“No athlete is truly tested until they’ve stared an injury in the face and came out on the other side stronger than ever” – Anonymous
No one ever plans to be injured in their lifetime, but it is important how we choose to respond to an injury that separates us from the rest. Physical therapists are the musculoskeletal specialists in both diagnosis of specific tissues and recovery specific programs designed to target desired tissue integration and healing.
There is a lot of science to healing; different tissues require different inputs and rehab timeline depending on the tissue damaged. In this blog, we will cover a lot of science of how we manage different injuries to facilitate our most efficient outcome.
Understanding the Recovery Process
Wounds normally heal in an orderly and efficient manner and progress through known stages of healing: Inflammation, Proliferation, and Remodelling phases. The process of wound healing can be quite complex with a variety of specialized cells that need to interact with each other for normal healing to occur.
Inflammation Phase: The inflammation phase occurs within the first 24 to 72 hours after injury. We have a massive influx of different cells responsible for the characteristic signs of inflammation like redness, heat, swelling, and pain around an injury site. Neutrophils, monocytes, and macrophages are the key cells during the inflammatory phase.
Proliferation Phase: The proliferation phase generally lasts from 4-21 days after an injury. The transition from inflammatory phase to proliferative phase represents a key step during any healing. The proliferation phase plays a key role in resolving the inflammation phase and allowing normal physiological healing factors to regulate cellular and molecular regeneration at a site of injury.
Remodelling Phase: The remodeling phase can last from 21 days – 1 year post injury. This phase is when granulation tissue matures into scar and tissue tensile strength is increased. An increase in granulation tissue also reduces the number of active cells in the healing and remodeling phase.
Although all injuries go through this same process of healing, not all tissues have the same timeline for cellular growth and replacement of injured tissue. Here is a chart that displays typical tissue healing time frames for different tissue types:
| Tissue types: | Range of time for healing: |
| Muscle | 2-4 weeks |
| Tendon | 4-6 weeks |
| Bone | 6-8 weeks |
| Ligaments | 10-12 weeks |
| Cartilage | ~12 weeks |
Not all injuries are “textbook” in their recovery times, and it is even more important how we address the targeted tissue in physical therapy to facilitate the best recovery. Some common misconceptions about recovery time is that “all tendon/bone/ligament injuries are the same”. There are varying degrees of injury alongside the specificity of the tissue that is damaged. For example, an 11 mm Hamstring tear may take longer to heal than a 4 mm Hamstring tear even though both injuries are classified as muscle injuries.
Recovery isn’t easy, and sometimes we can get lost along the path to recovery with the feedback to “avoid all pain”. This is another myth in the recovery world as there is to be some expected discomfort during recovery. We like to discuss the difference between pain and discomfort with our patients as everyone may perceive these differently. Pain generally ramps up with activity or post activity to a greater degree than expected while discomfort generally remains in a tolerable range during activity and is quickly resolved after exercise/activity.
When is it Safe to Begin Exercising Again?
Exercise is generally always going to be a part of recovery that can begin immediately. The varying difficulty and stress/strain on damaged tissue under guidance of a physical therapist. Whether before or after surgery if required, exercises will significantly improve outcomes. There are a few metrics we use to help guide our dosing of exercise:
- The amount of discomfort during exercise can be an indicator for readiness; more often than not, there are several ways of regressing loads
- Range of motion progression after an injury is a great tool to prescribe certain types of activity within your range available. If range of motion is not comparable to the unaffected side, this will change the prescription of activity to avoid range of motion that is not yet available.
- Strength testing of supporting musculature around a joint, or strength of an injured muscle or tendon are indicators of how much load can be prescribed
- Functional movement assessment allows us an insight into how well the body moves as a whole and is reintegrated into our kinetic chain of how we move each body part individually as well as in coupled motions alongside adjacent joints.
Some red flags of not being ready to progress include continued heat/redness/swelling that may indicate a failure to progress from the inflammation stage to the proliferation stage, pain worsening with activity and/or several hours later, and any structural damage that may inhibit load (for example certain fractures cannot be loaded until fully healed). Which leads to the point that medical clearance for return to exercise is dependent on the injury and the health care staff taking lead on the recovery process.
Setting a realistic timeline and progression of recovery is important for both physiological recovery as well as psychological recovery. Trying to recover quicker than appropriate tissue healing timelines can increase the risk of reinjury or inappropriate cellular makeup of tissue prohibiting recovery to pre-injury levels.
Creating A Return-to-Exercise Plan
The most effective return to exercise plan will include activities designed for each type of tissue that is involved. The program needs to be tailored to each unique patient and injury taking into account mechanism of action and desired goals for the patient. Recovery for returning to running is different from returning to lacrosse or soccer.
There are several factors into exercise prescription and strength building. Different tissues have different functions and loading those dependent on injury are critical to success of recovery. How we load different tissues and the quantity of loading is depending on the stage of recovery and the tissue damage involved. Working on a muscle for pure strength regain will have a higher load with fewer repetitions compared to working on a tendonopathy that will need to be loaded slower with higher repetitions and low load. Explosiveness and power come after strength and endurance to avoid over fatigue that may cause reinjury.
Recovery and rest following strenuous exercise is necessary for cellular repair and clearance of ms breakdown. Modalities and nutrition also play a large role in recovery after activity. Warming up is just as important to performance as an appropriate recovery period. Dynamic active warm ups, isometric facilitation of muscle groups all have been shown to improve output and performance while stretching prior to exercise has shown poorer performance outcomes.
