Soft Tissue Injuries and Healing

By Jason B. Kaster, D.C.

To begin I would like explain the soft tissue healing process. To understand soft tissue injury one needs to understand what the normal soft tissue anatomy looks like. Normal, undamaged soft tissue (loose areolar) has a crisscrossed pattern to it when you look at it under a microscope. Muscle, tendon, and cartilage tissue run longitudinally when viewed under a microscope. When there is an injury there is a clear sequence of events that occurs as described below.¹ ²

Phase 1 – Acute Inflammatory Phase

The tissues that were torn bleed, or leak inflammatory substances into the region for approximately 72 hours. This is why it is common for the patient to feel worse each day for the first three days after a automobile accident. After approximately 72 hours the capillaries have repaired themselves. This will begin the second phase of healing.

Phase 2 – Regeneration Phase

This stage will last about 6-8 weeks, during which torn tissue is tied or held down. Fibrous Scar tissue is laid down to bridge the tear that occurred. This new scar tissue is unlike the original tissue. The way that this tissue heals is also different because:

1. Fibrous scar tissue is not aligned in the same direction.
2. Fibrous scar tissue has smaller diameter fibers that are kind of glued and matted together.

Therefore, the resulting healing tissue has three important characteristics different from the original tissue.

1. The tissue is weaker because the strength of any soft tissue is dependent on the cross link. Researchers find that when they look at this tissue under a microscope it has fewer cross-links than the original tissue, also the fiber’s diameter is smaller than the original.Therefore, because it is weaker every time the patient stresses the area it will fail in the exact same place.
2. Healing tissue is stiffer than the original tissue, there are two reasons why:
   • Fibers: The fibers in the resulting scar tissue are lined up differently than a crisscrossed pattern and are weak. The fibers in muscle, tendon, and cartilage line up in a random fashion. Therefore, these tissues are not anatomically the same as before.
   • Glued factor: The glue factor tells us that everywhere these scar tissue fibers touch each other they glue together. In clinical examination we sometimes find this as decreased range of motion.
3. The tissue is more sensitive to territorial invasion. This principle has been well-established in the literature.³ ⁴ This means that the surrounding nerves actually grow into this tissue making it more sensitive and more sore than the original undamaged tissue. Under the microscope they actually find more neurofibrils, which are the little pieces of nerve in this as compared to the original undamaged tissue. As a result, it is common for people to have hypersensitivity where scar tissue has been laid down.

Phase 3 – Remodeling

Most of the remodeling takes about 12 months or more. During remodeling if you continually put forces into the tissue as the words in the literature say, “tension within the scar” it makes them lineup any direction of the stress and strain. Thus, the healing tissue can realign itself better.

During the healing of scar tissue, immobilization is bad and mobilization is good because the tissues slowly but surely arrange themselves more like the original undamaged tissue when mobilized.

Therefore, the individual will get a better end product during the healing process. The better the end product heals the smaller the likelihood there will be of a future flare-up or exacerbation of pain and spasms. However, it is impossible to get a perfect heal, because the tissues are weaker, stiffer, and more sore, and they may have periodic flare ups of pain and/or spasm. These are the rules rather than the exception. There is plenty of data to substantiate these types of findings.

Therefore, our chiropractic goal is to get the tissue to more closely resemble the original soft tissue in terms of structure and function.

James Cyriax, an orthopedic surgeon states: “treatment by resting had been found to result in chronic disability later, although the symptoms may temporarily diminish. During the past century, treatment by resting has given way to therapeutic movement in many soft tissue lesions. Movement may be applied in various ways: the three main categories are: 1) Active and resistive exercises; 2) Passive, especially forced movement; and 3) Deep massage.⁵ Although, Cyriax has outlined three basic ways to induce movement.

The therapeutic benefit of the movement of soft tissue appears to lie in the mechanical stress imparted to the developing scar. It induces the developing fiber network to be arranged in a more orderly longitudinal fashion. This more orderly longitudinal arrangement allows the scar to be more functionally adapted. In other words, movement enhances the healing process by stretching and breaking lesions or cross-links formed between the fibers of the scar’s developing network.⁵ ⁶ ⁷ ⁸

Therefore, the scar that has been healed in the presence of movement, manipulation, soft tissue therapy, and exercise more closely resembles the original tissue in terms of structure and function. ⁵

For your reference I am adding two pieces from the literature stating that soft tissue injury causes pain and disability that is essentially permanent. These are the results from those studies:

Residual symptoms after 10 to 15 years post MVA in 62% of these:

• 44% change permanently to lighter work.
• 62.5% modified leisure activity⁹

Residual symptoms 10.8 years after MVA:

• Only 12 percent recover completely.

Residual symptoms severity:

• Intrusive in: 28%
• Severe in: 12%

Residual symptoms location:

• Neck pain 74%
• Paresthesia 45%
• Lower Back Pain 42%
• Headache 33%¹⁰

This is why we do everything we can in the months immediately following a soft tissue injury (specifically whiplash) to insure the patient the best possible healing of tissue; the best possible prognosis, and the best possible outcome for his or her future.

Jason B. Kaster, D.C.

REFERENCES

1. KELLET, JOHN
ACUTE SOFT TISSUE INJURIES – A REVIEW OF THE THE LITERATURE MEDICINE AND SCIENCE IN SPORTS EXERCISE,
AMERICAN COLLEGE SPORTS MEDICINE, VOL 18 NO 5 1986 PP 489-500

2. ROY, STEVEN MD. AND IRVIN RICHARD
SPORTS MEDICINE: PREVENTION, EVALUATION, MANAGEMENT AND REHABILITATION
PRENCTICE-HALL, INC. 1983 PAGES 125-127
(REMODELING TAKES UP TO ONE YEAR)

3. GUN, C. CHAN
“PRESPONDYLOSIS” AND SOME PAIN SYNDROMES FOLLOWING DENERVATION SUPERSENSITIVITY.
SPINE, MARCH, APRIL 1980.

4. CYRIAX J. ORTHOPEDIC MEDICINE,
DIAGNOSIS OF SOPFT TISSUE LESIONS,
VOL. 1. LONDON: BAILLIERE TINDALE 1982.

5. WOO SL-Y, BUCHWALTER JA.
INJURY AND PREPAIR OF THE MUSCULOSKELETAL SOFT TISSUES.
JOURNAL OF ORTHOPEDIC RESEARCH 1987; 6: 901-931.

6. PALASTANGA N.
CONNECTIVE TISSUE MASSAGE. IN: GREIVE GP, ED. MODERN MANUAL THERAPY OF THE VERTEBRAL COLUMN.
NEW YOUR: CHURCHILL LIVINGSTONE 1986.

7. KIRKALDY-WILLIS WH, CASSIDY JD.
SPINAL MANIPULATION IN THE TREATMENT OF LOW BACK PAIN.
CAM FAM PHYSICIAN 1985: VOL 31.
FOR CERVICAL SPINE

8. HODGSON, S.P. AND GRUNDY, M.,
WHIPLASH INJURIES: AND THEIR LONG-TERM PROGNOSIS AND ITS RELATIONSHIP TO COMPENSATION.
NEURO-ORTHOPEDICS, 1989, 88-91.

9. GARGAN, M.F. AND BANNISTER, G.C.
LONG TERM PROGNOSIS OF SOFT TISSUE INJURIES OF THE NECK
THE JOURNAL OF BONE AND JOINT SURGERY, SEPTEMBER 1990

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