The Healing Process.
Any athlete will confirm, no matter how careful we are, injuries are inevitable. Injuries can occur from a sudden trauma or more gradually, for a number of complex reasons. When soft tissues are damaged, such as skin and muscle, the body starts an automatic series of events, known as the “cascade of healing,” to repair the injured tissues. The cascade of healing is divided into four overlapping phases: Hemostasis, Inflammatory, Proliferative, and Maturation.
Phase 1: Hemostasis Phase
Hemostasis begins at the onset of injury and the objective is to stop the bleeding. Firstly, the blood clotting system is activated, platelets and collagen in blood combine under the influence of an enzyme called thrombin which create a stable clot of fibrin mesh. This acts as a dam to block the drainage.
Phase 2: Defensive/Inflammatory Phase
Inflammation is the process of destroying bacteria and removing debris from the wound. This prepares the wound bed for the growth of new tissue. A type of white blood cells called neutrophils enter the wound to kill bacteria and remove debris. These cells peak in population between 24 and 48 hours after injury, this number reduces after three days. As the white blood cells leave, cells called macrophages continue clearing debris. Macrophages also produce growth factors and proteins that attract immune system cells to the wound to assist with tissue repair. This phase often lasts four to six days and is associated with edema, erythema (reddening of the skin), heat and pain.
Phase 3: Proliferative Phase
Once the wound is clean the proliferative phase begins, the objective now is to fill and cover the wound with new healthy tissue.
The Proliferative phase has three stages:
1) filling the wound;shiny, deep red granulation tissue fills the wound bed with connective tissue, and new blood vessels are formed.
2) contraction of the margins of the wound towards each other which will seal the wound.
3) covering the wound (epithelialisation). New epithelial cells form an epithelial layer over the wound.The Proliferative phase often lasts anywhere from four to 24 days.
Phase 4: Maturation Phase
The new tissue slowly gains strength and flexibility. Here, collagen fibers reorganise, the tissue remodels and matures and there is an overall increase in tensile strength (though maximum strength is limited to 80% of the pre-injured strength). The Maturation phase varies greatly from wound to wound, often lasting anywhere from 21 days to two years. The healing process is complex, and it can be interrupted due to local and systemic factors, including moisture, infection, chronicity, grade of injury, age, nutritional status and lack of appropriate rehabilitation (guidance and exercises) through each phase. When the right healing environment is established, the body works in wondrous ways to heal and replace injured tissue. The most important action you can take is to seek immediate help from a physiotherapist. Physiotherapists understand anatomy, physiology, and biomechanics. A good physiotherapist will properly assess a problem or injury, help accelerate the healing process, prescribe exercises to strengthen the affected area, and make suggestions of movements and exercises to avoid until the injury is completely healed.
Rehabilitation and safe return to sport is guided according to the phase of healing you are currently in. Your physiotherapist can help you optimise each natural phase of healing with different interventions. The phases of tissue healing are outlined below.
- PHASE 1: Acute phase: ( 1 to 7 days)
The RICE-method of Rest, Ice, Compression and Elevation is implemented in the very acute phase of injury. The goal of this method is to reduce inflammation and pain. Inflammation signs are heat, swelling, redness and pain. Maintaining gentle movements of the affected area is also priority at this time.
- PHASE 2: Subacute phase: (Day 3 to < 3 weeks)
As inflammation begins to reduce, muscle action is important to prevent muscle wasting (atrophy) . Gentle stretching and range of motion exercises are the initial focus. When the patient has a full range of motion without any pain, early concentric strength exercises can be done. Your physiotherapist will monitor your progress and when there is pain, the exercise will be specifically modified and intensity immediately decreased as needed.
- PHASE 3: Remodeling phase: ( 1 to 6 weeks )
The patient can generally continue stretching exercises to improve flexibility. Eccentric strengthening exercises can also be done in this stage. These exercises are heavier than concentric exercises. Therefore it is important that the muscle is regenerated because otherwise, reinjury is possible.
- PHASE 4: Functional phase: ( 2 weeks to 6 months)
The main goal is to return to sport without a reinjury. Your physiotherapist will assist this process by ensuring appropriate manual therapy and exercise prescription. This is necessary to increase strength, endurance, speed, agility, flexibility and proprioception until the patient is at pre-injury level. Sport specific activities are the best indicators for an appropriate and safe return to sport. These will be measured progressively by your physiotherapist.
- PHASE 5: Return to competition phase: ( 3 weeks to 6 months)
On return to competition, it is paramount to avoid re-injury. When the patient has a full range of motion, strength, coordination and psychological readiness, it is appropriate to return to competition. This will be guided by your physiotherapist. A study reveals that a program consisting of progressive agility and trunk stabilisation is effective in promoting return to sports and preventing re-injury. This program turned out to be less risky for acute reinjury than isolated stretching and strengthening exercises.
At PhysioCare, we run a range of exercise based classes including Pilates, that can compliment the return to sports specific activity. We also have a gym facility with clinical Personal Training to assist you on the best road to recovery.