Have you ever wondered what happens in your body after an injury? In this article we’ll talk about tissue healing in general and look at muscle injuries, their healing and what you can do to aid the healing process in more detail. 

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Tissue Healing

Tissues are muscles, ligaments, menisci, discs and fascia. These heal through three main phases: inflammation, proliferation and remodelling. These phases overlap somewhat and can happen simultaneously.

Inflammation
Inflammation occurs directly after the injury and usually lasts up to five days. The signs of inflammation are swelling, heat, redness, pain and loss of function. 

Treatment in this phase is directed towards relieving pain, preventing further injury, increasing blood flow as well as maintaining muscle tone and pain free range of motion. 

Proliferation (scar tissue formation)
Depending on the tissue that has been injured this phase can last anywhere between 48 hours to over six weeks. In this phase the immune cells that have arrived at the site of the injury during inflammation, start removing the debris and form scar tissue that tentatively connects the different sides of the injured tissue together. At this stage this connective tissue “bridge” is not very strong against tension because the new connective tissue fibres that are created haven’t been told what direction to take. That only happens when the tissue comes under progressive tension. If the tension is too strong, it’ll break the new tissue. Just the right amount of tension, on the other hand, will help to make the tissue stronger. That is why this phase requires a lot of patience from the patient.

Treatment in this phase is directed towards preventing early adhesions, orienting the repairing tissue along the line of tension, relieving pain, maintaining muscle tone and range of motion, reducing swelling, starting exercise to return to normal activity as soon as possible, addressing any possible psychosocial issues and preventing the transition into chronic condition.

You can support the healing with good nutrition including protein, fruits and vegetables and with some supplements. Especially vitamin C, zinc and magnesium are important. 

Remodelling 
The final phase of the healing process is the longest and can take anywhere between three months to over a year. In this phase collagen, the fibre that gives the tissue its strength, is remodelled to increase the functional capabilities of the tissue in the direction of stresses put upon it. This could take the form of stretching and moving the body part gently in the pain free range of motion. 

Osteopathic treatment in this phase is directed towards proper alignment for collagen, increasing the elasticity of scar tissue, reducing fibrotic adhesions, relieving muscle spasms, increasing strength and range of motion, normalising joint and muscle activity addressing any possible psychosocial issues and preventing the transition into chronic condition.

PRICED vs METH
Most of us have heard of the (P)RICED protocol to be used in acute injuries, but not many are familiar with the METH protocol. Right after the injury has occurred, the first aid is to do the PRICED protocol.
Protect - take care not to re-injure the damaged tissue
Relative rest - taking it easy, not putting pressure on the injured tissues, this is only for the first 1-2 days (sometimes also substituted with OL for optimal loading)
Ice - indicated if there’s a concern for compartment syndrome, excessive swelling and helps to relieve  the initial pain, only use for 1-2 days after the injury at the most
Elevation - elevate the injured limb to prevent swelling
Doctor - see a musculoskeletal practitioner, such as a Reg Osteopath, for accurate diagnosis and care plan

Later in the healing process it’s better to use the METH protocol.
Movement - when the acute pain has decreased, begin pain free gentle movement
Exercise - progressive rehab programme to get back to previous activities and strengthen the structures
Traction - helps to ease the tension in the tissues and re-establish range of movement
Heat - to increase blood flow and help with healing

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Muscle injuries and their healing

Muscle injuries can be put in three different categories based on the severity. The first and mildest form of injury is a grade l minor muscle strain where some of the muscle fibres get stretched (<10%). Some of the symptoms include mild pain with activity, muscle guarding, mild trigger points (knots) in the muscles and mild local compensatory joint motion restrictions. There’s no bruising or loss of function but slight weakness may be noted with strong muscle contraction. Delayed onset muscle soreness (DOMS) that is common after a hard workout is classified under this category. 
Usually rest is enough to let the tissues heal. Functionally the muscle heals in about 2-7 days, and has re-established its structural strength within 4-14 days. 

In grade II muscle injuries some of the muscle fibres are torn, so there’s a partial tear in the muscle. Common signs of this are moderate to severe pain, guarding the affected site, loss of function, bruising and swelling, decreased mobility, limping and muscle weakness. There is usually significant pain when the muscle is stretched. Sometimes the tear can be even palpable. In these cases it’s recommended to see your doctor and get diagnostic imaging (usually ultrasound) to evaluate the extent of the damage and need for surgery. If the tears are not treated properly, partial tears can progress into full thickness tears with repeated trauma and usage. Functionally partial tears heal in 1-10 weeks, structurally they are sound in a few months. 

