Massage and Acute Injuries – Part 2: The Inflammatory Phase
In Part 1 of this series I briefly discussed the healing process. To recap, the healing process has three main phases:
- Inflammatory phase (0-5 days)
- Regeneration phase (5-21 days)
- Remodeling phase (21-360 days)
To review from Part 1:
There may be a number of things affected by an acute injury (labrum, disc, meniscus, fractures, etc) but the purposes of this blog series we will only talk about soft tissue injuries such as ligamentous sprains or musculotendious strains (pulls, tears, etc).
And to reiterate the disclaimer from Part 1:
Disclaimer: To be clear, this is not to suggest, in any way, that massage is the only thing that needs to be done – it is only a small piece of the puzzle. The athlete should ALWAYS be encouraged to see a medical professional and then massage therapists should be encouraged to work as part of the team of professionals (Dr., PT, DC, ATC, Strength Coach) to ensure the athlete has a safe and healthy return to sport.
Part 2: The Inflammatory Phase
The inflammatory phase is the most acute phase, occurring just after the injury or insult to the tissue has happened and typically lasts for 0-5 days. This phase can be broken down into two sub-phases:
- Vascular Phase – The phase were bleeding is at its highest and characterized by a lot of swelling
- Cellular Phase -The phase where myofibroblasts move in to begin the healing process
Because of all the bleeding, swelling, and bruising, and because the myofibroblasts are have not formed strong, stable bonds with the tissue yet, being aggressive and going directly into the damaged tissue with your fingers, thumb, or elbow would not be the wisest idea – additionally, the amount of pain the individual is experiencing in this acute phase would indicate that they probably don’t want you jamming your fingers in there anyway. While this may seem like common sense, I can’t tell you how many times I have heard from strength coach friends of mine that a massage therapist took their elbow aggressively to the hamstring of one of their players who experienced a pull in the game the previous day.
Allowing the medical professional in your network to deal with the acute inflammation would make the most sense but this doesn’t mean that you, as the massage therapist, can’t play a role in trying to enhance the healing process.
Goal: Influence Physiology and Psychology
Below is nothing more than my own ideas on how a massage therapist can assist in facilitating the healing process. It should not be taken as gospel and is supported by nothing more then my own experiences.
Injury is an unfortunate part of sport and when it happens athletes are often put into a heightened state of alert as the damage that just took place is telling their brain that something is wrong, there has been a threat to the system, and the pain they are experiencing is telling them that they need to re-act to prevent further damage to the area. This reaction comes in the form of tightening/stiffening up and changing their movement to limit the amount of stress/load they place on the damaged tissue.
Tightening up doesn’t just happen locally on in the extremity that has been damaged (IE, tightening up the leg and limping if there is an ankle sprain or quad tear) but can be seen over the entire body as the stress and pain their are feeling has a global impact on how they move and experience their environment – you may see tension in the neck, the shoulders shrugging, tension in their face, and their thoracic spine in a more kyphotic position as they limp around and brace their body. Additionally, with this heightened state of stress and with the increase in inflammatory compounds being released at the site of injury there is an increased sympathetic state as the body is try to resist the stress that has been placed on it.
In this instance, massage can be part of the solution to help influence the individuals physiology. Our goal is not to locally work on the damaged site but to work remote to that site, on non-affected tissue, in order to:
- Minimize stress in tissue that is compensating for the damaged region
- Encourage a shift into a more parasympathetic state
Minimizing stress in tissue that is compensating for the damaged region can be extremely beneficial as part of the recovery process, especially as the athlete gets into later phases of healing and begins to work back into their return to play protocols. Oftentimes, changes that occurred in an individual’s movement during the acute phase of the injury can last even after the the damaged region has healed. These changes may be seen in loss of mobility, trigger point (or whatever people want to call them these days – abnormal impulse generating sites, etc) development in muscles remote to the area of damage which can create referral patterns and satellite trigger points within those referral patterns or antagonistic muscles that cause changes in movement or a painful response, and a lack of movement efficiency once the athlete is healed and ready to return to play. Working globally allows us to address the body as a whole and approach tissue that may be negatively influenced from the injury as it is forced to compensate and take on an additional role in this time of damage.
