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Understanding and Managing
Healing Process through
Rehabilitation Techniques for Sports
Medicine and Athletic Training
William E. Prentice
Rehabilitation requires sound knowledge
and understanding of tissue healing process
 Athletic Trainer designs, implements and
supervises rehab programs
 Rehab protocols and progressions must be
based on physiologic responses of tissues to
injury and understanding of how various
tissues heal
Primary Injury
– Injury from acute or chronic trauma
Secondary Injury
– Inflammatory response to primary injury
3 Phases of Tissue Healing
Inflammatory –response phase
Fibroblastic-repair phase
Maturation-remodeling phase
– Healing process is a continuum and phases
overlap one another with no definitive
beginning or end points
After injury, healing process begins
– Destruction of tissue produces direct injury to
cells of various soft tissue
– Characterized by redness, swelling, tenderness
and increased temperature
– Critical to entire healing process
Leukocytes and other phagocytic cells
delivered to injured tissue
– Dispose of injury by-products through
Vascular reaction
Chemical mediators
– Blood coagulation and
– Released from damaged
growth of fibrous
tissue occurs
– First 5-10 minutes
vasoconstriction occurs
 Best time to
 Followed by
 Effusion of blood
and plasma last 24
to 36 hours
tissue, white blood cells
and plasma
– Histamine, leukotrienes
and cytokines assist in
limiting exudate/swelling
– Amt of swelling directly
related to extent of vessel
Inflammatory Response Con’t
Formation of Clot
– Platelets adhere to
collagen fibers and create
sticky matrix
 Platelets and
leukocytes adhere to
matrix to form plug
 Clot formation occurs
12 hours after injury
and is complete w/in
48 hrs
 Set stage for
fibroblastic phase
Chronic inflammation
– Acute phase does not
respond sufficiently to
eliminate injury agent
and restore tissue to
normal physiologic state
– Damage occurs to
connective tissue and
prolongs healing and
repair process
– Response to overuse and
Inflammatory Response Con’t
Entire phase last 2-4 days
– Greater tissue damage longer inflammatory phase
– NSAIDS may inhibit inflammatory response thus
delaying healing process
Will assist with pain and swelling
Fibroblastic-Repair Phase
Proliferative and regenerative activity leads
to scar formation
– Begins w/in 1st few hours after injury and can
last as long as 4-6 weeks
– Signs and Symptoms of inflammatory phase
– Increased O2 and blood flow deliver nutrients
essential for tissue regeneration
Fibroblastic-Repair Phase
Break down of fibrin clot forms connective
tissue called granulation tissue
– Consist of fibroblast, collagen and capillaries
 Fills gap during healing process
– Unorganized tissue/fibers form scar
Fibroblast synthesize extracellular matrix consisting
of protein fibers (Collagen and Elastin)
– Day 6 –7 collagen fibers are formed throughout scar
– Increase in tensile strength increases with rate of collagen
Fibroblastic-Repair Phase
Importance of Collagen
– Major structural protein that forms strong,
flexible inelastic structure
– Type I, II & III
Type I found more in fibroblastic repair phase
Holds connective tissue together and enables tissue
to resist mechanical forces and deformation
– Direction of orientation of collagen fibers is along lines of
tensile strength
Fibroblastic-Repair Phase
Importance of Collagen
– Mechanical properties
 Elasticity
– Capability to recover normal length after elongation
– Allows slow return to normal length and shape after
– Allows permanent change and deformation
Maturation-Remodeling Phase
Long term process that involves realignment of
collagen fibers that make up scar
– Increased stress and strain causes collagen fibers to
realign to position of maximum efficiency
 Parallel to lines of tension
 Gradually assumes normal appearance and function
 Usually after 3 weeks a firm, contracted,
nonvascular scar exist
– Total maturation phase may take years to be
totally complete
Maturation-Remodeling Phase
Wolf’s law/Davies Law
– Bone and soft tissue will respond to physical
demands placed on them
Remodel or realign along lines of tensile force
Critical that injured structures are exposed to
progressively increasing loads throughout rehab
– As remodeling phase begins aggressive active range of
motion and strengthening
– Use pain and tissue response as a guide to progression
Maturation-Remodeling Phase
Controlled mobilization vs. immobilization
– Animal studies show Controlled mob. Superior
to Immobilization for scar formation
However, some injuries may require brief period of
immob. During inflammatory phase to facilitate
healing process
Factors that impede healing
Extent of injury
– Bleeding causes same neg.
– Microtears vs.