In full thickness tears (grade III) there’s severe pain at the time of the injury but very little pain afterwards. Other symptoms include severe bruising and loss of function as well as guarding the affected muscle. Usually tears are visible under the skin. In these cases surgery is most often needed and a return to full function might not happen and there’s often long term issues.. Functional healing time for these types of injuries is usually somewhere between 10 weeks to 6 months but structural strength takes longer, usually over a year. 

For the grade ll and lll, you need to see a healthcare professional to help you take care of your injuries. Osteopaths can help with evaluating the extent of the injury and give advice on how to take care of it including the right exercises and when. Osteopaths help to make sure that everything else is functioning optimally in your body so that it can concentrate on healing the injury and minimise the discomfort from compensations. Osteopathic treatment helps to increase blood flow which helps to promote healing and ease the pain. Osteopaths can also make a referral for ultrasound if a  muscle tear is suspected. 

What you can do at home
In the first few days after the injury apply PRICED or METH protocols (see above). Avoid aggravating activities and rest, and take painkillers if needed to ease the pain. Nutritionally eating more protein and making sure you’re getting enough zinc, magnesium, manganese and calcium, as well as staying well hydrated is going to help give your body all the building blocks and optimal environment to repair the muscle tissue. Be sure to take it easy and avoid reinjuring the tissue which could lead to prolonged healing and even chronic issues. 
Applying heat will improve blood flow and aid the healing process.. At this stage you can go see your osteopath for gentle treatment to improve your range of motion and to reduce stiffness and pain. When you can tolerate it, the osteopath will guide you to gently move  the affected site in pain free ranges of motion to avoid stiffness and contracture.

In the remodelling phase of healing your osteopath will give you exercises to improve your proprioception and balance and to start working on building back the strength in the injured tissues. As the healing progresses, the exercises will get more strenuous and more challenging, and if you’re an active person, more activity specific, to help you gain the level of confidence and strength needed to do the things you love doing. 

It is good to remember that muscle strains heal in three overlapping phases and the duration of the healing process depends on injury’s severity and on the general health, activity, nutrition and age of the individual. Lack of patience in the rehabilitation process and too early return to full activities increases the likelihood of reinjury and the development of chronic pain. Recurring injuries result in increased scar tissue formation and loss of function. So in the long run it pays to have patience in the beginning, that way it’ll take less time and your body will heal better overall. 

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As a cyclist, you may have experienced one or more of the most common injuries of this sport. Some of these are:

1. Falls: Falls are probably the most common cause of injuries for cyclists. Falls can cause different types of injuries, from skin bruises, clavicle and wrist fractures, muscle strains and problems that can bring more serious disorders, such as concussion.

2. Knee Injuries: Different types of injuries can affect the cyclist's knee, causing pain in different regions of the joint. They are: patellar tendinopathies, pes anserinus tendinopathies, patellofemoral pain syndrome, caused by excessive use, shortening and/or imbalance of the different quadriceps muscle portions, which can lead to patellar chondropathies and in particular, Iliotibial Tract Syndrome, which often requires extra treatment, especially if the athlete continues to compete.

3. Hip and Groin pain: Pain in the hip and groin region can cause marked discomfort and significantly decrease an athletes' performance.

4. Low back pain: As already mentioned, the cyclist's posture in extreme lumbar and hip flexion will commonly generate pain in the lumbar region, either by a flexion strain on the intervertebral discs, or by an overload of the extensor musculature of the lumbar region, which can reduce the stability in the region, leading to possible muscle injuries and overload in other regions, such as the hips and pelvis. A sign of concern is when pain spreads through the lower limbs, such as radiation, numbness and muscle weakness. This can occur due to problems arising from the lumbar region itself or due to excessive tension in some muscles, which can compress peripheral nerves of the lower limbs.

5. Perineal pain: The perineal region, or pelvic floor, is a set of muscles located in the lowest portion of the pelvis, between the anus and the genital region, which has several important functions and carries several vital structures, such as nerves, arteries and veins. Prolonged posture in the sitting position on the saddle can favour the compression of these structures, leading to changes in sensitivity, such as numbness and tingling, in addition to pain itself. Paresthesia can extend to the scrotum and penis, in men, and labia majora in women. The type of saddle and bike adjustment have a considerable influence on the emergence of these symptoms.
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6. Neck pain: As already mentioned, the cervical spine is always positioned in hyperextension during pedalling, especially the upper cervical spine. This positioning excessively strains the neck and shoulder muscles. The most affected muscles are the suboccipital muscles, which have a very important proprioceptive function, as they always act by making micro-adjustments in the positioning of the head so that we can keep our gaze horizontal. These muscles are among the most innervated in the body and they developed exponentially at the end of man's evolutionary process, when we adopted the bipedal posture and needed to keep our gaze horizontal to master the environment around us. For this reason, the cyclist's cervical posture can cause not only neck pain, but also headaches at the base of the skull and in the back of the eyes and forehead region.