Encouraging a shift into a more parasympathetic state following an acute injury is critical in my mind, as I view this as a way of trying to get the person into a state where healing can occur. If we can tune-down the system and get the individual relaxed we may be able to influence the way their body heals as this relaxed state can be a very healthy environment for the body – rather than allowing the person to sit there, stressed out and constantly dwelling on the injury and how bad it is. More general techniques, again remote to the site of damage, can be useful when taking this approach. Unfortunately, many sports massage therapists may discard these general techniques once they get out of massage school, in favor of more directed/specific techniques. I believe there is value to these basic techniques as I discussed in a previous blog article, Sports Massage: Don’t Forget the Basics.
Athletes have very distinct maps of their bodies and psychologically they are very dialed in when it comes to how their body feels and how certain body parts are moving or not moving. For example, a pitcher really understands his arm, how it feels, and when something feels “off” or “not right”, just like a soccer player is very aware of his hips, how they move, how they feel, and whether or not their “groin feels a little tight” or their “hamstring feels a little stiff today”. I believe this is a quality that great athletes posses and it allows them to sense things in their body at a level that to most normal people probably wouldn’t matter that much. For example, if my shoulder is a little sore today it usually is not that big a deal to me but it may be a huge deal to a starting pitcher.
This “hyper-awareness” is both a blessing and a curse. A blessing because it allows them to do what they do at a high level and a curse because when something goes wrong, psychologically, it can really go wrong! I am reminded of a story that Butler and Mosely told in their book, Explain Pain, about the professional violinists who were put in a study with normal people off the street and everyone’s finger was pricked with a little pin to assess their perception of what they felt. For the people of the street the pin prick was nothing more than a pin prick and no big deal. For the professional violinists it was a huge deal and they registered it being painful. The enhanced sensory map and awareness of their hands that a professional violinist has makes them hypervigilant to anything that may be remotely threatening. I believe that this may work the same way in an athlete.
That shoulder pain that doesn’t really bother me is a pretty big event for the Major League pitcher and, when an actual injury happens – for example a professional soccer player pulls their hamstring – then psychologically this is a huge “threat” to them and this alone may cause an increased amount of swelling and inflammation as their body is maybe “overcompensating” for the injury. This goes back to what I discussed above regarding an increased sympathetic state and our goal of getting the individual to shift into a parasympathic state. Sometimes, the injury might not even be “that bad” but because the athlete is so hyper-aware and sensitive to that region of their body they over produce the inflammatory response and things get over-exaggerated and blown out of proportion.
Side Note: I wonder if when a soccer player “flops” they actually do experience pain or a sensation that feels “abnormal” to them – in some of these instances because obviously in other instances they really are just doing their best acting job – due to this hyper-awareness? They then roll around on the ground for 20-30sec only to realize that it is nothing and then get up and sprint back into the game.
Our goal with massage during this phase should be to allow the athlete to experience ease and comfort. Sometimes, this alone, allows them to calm down enough to realize, “Hey, things aren’t that bad! This isn’t as horrible as I thought it was! It doesn’t even hurt that much right now!”, allowing us to “get inside their head”, so to speak, and turn the tables and create an environment which is favorable for healing to take place. Sometimes, this psychological shift, can influence swelling, inflammation, movement, and pain perception as the individual is now starting to feel confident and not so worried.
There are a few approaches that a massage therapist can take in the acute phase of an injury and these approaches are to try and influence the body in a more reflexive way rather than a very direct way, on the area of damaged tissue. The global approach to massage during this time should be centered around three key phases:
- Minimize stress in other regions of the body
- Cause a shift to a parasympathetic state
- Influence the psychology of the athlete and get them into a state of mind that is more relaxed
In Part 3 of this study I’ll get into some of the goals of massage in the second phase of healing, the Regeneration Phase.