– Increased pressure
causes separation of
tissue, inhibits neuromuscular control,
impedes nutrition,
neurological changes
effect as edema
Poor vascular supply
– Tissues with poor vascular
supply heal at a slower rate
– Failure to deliver
phagocytic cells and
fibroblasts for scar
Factors that impede healing
Separation of tissue
– How tissue is torn will
– In early stages shown
effect healing
Smooth vs. jagged
Traction on torn
tissue, separating 2
– Ischemia from spasm
to inhibit healing
Keloids or
hypertrophic scars
 Infection
 Health, Age and
Healing Process-Ligament
Tough, relatively inelastic band of tissue
that connects bone to bone
– Stability to joint
– Provide control of one articulating bone to
another during movement
– Provide proprioceptive input or sense of joint
position through mechanoreceptors
3 Grades of lig. tears
Healing Process-Ligament
– Inflammatory phase-loss of blood from
damaged vessels and attraction of inflammatory
– During next 6 weeks-vascular proliferation with
new capillary growth and fibroblastic activity
Immediately to 72 hours
– If extraarticular bleeding in subcutaneous space
– If intraarticular bleeding occurs in inside joint capsule
Healing Process-Ligament
Essential that 2 ends of ligament be reconnected
by bridging of clot
– Collagen fibers initially random woven pattern with
little organization
– Failure to produce enough scar and of ligament to
reconnect 2 reasons ligaments fail
– May take 12 months to complete
– Realignment/remodeling in response to stress and
strains placed on it
Healing Process-Ligament Sprains
Factors that effect healing
– Surgery or non surgical approach
Surgery of extraarticular ligaments stronger at first
but may not last over time
 Non surgical will heal through fibrous scarring , but
may also have some instability
– Immobilization
 Long periods of immobilization may decrease
tensile strength weakening of insertion at bone
 Minimize immobilization time
 Surrounding muscle and tendon will provide
stability through strengthening and increased muscle
Healing Process-Cartilage
– Rigid connective tissue that provides support
 Hyaline cartilage: articulating surface of bone
 Fibro cartilage: interverterbral disk and menisci.
Withstands a great deal of pressure
 Elastic cartilage: more flexible than other typesauricle of ear and larynx
Healing Process-Cartilage
Physiology of healing
– Relatively limited healing capacity
 Dependant on damage to cartilage alone or
subchondral bone.
 Articular cartilage fails to elicit clot formation or
cellular response
 Subchondral bone can formulate granulation tissue
and normal collagen can form
Healing Process-Cartilage
Articular cartilage repair
– Patients own cartilage can be harvested and implanted
into damages tissue to help form new cartilage
– Promise for long term results
– Depends on where damage occurs
– 3 zones of various vascularity
Greater that blood supply better chance of healing on own
Healing Process-Bone
Similar to soft tissue healing, however
regeneration capabilities somewhat limited
– Bone has additional forces such as torsion, bending and
compression not just tensile force
After 1 week fibroblast lay down fibrous collagen
Chondroblast cells lay down fibrocartilage creating
At first soft and firm, but becomes more firm and
Osteoblast proliferate and enter the callus
Form cancellous bone and callus crystallizes into bone
Healing Process-Bone
Osteoclasts reabsorb bone fragments and
clean up debris
– Process continues as osteoblast lay down new
bone and osteoclasts remove and break down
new bone
Follow Wolfs law-forces placed on callus-changes
size, shape and structure
Immobilization longer 3 to 8 weeks depending on
the bone
Healing Process-Muscle
Similar to other soft tissue discussed
– Hemorrhage and edema followed by phagocytosis to
clean up debris
– Myoblastic cells from in the area and regenerate new
– Active contraction critical to regaining normal tensile
strength according to Wolff's Law
– Healing time lengthy-Longer than ligament healing
Return to soon will lead to re-injury and become very
6-8 weeks?
Healing Process-Tendon
Not as vascular as muscle
– Can cause problems in healing
– Fibrous union required to provide extensibility
and flexibility
Abundance of collagen needed to achieve good
tensile strength
Collagen synthesis can become excessive can result
in fibrosis: adhesions from in surrounding structures
– Interfere with gliding and smooth movement
– Tensile strength not sufficient to permit strong pull for 4 to
5 weeks
• At risk of strong contraction pulling tendons ends
Healing Process-Nerve
Nerve cell is specialized and cannot
regenerate once nerve cell dies
– Injured peripheral nerve- nerve fiber can
regenerate if injury does not affect cell body
– Regeneration is very slow 3-4 mm /day
Axon regeneration obstructed by scar formation
Damaged nerve within CNS regenerate poorly
compared to peripheral nervous system
– Lack connective tissue sheath and nerve cells fail to
Rehabilitation philosophy
Choose therapeutic exercises/modalities that
facilitate healing process at specific phases
– Stimulate structural function and integrity of injured
– Positive influence on the inflammation and repair
process to expedite recovery of function
– Minimize early effects of inflammatory process
including pain, edema control, and reduction of muscle
Produce loss of joint motion and contracture
– Finally concentrate on preventing reoccurrence of
injury by assuring structural stability of injured tissue
Appropriate return to play guidelines