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But what about the role of Osteopathy in all this?
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If you are a bike lover and want to keep riding with the best possible quality of life and performance, then what is important - if not even more important, than taking care of your bike, is taking care of your instrument to ride - your body! Think of it like this, before you make the investment in a Bike Fitting, where the bike will be all adjusted to your body with the help of technology, you ideally will have already had checked the muscle imbalances, the alignment of your joints and your body's ability to adapt to the effort required to cycle first. That is exactly how Osteopathy can help you.

Osteopathy is a science that aims to evaluate changes in mobility and in the quality of the tissues of your body, to help you find your balance and your best state of health, guaranteeing greater comfort, performance and quality of life, preventing injuries and facilitating the recovery from these, keeping you active and healthy to perform your pedalling. Osteopathic Manipulative Treatment (OMT) achieves this by improving the mobility of joints and other body tissues, balancing muscle and ligament tensions, improving vascularization and oxygenation of your muscles and different tissues, increasing your body balance and coordination, ensuring a better relationship between your Central Nervous System (CNS) and your locomotor apparatus, among other multiple benefits that will keep your body in the best possible state of health and preparedness to reap the best results of a Bike Fitting for you and your bike.
I strongly recommend that anyone who regularly likes to have a Bike Fitting done with their bike, should come for one or two treatment sessions first, at around ten and then three days before doing their Bike Fitting. That will really take your Bike Fitting to another level. If you are not worried about performance and just want to stay active and healthy, come to see your osteopath regularly, once every two to three weeks or even once a month. This will be incredibly beneficial for your health. Remember that prevention is the best treatment. 
See you at City Osteopaths, let’s work together!

References
Di Alencar, Thiago Ayala M.; Matias, Karinna F. S.; Bini, Rodrigo R.; Carpes, Felipe Pivetta (2011). Revisão etiológica da lombalgia em ciclistas. Revista Brasileira de Ciências do Esporte (Impresso), 33(2), 507–528.
Salai, M.; Brosh, T.; Blankstein, A.; Oran, A.; Chechik, A. (1999). Effect of changing the saddle angle on the incidence of low back pain in recreational bicyclists. British Journal of Sports Medicine, 33(6), 398–400. 
K. de Vey Mestdagh (1998). Personal perspective: in search of an optimum cycling posture. , 29(5), 325–334.
Dannenberg, A. L.; Needle, S.; Mullady, D.; Kolodner, K. B. (1996). Predictors of Injury Among 1638 Riders in a Recreational Long-Distance Bicycle Tour: Cycle Across Maryland. The American Journal of Sports Medicine, 24(6), 747–753.
Weiss, B. D. (1985). Nontraumatic injuries in amateur long distance bicyclists. The American Journal of Sports Medicine, 13(3), 187–192.
C. A. Wilber, C. 1. Holland, R. E. Madison and 5. F. Loy, An Epidemiological Analysis of Overuse Injuries Among Recreational Cyclists. Int. J. Sports Med., Vol. 16, No. 3, pp. 201 -206, 1995
Asplund, Chad; Webb, Charles; Barkdull, Thad  (2005). Neck and Back Pain in Bicycling. Current Sports Medicine Reports, 4(5), 271–274.        
Alencar, T., & Matias, K. (2018). BIKE FIT E SUA IMPORTÂNCIA NO CICLISMO. Movimenta (ISSN 1984-4298), 2(2), 59-64. 
Educational Council on Osteopathic Principles. Glossary of Osteopathic Terminology. Washington, DC: American Association of Osteopathy Colleges: 2001.
Denslow JS. Pathologic evidence for the osteopathic lesion: The Known, unknown and controversial. En: Beal MC, ed. Selected Papers of John Stedman Denslow, DO. Indianápolis, IN: American Academy of Osteopathy; 1993: 154-160.
Korr I. The neural basis of the osteopathic lesion. En: Peterson B, ed. The Collected Papers of Irvin M. Korr. Colorado Springs, CO: American Academy of Osteopathy, 1979: 120-127.

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Diego Polo DO, Reg.Osteopath, MONZ

Click here for Diego's Bio

Phone 044991439 to talk to our front desk team
​Book online www.cityosteopaths.co.nz

A well-balanced and injury-free body is the dream of every athlete. Unfortunately, this is not always the reality. Osteopathy in sport has been used in different countries to prevent and treat injuries, giving the athletes a better quality of life, and helping them to achieve better results, no matter which kind of sport we are talking about.
There are a great number of top athletes that benefit from osteopathic treatment. In 1998, just after winning the World Cup, the former football player Zinedine Zidane said: “I owe a large part of my presence in the final match to my osteopath.” Fourteen years after that, he talked about Osteopathy again: “treating yourself naturally, with less medication and anti-inflammatories, allows you to preserve yourself after your sports career and age better". Currently, many other athletes utilise Osteopathic Manipulative Treatment (OMT), for example the Polish tennis player Jerzy Janowicz, the British olympic champion Mo Farah, and the French Real Madrid’s football player Karim Benzema.

