Massage and Acute Injuries – Part 3: The Regeneration Phase
After discussing the healing process in Part 1 and the goal of massage in the inflammatory stage (the first stage of the healing process) in Part 2 it is now time to move into the ways in which I believe massage can be used during the regeneration phase of healing following an injury.
Once again, just to reiterate what I wrote in part 1 and my disclaimer:
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).
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 3: The Regeneration Phase
The regeneration phase is the second phase of the healing process and follows the acute, inflammatory phase. Most of the literature would suggest that the regeneration phase can last anywhere from 5-12 days, or 1-3 weeks.
The regeneration phase, sometimes referred to as the proliferation phase, is characterized by a decrease in pain and swelling (the tissue may begin to look bruised and discolored) however the individual may still have pain with tissue stretch, muscular contraction, or palpatory pressure. Additionally, this phase marks the formation of new collagen as the less mature, type III collagen fibers begin the process of rebuilding tensile strength. This phase is often when scar tissue remodeling takes place.
During this phase the massage therapist has two key goals:
- General reflexive treatments as discussed in the inflammatory phase in Part 2 of this series.
- Assisting in functional scar tissue formation
General Reflexive Treatments
As I discussed in Part 2 of this series, the role of the massage therapist to provide general treatments that are reflexively based in order to stimulate the physiological system to create a shift into a more relaxed state, where healing can occur, and to address global soft tissue changes that may have come about from the acute phase where movement patterns are altered in order to prevent further damage to the injured tissue is a critical piece of the puzzle. (For my discussion on general approaches to massage please see a previous article I wrote, Sports Massage: Don’t Forget the Basics).
In this phase, this goal should still be of prime importance. As the athlete’s swelling begins to be reduced and light passive and active movements may begin to take place these sorts of treatments are essential to assist the athlete in an overall feeling of well-being and confidence. Just that psychological shift alone can be the “candy for the brain” that makes the healing process and the return to play that much quicker.
Assisting in Functional Scar Tissue Formation
During the recovery process scar tissue is laid down as a means of re-enforcing the damaged tissue to help assist in strength and stability and prevent further injury. As stated above, in this phase, the first pieces of collagen to be laid down are Type III collagen and they are less strong or mature then than the Type I collagen fibers which will be more prevalent in the final phase of healing, the remodeling phase.
That being said, connective tissue, like bone, is modeled along patterns of stress/strain. If we have more stress in one direction or plane of motion then there is a greater amount of tissue that is laid down to support it. In the later phase of the regeneration process the athlete will transition into a period where pain is now minimal (or completely gone save for some pain with palpation or possibly tissue stress). During this time period the athlete may see a decrease in range of motion or some muscle weakness but some local massage can begin in this later phase. You must work with the medical professional in your team (this is a team approach) to get their ideas of when you can begin to work on the area directly and what their thoughts are.
In this later portion of the regeneration phase, when I begin with local massage, I prefer more superficial type of work over pushing directly down into the tissue that may be painful (or may still have some residual swelling). Light skin work and gentle movement – starting with passive, pain free range of motion progressing to gentle active range of motion – to help the process along as far as getting the newly formed collagen fibers to remodel in the line of stress/strain that we are attempting to create, rather than allowing the individual to be totally passive and allow the collagen to form a mass of scar tissue and fibrosis that may limit function later on down the road. I always start gentle with this work and never force anything. Exercise caution (remember, this tissue being laid down is still not totally mature), start easy, and, again, always be sure to discuss the approach with the medical professional involved.
The two main goals for a massage therapist during the regeneration phase are to assist the athlete into a state of relaxation and recovery (similar to the approach during the inflammatory phase) and to begin to assist the the tissue in healing by encouraging functional scar tissue formation and discouraging non-functional fibrosis to develop. Through this process the athlete should begin to see further reductions in pain (if there is pain still present), improved range of motion, and strength returning back to a normal level.
In the final part of this series I will cover the last phase of the healing process, the remodeling phase.