Healing and continuing to live a normal life are mutually exclusive activities. You must choose: Put everyday life on hold and heal; or decide not to heal and continue normal activities. This second choice makes symptoms long-term or chronic. Any trauma, even a controlled trauma like surgery, creates a natural cascade of inflammation (swelling) as part of your body’s natural healing process. Pain is a gift from your body to your brain helping you to find the trauma. Learning how the body’s smallest repair cells work can help you understand the value of adequate healing.
OSTEOBLASTS AND FIBROBLASTS
To heal a break in the bone, both ends of the fracture must align and be held stable by a cast, a brace, or surgery with screws, plates or pins. Make certain both ends are in close proximity and keep the surrounding tissues relaxed to allow the specialized bone-healing cells called osteoblasts to come to the fracture site. These osteoblasts work inside the bones knitting the two pieces together. The bone osteoblasts eventually build enough bone so it will heal and function normally. Bone requires 8 weeks to heal adequately.
The soft tissue healing cells, called fibroblasts form connective tissue and secrete connective tissue proteins such as collagen. Soft tissue healing occurs when fibroblasts migrate to the area of inflammation and knit bridges of collagen, called anastomoses, in the ruptured tissue. The traumatized torn soft tissues such as skin, muscle, tendon, ligament, lymphatic collecting vessels, veins, and arteries heal by the fibroblasts when the torn ends are left close enough for a long enough time. If a tendon or ligament has a complete rupture they will need surgery to repair. Soft tissue requires 6 weeks to heal adequately.
Torsten Wittmann of the University of California San Francisco prepared and took this remarkable photo. This shows Mouse fibroblasts stained for actin (blue), microtubules (yellow), and nuclei (green). This image won first place in the 2003 Nikon Small World contest.
Injured tissue anastomoses or bonds created by the fibroblasts or osteoblasts break with continued movement of the body part. This creates a new trauma that starts the cycle of injury over again. To heal adequately, the tissue must rest well enough, long enough. If the cycle of continued injury is not broken these acute traumas turn into chronic issues.
Cycle of Continued Injury
Trauma with inadequate rest and continued overuse of involved tissues leads to:
↑ muscle/tendon tearing
Loss of Strength
Loss of range of motion
Trauma and the entire sequence continue.
If the cycle of injury continues, the tissues eventually rupture, pulling away from the bone or one another, requiring surgery to repair the damage. Leaving the injury without repairing it means losing the use of the injured tissues permanently. Other tissues will now be at risk for the same cycle, ultimately ending in a disability. Too often, the end point of the cycle is being placed in a nursing home. Ending the cycle by using appropriate treatment strategies will promote adequate healing so that you can resume your normal lifestyle. Learning to change your behavior and recognize early signs of tissue damage will help you prevent recurrence.
Watching professional sports has become increasingly difficult for me as a Physical Therapist: Observing Kurt Schilling pitch despite a significant ankle injury when I knew he had been patched up enough to play the game was eye-opening. Winning was more important than healing. No wonder patients in the U.S, healthcare system do not heal. When an activity is valued more than healing the body no healing will occur. For example, consider crocheting for hours at a time, ignoring any discomfort. If you push yourself this way, it is similar to running a marathon without adequate training and you are choosing to stay in the injury cycle.
What can you do to promote healing?
To promote healing, the first thing you need to do is rest and stop using the injured body part no matter how simple you believe the movement is. While healing, pain may go away so you think it’s okay to use the body part. But if you notice pain later, this means you caused more trauma and swelling and the healing process will have to start all over again.
To help heal injured tissues, anything you can do to reduce inflammation and prevent new inflammation in the area will be beneficial. Rest, use ice, lymphatic drainage massage, and compression with a garment or bandage, and over-the-counter anti-inflammatory meds like ibuprofen (taken according to package directions or your physician’s instructions) are all strategies that can help with healing. Resting to allow the osteoblasts and fibroblasts to do their job repairing the damage is the most important treatment for healing. Because moving that body part will tear all the work apart and the repair work will have to start all over again or it will never heal.
Compression helps promote fluid reabsorption back inside the veins and lymphatics. Bandages or compression garments can help your body carry fluids back to the heart. If the swelling is acute you may be able to wean off of using this compression eventually. If you try removing the compression and the swelling returns, you will likely need to continue using the compression to maintain the reduced swelling. To decide if you need to use compression at night, remove the compression before sleeping and assess the body part in the morning. If the injured body part is swollen or becomes more painful, you need to wear compression at night.
During the day you want to see the size maintained in the evening/night compared to the morning as well as prevent any worsening of symptoms. This indicates you are doing the right amount of activity and treatment which includes wearing the right amount of compression. If you wear no compression during the day and you swell in the evening it means you need to do more treatment to keep it under control. You can try increasing how often you do the Manual Lymphatic Drainage (MLD) massage (a technique that will be taught later) and if this takes care of it then that is your answer.
However, if you increase your MLD massage and you still swell, you have to change a different variable i.e. are you doing too much? If so, then you need to rest more. Using ice for 20 minutes at a time with a towel next to the skin is another good way to manage swelling or pain. If you are resting and doing the massage at least four times a day then other options would be to increase the massage even more frequently, ice more, rest better, and continue to wear the compression.
Maintaining available range of motion
Another important treatment is to follow your doctor’s advice and perform passive range of motion (PROM) to make sure the soft tissues stay stretched out while you are resting them. If done with something other than the injured muscles doing the movement it should not cause increased swelling or trauma to the area. For example, on an injured shoulder the other hand can carry the weight of the arm, or the injured arm can be placed on a countertop or dresser and moving the body away from the injured body part works well. Have someone else move the injured body part is a good way to rest the injured area. This PROM is done 4 times a day.
One exception for PROM is for cancer patients when lymph nodes have been removed. The range of motion should be delayed until the fibroblasts have repaired the lymphatic vessels. More will bediscussed about this later.
Once the inflammation is well controlled and the tissues have been given an adequate amount of time to heal, the next step is to VERY SLOWLY test to see if you are ready to start exercising to gain strength. If the trauma has been less involved it may not take 6 weeks of resting. To test the waters after 3 days of no pain at all try a very small bit of activity, no more than a few repetitions of a movement. If the body part remains pain-free without swelling the next day then the body tolerated this amount of activity. Very slowly and gradually increase activity as long as no pain increases and range of motion and strength remain without seeing any swelling.
If you continue to use an injured body part and not give it rest then you are choosing disability. Learning to listen to early warning signs and reacting more rapidly will help you heal faster and prevent disability.