Here at Primal Physical Therapy, we emphasize integration of any injury to the rest of the system. Early days in a lower extremity injury will focus just as heavily on the upper body and trunk to build a solid foundation. As we progress, movements need to occur in all planes with varying degrees of freedom while engaging the system to move in unison from a grounded trunk.
Specific Strategies for Common Injuries
Ankle sprains: Ankle sprains are very common not only in sports, but in everyday life as well. Physical therapists can help diagnostically by testing the specific ligaments that may be involved in a sprain to help gear rehabilitation towards specific involved tissues. Here at Primal, we address the entire frontal plane (side to side) stability all through the trunk and shoulder girdle to facilitate support of the entire kinetic chain.
Knee injuries: Knees take a beating; they require so much stability and have to adapt to the rest of our body to keep us upright. Rehabilitation looks different whether it is an ACL, cartilage (meniscus), or tendon injury. Just like with ankle sprains, getting weight bearing quickly will improve proprioceptive input.
Rotator cuff issues: Rotator cuff injuries require a lot of stability training; the function of the rotator cuff is to maintain a compressive load of the shoulder joint throughout its entire range of motion. Developmentally, this is where we start getting our strength and stability in tummy time and up on our elbows as infants. Recovery from a rotator cuff injury at Primal always includes weight bearing stability as soon as possible.
Lower back pain: It is well known the correlation to core and trunk stability and low back pain. Our core is the keystone to the body in which all appendages move. Whether it is a segmental dysfunction of a vertebrae or a disassociation of our upper half to the bottom half, we work on training in 3 dimensions of motion starting with a short lever arm to reduce load progression to full levers.
Hamstring strains: The hamstring ms group is responsible for stabilizing both the hip and the knee joint which increases the susceptibility of injury and strain. Functional training and return to sport requires trunk and hip strength to support the hamstring proximally and the ankle muscles to stabilize the knee and ankle from below to offload the amount of force production on a hamstring ms group.
Achilles tendon injuries: Achilles tendon has a lot of tensile strength and under repetitive loads, the tendon thickening can be a predisposition to an achilles injury. Improving torsional load and tensile strength through plyometrics and eccentrics to prevent injury.
Tools and Techniques for Safe Progression
While returning to activity after an injury, we lose proprioception (our orientation in space) along the strip of our brain. Increasing input with multiple load intensities and load directions help us recognize our spatial awareness and improve the input to the brain. Proper form and technique are critical in recovery and is recommended to be guided by a physical therapist at each phase of progression. As we become more aware, we will require less cues and have more sense internally of how we are moving and our form.
Different tissues need different sources of input. Most commonly in ligamentous injuries, structures may need some taping or use of a brace initially to improve tensile healing of ligaments that may have been overstretched and lost some integral stability.
We also can use modalities to help facilitate chemistry and input to further facilitate healing. Heat can help bring blood flow in to improve tissue healing biochemistry, ice can help lower inflammatory makers to help end the inflammation phase and advance to the proliferation phase of healing. We can use these synchronously to create a pump as well; contrasting hot and cold applications can create a pump to facilitate more blood flow getting old inflammation out and new blood flow healing in. Compression sleeves also help with increased awareness and proprioception; our signals to the brain that report pressure and compression travel faster than pain receptors and sensory receptors which improve a sense of stability and awareness. In acute instances, elevating an extremity above the heart uses gravity to assist with lymphatic draining to reduce swelling. Myofascial release options also help relieve tension patterns around injured tissue to facilitate healing around an injured tissue.
Tracking progression can be both subjective and objective: sense of healing and ability to progress in power, strength, and range of motion testing are all positive signs of recovery. We can also use more objective measurements of quantity of reps, force output of a rep max, and endurance/fatigability of isometric contractions that help us show progression.
Long-term Strategies for Injury Prevention
As stated previously, tissue healing and remodelling can occur up to 1 year post injury. Maintaining consistency of exercises and progression of loading strategies even in an asymptomatic state is important to continue facilitating appropriate and efficient remodelling. Training across different sports and activities allow us to access different parts of our fitness and improve overall cardiovascular health/output.
There are several life factors that also play a role in our healing. Our chemistry in maintaining a healthy diet and staying hydrated to provide an appropriate environment during remodelling. Sleep habits and healing is the time our bodies have to heal without load onto our musculoskeletal system. Proper positioning can also influence adequate blood flow to the involved extremity or spine. Stress can also play a factor in the biochemistry of healing and impede progression of proliferation phase keeping us in a chronic inflammation systemically.
There are several factors that contribute to injuries and how we heal them. Under the guidance of a Primal physical therapist, we take all variables into our plan of care allowing us to access the multivariable modes of healing as well as integrating our bodies and systems as a whole. No singular event or injury affects only one joint; accessing our foundation and building from there will lead to improved power, strength, and return stronger than before.
References:
1.Schultz GS, Chin GA, Moldawer L, Diegelmann RF. Principles of Wound Healing. PubMed. Published 2011. https://www.ncbi.nlm.nih.gov/books/NBK534261/
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3.Kraemer W, Denegar C, Flanagan S. Recovery From Injury in Sport: Considerations in the Transition From Medical Care to Performance Care. Sports Health. 2009;1(5):392-395. doi:https://doi.org/10.1177/1941738109343156
4.Blanchard S, Glasgow P. A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy in Sport. 2014;15(3):131-135. doi:https://doi.org/10.1016/j.ptsp.2014.05.001
5.Gouin JP, Kiecolt-Glaser JK. The Impact of Psychological Stress on Wound Healing: Methods and Mechanisms. Immunology and Allergy Clinics of North America. 2012;31(1):81-93. doi:https://doi.org/10.1016/j.iac.2010.09.010
