by Martin Kingston
http://www.massage-therapy-london.co.uk
+44 20 8400 9712 / +44 7710 314432
This article appeared in the newsletter for BodyworkersLondon.com
THIS ARTICLE REFLECTS THE PRIVATE VIEWS OF THE AUTHOR AND SHOULD NOT BE CONSIDERED A MEDICAL REFERENCE..
"Soft tissue" is a vague term that can mean just about any tissue in our bodies. We think of bone as a hard tissue because we see dried dead bones, but in living things, even bone is mostly soft tissue.
More often, however, soft tissue refers to muscles and connective tissues like tendons, ligaments and fascia. Although we like to cut up and separate these tissues in our heads and on anatomy diagrams, they are made up of very similar materials, often arranged slightly differently, depending on function.
The 3 main stages of the repair process are named
"Inflammatory" (or "Acute") Stage,
"Regeneration" (or "Post-Acute") Stage and
"Remodelling" Stage.
The Inflammatory Stage commences at injury.
Blood clots dam any breaks in the body, to stop fluid leakage and infection entry. The fibrin cobweb created by clotting becomes a structure on which collagen and other fibres build, in a random fashion. These can become unhelpful adhesions if allowed to grow unchecked.
Mast cells and other cells in the damaged tissue release histamine and other inflammatory chemicals like prostaglandins. These make arterioles nearby vasodilate, bringing blood to the area. This is displayed as redness in the area when superficial.
Capillaries fenestrate, becoming holed like colanders, allowing more fluid into the interstitial space, causing local swelling and stiffness, reducing mobility and stopping the spread of infection. Neutrophil and Monocyte white blood cells are attracted and migrate from the capillaries into the area, mopping up debris, infection and damaged cells. Extra nourishment is brought with the fluid, to help repair.
The objective of this stage is to prevent the spread of any infection, and clear debris for regeneration.
Treatment should be conservative, because the key risk is further damage to weakened structures. The aim is to assist a quick finish to the inflammatory stage, to cut extra blood clotting and to avoid a build up of unhelpful fibrous adhesions clogging the area. Treatment should help lymphatic drainage, which can be inhibited by the swelling. Compression and elevation of the area above the heart can help this, as does Ice in a damp tea towel (up to 5 minutes on, 20 minutes off). Comparative rest (or rather, movement within a pain free range) stops further damage. Gentle lymphatic drainage (eg. Effleurage) proximal to injury and other destressing moves may help.
After about 24 hours - 6 days (depending on the scale of injury and tissues affected), regeneration takes over. The fibrin clots produced by bleeding in thin the area form a basis for fibrocytes to randomly lay down collagen and elastin fibres. With gentle movements, scar tissue adhesions get broken down, so there is a gradual build up of helpful structures with increased tensile strength along lines of stress. Therefore, patients should consider gradually stepped up activity - maybe in a different sport to the one causing the injury (to not stress the injured areas).
Regeneration involves timescales of weeks, depending on the structures involved. Muscle regenerates quickly, because of good blood supply, but ligaments can take far longer. More extensive injuries and the repair after surgery can take months.
The injured site may be progressively mobilised and massaged, to encourage blood flow and helpful structures - so long as pain is avoided more than 30 seconds after activity ceases (or revert to RICE protocol for 48 hours). Petrissage, gentle passive STR, RI MET are indicated.
Over a process of months, as tissue builds up and repairs, remodelling of tissues can be supported by gentle return to activity which caused the injury, with proprioceptive exercises to rebuild nerves and muscle which have been damaged, or wasted in the lessening of activity following the damage.
For surgery, remedial remodelling should be considered to take up to 2 years.
More intense treatments are indicated, to break unhelpful fibrous adhesions and scar tissue which restrict mobility, especially after forced inactivity (eg. Fracture).
STR and deep friction to break up scar tissue, with MET to lengthen shortened
structures. Stronger massage will encourage blood flow, to improve the remodelling
process. Exercise involves returning to the sport and activity which caused
the injury, monitoring progress to ensure fresh injury does not reoccur (re-spraining
an ankle is very common, especially if proper proprioceptive exercises are not
included in the programme; these exercises will aim to improve balance and nerve
response).
Most people think the repair is complete when the swelling has gone down and the soreness ceases. However, this is just the completion of the first stage.
For a proper recovery from a soft-tissue injury, the patient must be involved in a project of graduated exercise and rest, combined with treatments to improve good healing and recovery of use of nerves and muscles.