November 2024
The body has a remarkable ability to heal itself. When a body experiences injury—whether from an accident, surgery, or any physical trauma—the healing process begins almost immediately. The body responds with inflammation, which is essential for repairing tissue, and continues with an effective coordination of cellular activities, growth factor release, and collagen formation. Although the healing process is extraordinary, complications can arise, leading to scars and adhesions that may affect health and performance. Fascia can become thickened, hardened, or adhered to underlying structures, resulting in pain and restricted movement anywhere in the body. Dr. Haussler explains the whole process in his blog.
During this Gathering, Dr. Haussler’s guest collaborators – both with years of experience treating patients using Sharon Wheeler’s ScarWork – talk more about the healing process and what can go wrong. They discuss their assessment methods, treatment principles, and share some successful cases treating both humans and animals.
Prior to this meeting, attendees may wish to read Scars, Adhesions and the Biotensegral Body – Science, Assessment and Treatment, co-edited by guest collaborator Jan Trewartha. You may also wish to watch our September Gathering on The Science of Light Touch.
Gatherings are 1.5-hour meetings including 30 minutes devoted to audience insights and experiences.
Understanding Soft Tissue Trauma and the Healing Process
Scar tissue formation is an inevitable part of healing following many injuries and surgeries. While scars may initially be viewed as imperfections, understanding the science behind scar formation can shed light on their significance in the body’s healing process. Let’s look at how scars develop, the different types of scars, and effective ways to manage them.
Contributing factors
A scar is the body’s natural response to injury, resulting from the healing of skin or other tissues after damage. When the skin is cut, burned, or otherwise injured, the body initiates a complex healing process that leads to scar tissue formation. This tissue is usually thicker and less flexible than the surrounding skin, as it consists mainly of collagen fibers.
Tissue trauma and surgical procedures are obvious causes of acute soft tissue injury. However, chronic, repetitive use injuries are likely more common and widespread causes of myofascial pain and restrictions.
Let’s take an equine example…
- Overexertion: Horses that are pushed beyond their physical limits during training or competition are at higher risk for soft tissue injuries.
- Poor conditioning: Horses that are not adequately conditioned for their workload may experience strains or sprains.
- Improper training techniques: Sudden changes in training intensity, lack of warm-up, or inadequate rest periods can contribute to injury.
- Surface conditions: Hard or uneven surfaces can increase concussive forces and the risk of slips and falls, leading to injuries.
- Conformation and genetics: Certain conformational traits or inherited weaknesses such as hypermobility may predispose some horses to soft tissue injuries.
Signs of soft tissue trauma
Recognizing the signs of soft tissue trauma early is crucial for effective management. Again, taking the example of the horse…
- Lameness: Varying degrees and types of lameness are often associated with a soft tissue injury.
- Swelling and heat: Localized heat and swelling around an affected area suggest inflammation.
- Pain: Horses may exhibit signs of pain when the affected area is touched or manipulated.
- Reduced range of motion: Soft tissue injuries can lead to stiffness and limited movement within the affected limb or body segment.
The healing process – an incredible journey
The body has a remarkable ability to heal itself. When a horse, for example, experiences an injury—whether from an accident, surgery, or any physical trauma—the healing process begins almost immediately. The body responds with inflammation, which is essential for repairing tissue. There is a remarkable coordination of cellular activities, growth factor release, and collagen formation, which highlight the body’s incredible ability to repair itself.
The healing process can be broken down into several phases:
1. Inflammatory phase: Lasting a few days, the inflammatory phase involves the formation of a blood clot at the injury site, which stops further bleeding and acts as a temporary barrier against bacteria. Tissue damage triggers an inflammatory response, characterized by pain, swelling, heat, and loss of function.
2. Proliferative phase: After a few days, the body starts to rebuild tissue. Tissue regeneration is characterized by collagen deposition and angiogenesis. Fibroblasts—cells that produce collagen—play a significant role in this phase, creating a matrix that supports new tissue growth. The collagen produced during the proliferative phase is initially disorganized as the body attempts to rapidly fill in the soft tissue defect. Horses often produce excessive granulation tissue (i.e., “proud flesh”), which can inhibit tissue healing and promote fibrosis. This phase of tissue healing can last several weeks depending on the type and severity of tissue trauma.
3. Remodeling phase: Over weeks to months, the scar tissue undergoes remodeling, where collagen fibers are reorganized and replaced to increase tissue strength and flexibility. Mechanical loading is essential during this phase to enhance tissue properties. This final phase can last for months to years.
What can go wrong
However, this remodeling process may not perfectly restore the original tissue architecture. The final scar tissue is typically less vascularized and has a different composition compared to the surrounding tissue, resulting in decreased flexibility and potential functional limitations.
While the healing process is extraordinary, complications can arise, leading to scars and adhesions that may affect the horse’s health and performance. Fascia can become thickened, hardened, or adhered to underlying structures, resulting in pain and restricted movement.
1. Densification: Chronic, repetitive use injuries may cause viscoelastic changes within the loose connective tissue. Densification can produce palpable changes in tissue tone or texture but are not typically associated with histological changes within the fascial network.
2. Fibrosis: When tissue heals, it often forms scar tissue, which is less flexible and has a different structure compared to normal tissue. This scar tissue can restrict movement, especially if it forms in critical areas like joints or over muscles. The appearance of the scar can vary, often presenting as raised or thickened skin.
3. Adhesions: If the fascia becomes inflamed or damaged, the normal gliding function between fascial layers may be compromised, leading to the formation of adhesions. Adhesions commonly occur following surgery or significant trauma. In horses, adhesions can also occur within the abdominal cavity, contributing to recurrent colic episodes. Adhesions can lead to restricted movement in adjacent or regional myofascial structures, which may manifest as lameness, discomfort, or reduced athletic performance.
