In yesterdays post, I touched on the healing process of soft tissue in the body. It's an amazing process that I believe that we take for granted a lot of the time. We just expect the body to "do its thing" without an appreciation for the process; however, maybe a lack of appreciation of the process stems from a lack of understanding. Functionally, speaking, we must allow the body to heal so creating an environment of optimal healing is of the utmost importance.
A DEEPER LOOK AT THE HEALING PROCESS
There is definitely a simple complexity in the soft tissue healing process. Let's take an injury that unfortunately, I have had more than my share of experience with. This year, my football players have been afflicted with Acromioclavicular Joint (AC joint) sprains. They have mostly been Grade 1's but there was one pretty nasty Grade 2 that required that we take the athlete to the hospital to make sure it was nothing more than an AC joint sprain. The area of injury was the ligament soft tissue that connects the acromion to the clavicle. Sometimes we will see a superior displacement of the clavicle and you can see the discontinuity in the form of a little ridge. I tell my boys that their days of modeling tank tops is over. (Lame, I know)
With this injury, there will usually be pain, redness, swelling and heat (all the signs of an acute injury). There is also instability in that joint because of the tissue disruption.
As stated in Part 1, the four phases of healing are:
Inflammation Phase
Granulation Phase
Fibroplastic Phase
Remodeling Phase
Let's be practical and take an Grade 1 AC Joint sprain, and go through the 4 Phases.
Inflammation Phase: In this phase, we see the body immediately respond to the injury by sending chemical and mechanical changes that increase blood flow to the area which will cause the redness, swelling, pain and heat. This process is the SAME for all injuries. This stage typically lasts 24-48 hours depending on the severity, location, etc of the injury. At this stage immobilization of the injury would be advantageous as further movement may cause more tissue damage and/or disrupt clotting. Modalities like icing as well as proper positioning and anti-inflammatory medicine is advisable.
Application: If we suspect an injury to the AC joint, our first course of action is to immobilize the arm in a sling and to ice the joint. With our grade 2 sprain, we took him to the hospital for x-rays. When the doctors didn't see any fractures, he released him with a perscription for an anti-inflammatory medicine. Great! According this one athlete, the most challenging thing was sleeping that night. He's used to sleeping on his right side, but could not that night since that was the injured side. If that was the worst, we were doing pretty well. The following day, after he had iced, we wanted him to move around and not just sit in bed all day. He still had the arm immobilized but that was it. If he was able to walk, pick up things with his other arm, stretch, etc, we wanted him to do that within reason of course. KEY: IMMOBILIZE THE INJURY, NOT NECESSAILY THE ENTIRE BODY, IF POSSIBLE.
Granulation Phase: This phase is named because of the appearance of tiny capillary buds that look like granules. This process is essential to the repair of the soft tissue as the body will not heal without the increased vascularity to supply the injury with the proper nutrients that it requires.
Application: Immobilization of the injury still but not of the body. Heat is not advised as this causes vasodilation which could increase the likelihood of further bleeding in that area. It should be noted that ligaments are very different physiologically and the healing times compared with muscles or skin, will be longer. Also, because of the nature of ligaments, they may not regain the "creep" or stability to the joint thus increasing the likelihood or reinjury unless it is functionally rehabbed.
Fibroplastic Phase: This is the phase where things can start to get a litte more fun. Here we see the appearance of fibroblasts and collagen synthesis. As collagen is laid down at the injury area, it is done in a disorganized manner. It is important to remember that the strength of the bonds of the collagen is determined by the bonding of the collagen and not the quantity of collagen laid down. Here is where we see movement being an important part of the rehabilitation process as the the collagen fibers will align on the axis of movement. Again, because of the composition of different soft tissue, we see very different times of healing. Muscles and skin can be in this phase from 5-8 days while tissues like tendons and ligmaments can be in this phase from 3-5 weeks.
Application: After a few days of having his arm immobilized, the decision was made for our athlete to start the process of regaining mobility and stability. He was directed to begin moving, his arm into the 3 planes of motion at initial-mid range going from flexion to extension, horizontal abduction and adduction and internal and external rotation. We also made sure that his scapula was moving as it tends to get gunked down during the immobilization of the arm. Experience has shown that if the 3-D biomechanics of the scapula and humerus are not acknowledge and functionally applied, our healing process may not be as efficient as possible. As always, this movement was gentle and way beneath his physical threshold. The goal was to start motion without pain.
Remodeling/Maturation Phase: This is the final phase in the scarring process. This may take place between 3 weeks and 12 months depending on the location and severity of the injury. It is in the this phase, that proper stress needs to be applied in order for the functional mobility, stability and strength to be maximized. Low load, long duration stress has been shown to lengthen the scar to its proper dimensions necessary for function.
Application: As we move into the maturation and remodeling phase, it is vital that we understand Principles of Function as well as Chain Reaction Biomechanics to continue creating an environment of success. For our AC Joint sprain athletes, we are diligent in starting to take through the ROM of the joints. For instance, we may place our athlete in a left foot forward stance, give him a 2-3 lb weight and ask him to go to an right arm reach to overhead with care that the following also takes place:
Ankle Dorsiflexion
Knee Extension
Hip Extension
Spinal Extension
These are the Chain Reaction Biomechanics for the back leg in gait in the Sagital Plane ONLY. There are two other planes that I did not go through, however, we want to take our athlete through this Zone of Transformation slowly so that he is going through the proper biomechanics. In a post-rehab situation that is not far out from injury, we tweak out planes of motion rather than tweak them in. Allowing the athlete to be successful by helping them create an enviroment where success is easy to attain will be rewarding in a body/mind/spiritual approach. As we take our athlete into these Zones of Transformation, we go into or thru the scar tissue using various drivers with gentle oscillations using FUNCTIONAL MANUAL THERAPY . This is what separates this techinque from other methods that apply a direct mobilization of the scar tissue. With the AC joint, we want to be recruiting the entrire body to start to provide stability and be a friend to the shoulder. As the athlete progresses, we start to add more load, speed, various angles, depths, etc. We use our PRINCIPLE OF ENHANCED FUNCTION VIA TWEAKOLOGY.
The fibrotic process will be visited in the next week or so. This process is important to understand as many of our athletes, clients, patients may be caught in a cyclical fibrotic process that is causing pain and dysfunction in the body and will continue to do so until the source of the problem is found and dealt with accordingly.
Please look for the continuation of the 3-D Soft Tissue Therapy that will start to integrate all of the information regarding the anatomy and Chain Reaction Biomechanics of the body.
I would like to thank Lenny Parracino, CMT, FAFS from the Gray Institute with his guidance, knowledge and experience with the Functional Soft Tissue Therapy work. He is truly a GIFTED therapist and friend.
As always, I welcome your thoughts and comments.
Happy Tuesday!
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