By Dr. Nick Barber, DC
How Long is This Going to Take to Heal?
I hear this question nearly on a daily basis and almost invariably from anyone who has just suffered a training-interrupting injury. When up to 85% of people training for an endurance event will suffer some form of injury within a training year, this is a very important question and having an educated answer is crucial.
As tough and as broad as this question can be, some light can be shed on the answer when we look at the various stages of natural tissue healing and the processes that are occurring during each stage. To highlight these stages we can look at the process through a very common running injury – the acute ankle sprain.
Tissue healing can be broken down into 3 phases or stages: the inflammatory stage, the repair and regeneration stage and, finally, the remodelling and maturation phase.
Phase 1 – the inflammatory stage. This is the earliest stage after an injury and is usually the most noticeable; when the body is sending chemical signals to nearby cells and informing them an injury has occurred and needs to be dealt with. This phase is occurring during the first 24-72 hours after the inciting event and is signaled by the presence of swelling, warmth, redness and pain in and around the injured area.
Generally treatment during this stage is tailored to controlling the inflammation, however some care should be taken in order to limit the disuse of the surrounding muscles and maintain or improve circulation. Treatment can include anti-inflammatories, resting, icing, bracing and gentle range of motion exercises within a pain-free range. As tolerated, exercises that begin to increase proper muscular control of the area can be extremely important. In the case of an ankle sprain these exercises could include rotating the ankle slowly on a wobble-board or ball and trying to ‘write’ the alphabet with the big toe. Additional therapies that a chiropractor or physiotherapist may utilize could include ultrasound or acupuncture to improve blood flow or certain electric modalities such as microcurrent or TENS to decrease inflammation, relieve pain and increase circulation. Traumeel injections can be extremely useful in order to control inflammation. These treatments in addition to the home rehabilitation techniques can significantly decrease the time spent during the inflammatory phase and speed the body into repairing the damaged tissue.
Phase 2 – the repair and regeneration stage. This is the stage where the various cells receiving the inflammatory information start to produce and lay down scar tissue in order to actually heal the injury. Usually this stage will begin within 48 hours after an injury and can last up to 6 weeks. When a therapist feels the injured area during this stage they will sometimes notices a more ‘stringy’ texture to the tissues and perhaps indicate if a tear or scar can be palpated. Pain usually is more definitive directly over the site of injury and the boggy swelling from inflammation begins to dissipate. This is a very crucial stage during injury rehab where proper exercises and intensity are extremely important. The scar tissue being put down can be quite fragile and easily re-broken if too much stretch or impact is placed on the injured site. On the other hand, if too little movement is done, the tissue can become overly scarred, mobility can be severely reduced and healing can plateau.
Treatments at this stage are primarily designed to increase the range of motion of the affected area and can usually begin to increase in intensity once the range of motion has recovered to 75% of normal. Resistance exercises can be initiated however should continue to be very light, focussing on the quality of the movements not the quantity. For an ankle sprain, tubing exercises in all ranges of motion with emphasis on the negative component are usually begun in this stage. Initiation of weight bearing exercises and walk training may be initiated. In addition to previous modalities, therapists may begin to mobilize the forming scar tissue using various soft tissue therapies such as Graston or Active Release in order to break down extraneous adhesions and increase circulation to the site. Utilizing these therapies during this stage can significantly improve both the speed and quality of healing and ensuring over-scarring in an area does not develop.
Phase 3 – the remodelling and maturation stage. It is a well known physiological process that tissues will adapt and remodel to the demands placed on them. This stage begins around 3-6 weeks after injury and can last up to 12 months. It is defined by the body breaking down the previously formed scar and transitioning it into normal fibres and cells for the specific tissue that was injured – muscle, ligament, tendon, bone or cartilage. This stage, if done properly, is what can return an athlete to 100%, or if rehabilitation is ended too early or done improperly, this could be the injury that persists or recurs. Palpation during this stage can reveal a very tight, ‘ropey’ texture to the tissue which can indicate the presence of old scar tissue and various other adheasions. Pain may or may not be a factor and likely should not be the only guide for recovery. Full range of motion and full strength should be accomplished pain-free and progressing exercises to sport-specific movements in order to limit or remove compensations is critical.
Treatments during this stage can be quite aggressive at helping to remove the scarring and continue the process of transitioning the tissues. Many ‘old’ injuries have stalled during this stage with scar fibres remaining in the tissue and causing adhesions or improper motion of joints and muscles. Active Release and Graston techniques could be extremely helpful in breaking these adhesions, increasing circulation to an affected area and forcing the body to continue the healing process. Shockwave Therapy can be used to break apart tougher adhesions or to stimulate healing processes in deeper tissues, especially where tendons attach to bone (a very common location for tough scar tissue).
Regarding the original question ‘how long is this going to take?’ one can see there is quite a large window that can still be considered normal, and even after pain and function have recovered significantly, treatments can still be warranted and rehabilitation or training may still be required. Proper identification of both the injured tissue and the current healing stage is critical in making recommendations for how to treat, train and progress an injury to towards full recovery.
Dr. Nick Barber is a chiropractor at Synergy Health Centre. Originally from Victoria, Dr. Barber has just recently moved back to be closer to family and friends. After graduating from the Canadian Memorial Chiropractic College in 2008 with Cum Laude and clinic honours, Dr. Barber began working at a busy sports medicine centre in Barrie, Ontario. Here he was able to gain extensive experience working with all types of chiropractic patients and injuries – from professional athletes to weekend warriors, and postural complaints in office workers to repetitive strain injuries in factory workers. Dr. Barber is fully certified in Active Release Technique (ART) and Graston Technique and has experience in Functional Movement Screens, athletic taping and orthotic assessment.
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To ask Dr. Barber a question or for a no obligation pain and injury assessment please call 250-727 3737 Ext. 2 or email [email protected].