Therefore, it is no surprise that a team of osteopaths have been present in all Olympic Games since ‘London 2012’. That was the first time that 25 osteopathic health professionals joined the health team of the biggest sporting event in the world. There were more than 900 treatment sessions there. In ‘Rio 2016’, the number of osteopaths that joined the health team increased to 30. Consequently, the osteopathic approach has become a reality for prevention and treatment of injuries for high performance athletes.
However, amateur athletes can also benefit from osteopathic treatment to increase their health status, quality of life and improve their performance. Presenting a truly holistic approach, Osteopathy considers the body as a single unit, where all the systems are interrelated and interdependent, also considering all the other aspects that are common to every human being, like the psychological, mental, social, environmental and spiritual fields.

According to New Zealand based research by Kovanur and Roy (2015), most practising osteopaths in Aotearoa come across patients with a history of mood disorders.

As the New Zealand mental health 2020/2021 survey has shown, psychological distress in adults, and also in children, has increased from 7.5% the previous year possibly due to the pandemic and lockdowns.

According to the same research, 100% of manual therapists perceived the need to manage and support clients with mood disorders during the osteopathic treatment. Being a current topic, I decided to show the evidence from our osteopathic point of view in how to manage patients affected by mood disorders. “Mood disorders are defined as serious mental illnesses that include depression, negative thoughts, anxiety, mood swings and bipolar behaviour”.

​Osteopathic point of view and manual treatment
The balance between health and disease will always depend on the dynamic interaction between the intrinsic components of physical, mental and emotional states. Thus, a dysfunction of one of these three components can have repercussions on the others.
The core principle of osteopathy is that “structure and function are interrelated at all levels”.

In this context, it has been studied that emotional stress can alter the functionality of the cardiovascular, respiratory and musculoskeletal structural systems, increasing blood pressure, pulse, respiratory rate and sustaining the onset of musculoskeletal disorders.

Diaphragm muscle
Mood disorders commonly affect the functionality of the respiratory system and, consequently, the structure of the respiratory diaphragm muscle. During a stressful time, it has been shown that people tend to breathe quickly and shallowly, constantly increasing the tension in the diaphragm muscle

Osteopathic manual treatment
At City Osteopaths, we offer fascial visceral treatment to assist the diaphragm muscle and the very gentle cranial osteopathic approach via the cranial rhythmic impulse. We also further support your recovery with the addition of specific guidance in breathing exercises, to help normalise the psychosomatic and somatic states.

Musculoskeletal system
​As mentioned above, diaphragm muscle dysfunction can happen as a consequence of mood disorders; but what is the connection with the musculoskeletal system and pain? To clarify this concept it is important to mention some anatomical information.
The diaphragm muscle is the most important respiratory muscle and it separates the thoracic cavity from the abdominal cavity. There are three attachments of the diaphragm: the xiphoid process of the sternum, costal cartilages of ribs 7-12, lumbar vertebrae ligaments, arcuate ligaments, right crus that arises from L1-L3 vertebrae and left crus that arises from L1-L2 vertebrae. The muscle fibres of the diaphragm combine to form a central tendon. Its innervation is via the phrenic nerve from the cervical roots of C3-C5.  

If the diaphragm goes into fatigue, it follows that its attachments have a structural mechanical overload causing rib cage, dorsal spine and low back pain. Moreover, it’s also a common cause of neck pain in patients with high levels of stress, due to the neurological connection of the phrenic nerve that receives excessive aberrant signals from the dysfunctional diaphragm muscle back into the neck nerve spinal roots.

Osteopathic manual treatment
At City Osteopaths, we put into practice anatomical principles to treat the body structure and vertebral column in order to improve the function of the diaphragm muscle and, consequently, helping patients affected by mood disorders to increase their quality of life. Our goal is the patient’s wellbeing and we assist this with manual therapy.

Bibliography:
● https://www.health.govt.nz/publication/annual-update-key-results-2020-21-new-zealandhealth-survey
● Kovanur Sampath, K. and Roy, D. E. (2015) ‘Management of mood disorders by osteopaths in New Zealand: A survey of current clinical practice’, International Journal of Osteopathic Medicine, 18(3), pp. 161-170.
● Paulus, S. (2013) ‘The core principles of osteopathic philosophy, International Journal of Osteopathic Medicine, 16(1), pp.11-16.
​ ● Sagrillo, L. M. and Frigo, L. F. (2016) ‘The respiratory diaphragm in osteopathic vision: a literature review’, MTP & Rehab Journal, 14: 414, pp. 1-6