Why do complications occur?
Complications can result from several factors:
- Severity of trauma: Deeper and larger wounds are more likely to have excessive fibrosis and scar formation.
- Infection: If an injury becomes infected, the increased inflammatory response can lead to excessive scar tissue formation as the body attempts to wall off the infection and heal.
- Reduced blood supply: Areas with limited blood flow may not heal as effectively, resulting in abnormal tissue formation.
- Location of the injury: Areas of high tension, such as over joints, may result in more prominent scars due to the stress placed on the healing tissue.
The impact on animals
Horses, for instance, with significant scarring or adhesions may exhibit various clinical signs including:
- Pain: Adhesions can cause chronic pain, which directly affects the horse’s ability to perform daily activities or compete athletically.
- Restricted motion: Scar tissue can restrict movement, leading to stiffness or altered gaits.
- Behavioral changes: Horses with fascial restrictions may exhibit changes in behavior, such as reluctance to move, increased aggression, or anxiety.
- Muscle atrophy: Chronic pain or restricted movement can lead to muscle wasting in the affected areas.
Diagnostic approaches
Comprehensive myofascial examinations allow detection of often subtle changes in the fascial tone and texture, which can be indicative of normal tissue healing or fibrosis and adhesions. The quantity and quality of fascial movement provides insights into sites and the severity of myofascial pain and restrictions. Scars and adhesions are characterized by local changes in tissue texture and mobility; however, detrimental regional or systemic effects have been reported in some affected horses.
Soft tissue mobilization and passive range of motion are useful techniques to assess the depth and breadth of fibrosis or adhesions. Diagnostic ultrasound can be used to visualize the extent of scar tissue formation and to monitor changes over time.
Treatment options
- While some scars fade naturally over time, various treatments can help improve their appearance.
- Anti-inflammatory drugs and analgesics are used to manage pain and inflammation during the initial inflammatory phase of tissue healing.
- Fascial densification and fibrosis can be managed with manual therapy techniques, such as light touch, massage, and stretching, to promote mobility and reduce fascial restrictions.
- Deep tissue heating modalities like therapeutic ultrasound, class 4 lasers, and diathermy can be used to reduce pain and increase tissue extensibility. Combined tissue heating and manual therapies can be very effective for restoring soft tissue texture, tone, and mobility.
- Biological therapies such as platelet-rich plasma (PRP) or stem cell therapy may offer promising results in treating adhesions and promoting tissue healing.
- In cases of severe adhesions, surgical options may be considered to release or resect excessive fibrous tissue.
In closing…
Scars are a natural part of the healing process, representing the body’s resilience and ability to recover. Understanding the pathogenesis of scar formation and the histologic process of fascial adhesions is essential for effective management of animal injuries. By recognizing the stages of healing and the factors that contribute to abnormal tissue repair, practitioners can develop targeted treatment strategies to minimize scar tissue and adhesions. This knowledge ultimately contributes to improved recovery outcomes and enhanced quality of life for animals. Effective rehabilitation, monitoring, and timely intervention can significantly impact the healing process, ensuring that animals can return to their full potential.
Some questions to ponder as you continue your learning
- How do surgical incisions heal differently from traumatic wounds or lacerations?
- How do you know if the presence of scar tissue is clinically relevant? How do you know when scar tissue is not clinically relevant?
- Are there sites where scar tissue is more problematic than at other sites?
- How does a deep wound heal differently from a more superficial wound?
- What are the best methods for preventing scar formation?
- Are all scars created the same or are some more troublesome than others?
- What are the most effective methods for treating scar tissue once it has formed?
- How are different tissue types affected by scar formation?
- What are the clinical implications of fibrosis versus adhesions?
Provided by guest collaborators:
Jan E Trewartha and Sharon L Wheeler, editors. Scars, Adhesions and the Biotensegral Body – Science, Assessment and Treatment. Handspring Publishing, 2020.
Nancy Keeney Smith and Catherine Ryan. Traumatic Scar Tissue Management – Massage Therapy Principles, Practice and Protocols (a textbook). Handspring Publishing, 2016, reprint 2018.
The Fascia Hub:
https://thefasciahub.com/blog/abdominal-scars-and-adhesions-effects-and-approaches
https://thefasciahub.com/blog/the-power-of-following-the-tissue-3
The Wound Pros https://www.thewoundpros.com/post/understanding-scar-tissue-pain-symptoms-sensations-and-risks
Managing Horse Wounds to Prevent Scarring – The Horse
Research by Karel Lewit
Shared courtesy of Debranne Pattillo, Equinology:
The power of fat and its adipose‐derived stromal cells: emerging concepts for fibrotic scar treatment: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724515/
An Overview of the Use of Equine Collagen as Emerging Material for Biomedical Applications: https://www.mdpi.com/2079-4983/11/4/79/pdf
Castration Scar Manipulation – Dr. Louise Cosgrove from Exclusively Equine Veterinary Services:
https://eevs.com.au/?s=castration
https://www.facebook.com/watch/live/?v=202919467749644&ref=watch_permalink
https://www.listennotes.com/…/episode-3-castration…/
The Trouble with Gelding Scars: https://www.equitopiacenter.com/the-trouble-with-gelding…/
Gelding Scar: https://issuu.com/hoof…/docs/gelding_scarring_-_hoofbeats_
Shared courtesy of Elisse Miki, EQ Therapeutics:
Effective Assessment and Treatment of Gelding Scars in Horses (contains more references)
Shared courtesy of Ruth Mitchell-Golladay:
You can also stream just the audio or download to listen offline.
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