Many patients have asked me as I treat them, “is that scar tissue” or “My Doctor says I have scar tissue” but do you really know what scar tissue is, what it looks like or how it forms. We all know what the scab on your arm looks like after you cut yourself, but is it the same deep in your body? Does it look like that!? I’m sure many practitioners are not exactly sure what it is but throw around the words “scar tissue” or “adhesions“. But these types of “adhesions” ARE different in different places.
This is by no means a detailed paper on the biology of scar tissue however it hopefully will give a better insight to what is exactly happening after an injury.
A scar by definition is the connective tissue that forms a scar; consists of fibroblasts in new scars and collagen fibers in old scars. So what does all that mean?
Our bodies response to injury is to send special cells to the area that act like a “glue”. This bodily glue is actually called granulation scar tissue. It is the first phase of three that take place within our body, the innate act that will happen whether we want it to or not. The three phases of healing are;
- The inflammatory phase
- The fibroplastic phase
- The remodeling phase
The first phase, the inflammatory phase, is an very important stage that must happen for healing to start to take place. We’ve all seen it, the reddening of the skin and the puffiness around an area. Damage cells release histamine, and this causes an increase in blood flow to the area. Why? Because increased blood flow brings with it a huge amount of fibrinogen to the area, stuff that coagulates in and around area of the injured part. So inflammation IS necessary – if there is no inflammation, healing does not begin. Too much inflammation and healing becomes excessive with too much scar tissue being formed.
The second phase is the fibroplastic phase. This is aptly named for the fibroblasts that infiltrate the area. Although other cells are involved, this phase cannot happen without the previous phase completed. Once this phase begins (approximately 3 weeks following initial injury) the fibroblasts begin their very precise work of creating strength and resurfacing the area. A series of events happen during this phase (epithelialization, wound contraction, and collagen production), but in order to spare boring you, the wound becomes stronger. (Think of a road being resurfaced – first the grader comes in and carves out the general shape of the road – phase 1. Next the top soil and gravel is rolled and pressed to create a more defined road and give a better structure for the blacktop – phase 2)
The third phase, the remodeling phase, is the phase, as a Massage Therapist, that I am most concerned with in my treatment. This is the phase in which the scar tissue actually changes to fit the tissue injured. I’m sure up to this point, reading this, you have visualized that cut on your skin. But what about that pulled muscle in your back, or recently, my patient who tore his bicep from the attachment on his arm? Does it look like that scar on your finger? No. In this phase the tissue changes, abet not as perfect as the original, but does it’s best job. A ligament that has been torn requires that the healed tissue has some sort of tensile strength, whereas a torn tendon needs to move and stretch. And if the wound is in and around both of these structures it better not heal them in the same way, even though they are millimeters apart. Studies have shown that this remodeling process occurs under the movement of the part. Seyfer and Bolger, using an electron microscope found that gliding tendons had lengthy, elongated adhesions, whereas restricted tendons had short, dense adhesions.
It is during this phase that your therapy be followed. Whether you have a gapping open wound or a torn bicep, your massage and exercise movement therapy is imperative. Scars that are formed in dense tissue need feedback so it can remodel and mimic the surrounding tissue in it’s effort to make it the same. Without the movement the remodeling phase will be haphazard. And with this haphazardness comes contracture, that debilitating state we’ve seen with burn victims. The skin and fascia contracts so much that it pulls a part into a distorted posture. This can happen within our body also, the myofibroblasts generating and maintaining contractile forces over years. In fact this shortening and contracture has been shown to be a slow, somewhat semi permanent and a very low energy process that can continue for years following an injury.
So that part I’m working on in your back or bicep or quad. It’s not like a scab, but more like the tissue that is there, only if you didn’t get proper rehab following the injury, it sure isn’t going to feel very good under my fingers and probably won’t allow that tissue to move properly. And so what am I going to do? Work it, kneed it, stretch it, break it down somewhat and re-introduce the proper protocols for getting that part to act the way it was meant to when you were born. Whew, a tall order but I’m up for it!
Any questions, please do not hesitate to contact me.
Peter Roach, RMT, CNMT, Laser Therapist