with bones and internal organs.
What About Joints?
Joints are not largely soft tissue structures; however soft tissues highly impact the function of a joint. Looking into the anatomy, joints consist of:
Hyaline cartilage lining the bony surfaces
Joint capsule encircling the joint
Ligaments passing around and occasionally through the joint
Some joints have a fibrocartilaginous structure (either a meniscus or labrum depending on the joint) attached within to increase joint surface area
The cartilaginous structures are not adaptable or malleable like soft tissue, and do not have much blood supply so are poor at healing. The joint capsule, on the other hand, is soft tissue and is similar in tissue type as tendons and ligaments. However, it isn’t just the joint capsule and ligaments within a joint as soft tissues impacting the function of the joint. The muscles which pass over joints, and tendons which attach closely to joints also impact the joint. In this following section we’ll look at how soft tissue issues can affect not only the joints, but the whole musculoskeletal system.
Spectrum of Soft Tissues Issues
The main issues which appear within soft tissues can generally be placed on a spectrum here between tight tissue to lax tissue. The extremes of both are placed on either ends of the scale and most other conditions can be placed in between.
Here is a list of common soft tissue issues placed into this spectrum:
Ligament sprains – can be partial tear or complete tear
Muscle strains – can be partial tear or complete tear
Tendon strains– can be partial tear or complete tear
Tendinopathies – overuse due to sustained lengthened position
Fasciopathies – overuse due to sustained lengthened position
Nerve entrapments – associated soft tissue condition due to tightness of the soft tissue encapsulating the nerve
Muscle issues such as tightness or spasm – shortened condition of muscle
Myofascial postural pain – both shortened and lengthened conditions of the fascia and muscle
Scar tissue of all types of soft tissue – shortened position of the soft tissue
Adhesive capsulitis – shortened position of the joint capsule
Linear Spectrum or Circular Spectrum
Although this seems to be a well-fitting linear spectrum of the conditions, it is only displayed as so to demonstrate the polarized ends of the spectrum between tight and lax. In reality it works more like a circular spectrum. On one side of the spectrum, the body reacts to a complete tear by forming scar tissue, bringing it to the polar opposite tightness side of the spectrum. On the other side, due to the brittle nature of stiff fibrosed tissue, contracture tissues can more readily tear, bringing it to the other side of the spectrum in a circular manner.
Viewpoints of Soft Tissue
What we’ve just covered is only one viewpoint in which soft tissue can appear to have issues in. We can call this viewpoint the reductionistic view. Reductionistic view refers to observing each soft tissue structure individually as it is. For example, if someone sprains their anterior talofibular ligament (ATFL), looking at this in a reductionistic manner gets us thinking about what has happened and what is happening to this ligament in a cellular level from the physiology (normal cellular function) to pathophysiological mechanism (disordered cellular function). This viewpoint is the most common view in general western medicine.
There are two other viewpoints which help us fully understand soft tissue issues. These are the Interactive Anatomy viewpoint and Functional Movement viewpoint:
Interactive Anatomical View
In this view, we not only look at the soft tissue structure which is symptomatic but we see how different anatomical structures impact one another. Here the focus is looking at how different structures impact each other for example looking at a tight muscle, how that may affect the joint it passes over, how a loose ligament may result in increased tightness of the adjacent muscle, how fascia that is tight in one region may overly strain another region, or how entrapment of a nerve may result in altered sensation or power in another region.
Interactive Biomechanical View
Similar to interactive anatomy, in this view we don’t just look at the symptomatic soft tissue structure but how different musculoskeletal structures impact one another mechanically. The difference between interactive biomechanics and interactive anatomy is that biomechanics isn’t looking at the actual anatomical attachments between each structure but rather the movement and posture and how they interplay with one another. For example, it would be looking at how the hip joint mobility and muscle control would affect the knee joint, how the pelvic positioning would affect the neck positioning, how strong abdominal stabilizers would reduce rotator cuff strain in the shoulder, or how protracted shoulders in a seated position increases cervical disc strain.
The truth is that these two other views of soft tissue issues are speculative in comparison to the reductionistic view as there is much complexity and therefore difficulty in substantiating how each structure interacts with one another anatomically and biomechanically as each body is different anatomically, and differs in movement. Also, that the human body is more than just the musculoskeletal system – there are involvements from the mind, especially when it comes to pain and discomfort, and also from the social circumstances. Even though there is this uncertainty and speculation, there is sense in it and there is continual research poured into this area to understand the interactions. To properly understand musculoskeletal health and how to deal appropriately with each condition, it is important to take into consideration all three of these viewpoints and be open to look into the other perspectives especially when a pleateau occurs within treatment and management of a condition. It is also through these viewpoints that we come to understand more about why there are possible different opinions for each person’s musculoskeletal opinions.
Treatment for Soft Tissue Issues
Assessment (link to MSK assessment) of an issue is always more important than the treatment as the assessment will lead you to where the issue is. Otherwise, you would be blindly treating, hoping that something works on the issue. Soft tissue issue treatment therefore depends on the assessment of where on spectrum the soft tissue issue falls in, and the viewpoint that you take on the issue.
Dependent on the spectrum. For soft tissue issues falling on the tight side of the spectrum, the general idea would be to loosen the region. Issues falling to the loose side of the spectrum, the general idea would be the opposite – to strengthen and tighten the region. For example, with tight contractures and adhesions, you would be looking at stretching and lengthening out the soft tissue. With partially torn tendons and ligaments, you would be looking at strengthening and stabilizing the damaged area.
Dependent on the viewpoint. If one is looking at the issue from a reductionistic point of view, they would be looking at tissue changes which help move the tissue from a pathophysiological state to a physiological state. This would involve directly strengthening the damaged muscle, directly breaking down scar tissue on the damaged site, or surgical intervention to suture the damaged tissue.
If one is looking at the interactive anatomical view, they would be looking at how changing the adjacent tissues and structures would help with healing/protecting/unloading the affected area. This would involve strengthening muscles surrounding a problematic joint, stretching a tight muscle which attaches to a symptomatic fascial structure, nerve gliding to reduce tightness in the supplied muscles.
If one is looking at the interactive biomechanical view, they would be looking at changing movement patterns and postures to help with healing/protecting/unloading the affected area. This may look like strengthening a hip to control the strain across a knee, improving thoracic rotation for a swimmer to reduce shoulder strain, changing a running style to reduce loading through the Achilles tendon.
As mentioned above, an approach which targets all three viewpoints works best as they all play a part in soft tissue health.
So welcome to this world of soft tissue. It’s a complex world where issues can and do arise, causing pain, limitation and functional decline. Hopefully what’s been mentioned here will have helped you better understand what it is. Be a good DIY physio and look after your soft tissue better. There may be times when you need further advice in how to care for soft tissue issues, a professional third eye for assessing biomechanics or facilitation from specialised manual treatment. If you are stuck, drop the Abbey Mobile Physio a line. I’ll be able to help!
Reference List:
Medline Plus, 2021, Tissue Types, Available at: https://medlineplus.gov/ency/imagepages/8682.htm#:~:text=There%20are%204%20basic%20types,various%20passages%20inside%20the%20body (accessed 25/01/23)
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