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 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.
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
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.