Massage and Acute Injuries – Part 4: The Remodeling Phase
This is the final article in this series. To review the previous articles please click here:
Just to review, again, 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 4: The Remodeling Phase
The remodeling phase, which textbooks will often indicate can last anywhere from 21-360 days, is the final phase of the healing process. Similar to the regeneration phase that comes before it, this phase is characterized by scar tissue formation except that type I collagen is now being synthesized, which is much stronger and stable than the type III collagen which preceded it. In this phase inflammation has now been resolved and there should no longer be pain with tissue contraction although sometimes athletes will still report pain with movement or activity. Function may still be limited as the athlete is usually now begging to train to play again.
The main goals for massage in this phase are:
- Assisting in functional scar tissue formation and helping to restore function
- Assisting in the recovery process following training, practice, and/or return to play protocols
Assisting in Functional Scar Formation and Restoration of Function
As I discussed in the previous article in this series, as collagen fibers are laid down scar tissue begins to form which helps to re-enforce the tissue, strengthen it, and provide stability. Scar tissue, like bone, will model itself along the line or plane of stress. In the previous phase, the regeneration phase, the collagen tissue was less mature and being aggressive with this less mature tissue can mean that it wont form a strong bond and the tissue doesn’t heal with the strength and stability that it needs, leaving the athlete open to another potential injury. In the remodeling phase though the tissue is now stronger and more mature meaning that we can take a much more proactive approach to how we address it and assist it in lining up along the line/plane that we want it to to help assist in restoring function. Additionally, we can take a more aggressive approach to our stretching, exercise, and movement and now work more locally than in previous phases as the tissue is in a stable place at this time. Again, always speak with the medical staff that is part of your team to discuss your goals, their goals, and what you are going to attempt to do in order to get the green light from them.
The techniques that can work well in this phase are:
- General gliding techniques
- Pin and stretch
- Muscle Energy Technique Approaches
The frequency/amount/duration that you spend with each technique or the technique you choose to employ the most is really up to how the individual is responding/adapting to the treatment. Gliding techniques are often a good start to the treatment as a way to warm the individual up and introduce yourself to their nervous system and friction techniques can be used at very specific areas of the muscle or tendon. The pin and stretch techniques (either active or passive) are a good way to get the client involved in the treatment and, rather then having them lie there passively, engage their nervous system in the process and introduce movement which may have a positive influence on mechanoreceptors and assist in a quicker return to function. Finally, muscle energy techniques can be used in multiple ways. Contract-Relax or Contract-Relax-Contract Antagonist can be used to help teach the nervous system how to go through newer ranges of motion and restore range of motion that may have been lost by the injury while some of the resisted eccentric techniques can be used to help create a strain/stress on the tissue and assist in collagen formation in a more parallel order, rather than being laid down in a random and messy fashion.
Assisting in the Recovery Process Following Training
During this final phase of healing the athlete is often participating in a variety of return to play protocols, light practices, and more aggressive training in order to prepare their body to get back into the game. Training is supposed to disrupt homeostasis to a certain point and create some inflammation – both are favorable as they begin the healing process and set up the internal environment to adapt to the stress being placed on the body with the ultimate goal of elevating the athlete’s level of fitness. That being said, coming back from a sprain or strain can often mean that there is going to be some stiffness, soreness, or slight pain following training. During the remodeling phase, in this situation massage can be used to help with the recovery process and, as I discussed in the previous phases, can provide a large psychological boost to the individual as their sense of well-being improves from the touch therapy, allowing them to be more comfortable with the increasing volume, intensity, and frequency of training. The techniques would be similar to those above and aside from just working locally the therapist is encouraged to perform more global massage as well to treat all areas that may potentially be stressed due to changes in movement and mechanics as the athlete returns back to play.
The main objectives for the massage therapist in this final phase of recovery are to assist in functional scar tissue formation and use other massage approaches to enhance stress resistance and improve recovery as the athlete begins to stress the tissue in the training environment during their return to play.
One thing I should note is that the time domains for each of these phases of healing are rather long. I do believe that if we do everything correctly we can sometimes turn the tables quicker and shorten up the time period for healing (depending on the injury and severity, of course, as that will dictate how quickly things can happen – never try and rush things purposefully and risk the athlete’s health!). As I discussed in Part 2 of this series, there is a huge psychological component to injuries and maybe sometimes, because high level athletes are so hypervigilant and hyper-aware of their bodies some injuries may not be as bad as they are initially perceived. The better we can get into the athletes head the faster their body may take to the recovery process.
Finally, it is important to note all the other stuff! How the athlete balances out the ecosystem of their body and tolerates all of their life stresses (what I call Your Stress Account), for example, things like nutrition, hydration, sleep, life stress, etc. will also play a role in their recovery. Athletes that do all the little things right, stay in shape, eat well, get good sleep, and manage their stress tend to recover quicker, as I talked about in the article Recovery: Athlete vs. Average Joe. Remember, all therapy – like training – is a stress that the body needs to adapt and respond too. If you tolerate stress well then you can adapt at a much easier rate and tolerate more stress. If you don’t take care of the little things, get out of shape, keep a poor diet, and have a poor lifestyle then your ability to tolerate stress and make favorable adaptations to the therapy will slow down the recovery process.
I hope you found this series useful and I do stress that, as a massage therapist, you should seek out a team of medical professionals to ensure you are in the right place at the right time. Do not simply go rouge and take matters into your own hands. Be a team player.