Return to the pitch: Should Pain be the Guide ?
Tissue trauma is a frequent occurrence in contact sport. Although the severity of the trauma, and the tissues involved will vary from injury to injury.
Tissues include bone, muscle, tendon, ligament, fascia, skin, cartilage also the internal organs. All of the body is made of a form of tissue and all tissues can be traumatized
Different tissues heal at differing rates, and while there are guidelines, healing time will also vary from individual to individual.
Some of the factors which can effect tissue healing are blood supply, age, individual general health and activity levels during healing.
Pain is misleading
Many people taking part in sport use the ‘does it still hurt ” question, to judge whether their torn tissues are better. They prod the tissue to evoke pain, and if it doesn’t hurt, they try out their injury in a progressive training session. If they don’t get pain during training, or they can train without later pain, they consider their injury ready for full contact sport.
But, pain is a very poor indicator of the degree and strength of tissue repair. To sustain the strains and pressures of full contact sport, tissue needs to have reached the stage of forming a strong tight scar, which usually takes much longer than anticipated.
Having information on tissue healing can assist players to be better informed about the probable stage of their injury healing, and therefore plan their injury free return to play. Healing tissue, can be pain free before it has reached regeneration, repair stage, or remodelling stages. Recurrence of pain after activity is usually a sign that further damage has occurred, and set back overall recovery
Stages of Healing
The first stage of injury healing is called the Inflammatory Phase, and occurs immediately after tissue trauma.
This period can last up to 96 hours (4 days) and involves a number of inflammatory responses, manifested by pain, swelling, redness, loss of function and increased local temperature.
The second stage in healing is the Regeneration and Repair Phase: The Fibro-elastic/ Collagen-forming Phase.
This stage starts as the inflammatory phase has finished its task, and lasts minimally 48 hours for a simple injury to 6 weeks or more for a more severe injury During this time structures are rebuilt and regeneration occurs. The pain, swelling, redness and raised local temperature of the inflammatory phase are passing, at this stage, the tissues start to feel thickened or lumpy to touch. They can now respond to electrotherapy, and gentle graded mobilisation and exercise. The Fibroblasts begin to generate immature scar tissue. These are poor quality tissues with a low level of tensile strength. This tissue can be broken down easily by loading, twisting or shearing actions. A break down at this stage puts the damaged tissue back to the first stage of injury with inflammation and pain.
The final stage of healing is the Remodelling Phase
This final phase takes place after the previous two stages, and can last between 3 weeks to 12 months depending on the degree of the original injury.
Gradually, cross-linking and shortening of the collagen fibres promotes the formation of a tight, strong scar. This phase is characterised by remodelling of collagen so as to increase the functional capabilities of the muscle, tendon, or other tissues. During this phase gradual and progressive loading of tissues can be commenced safely
Pain, inflammation, swelling, raised temperature loss of function
Tissues forming immature scar tissue
easily broken down
Tight strong scar tissue formation
Up to 96 hours
48 hours to 6 weeks
3 weeks to 12 months +
The minimum time for simple tissue injury healing is approximately one month
Severe tissue damage can take more than 14 months to complete
How do I know how healed my injury is ?
A skilled Physiotherapist or Musckuloskeletal specialist Doctor experienced at palpating tissue and assessing healing state can usually give an indication of the state of the tissue repair. True state of the tissues can only be shown by X-ray, MRI or ultrasound scan.
Any pain to general palpation, or on activity indicates that the tissues has not reached the remodelling stage. Discomfort or tightness can indicate that the tissue is still at the remodelling phase
What should I do while I am injured ?
Aim to be able to be as active as possible, put in place an alternative training routine to avoid losing general fitness and low mood swings
Rest Ice Compression & Elevation with movements where possible in the inflammatory stage, with NSAID’s if needed, or homoeopathic remedies.
In the regeneration phase a wide range of gentle activities should be planned which keep fitness levels up, without stressing the immature healing scar tissue at the injury site. Runners, rowers and rugby players can maintain cardio fitness in the swimming pool. Muscle groups which are not injured can be maintained with weights. Advice and a programme of graded progression can be set by your Physiotherapist
You should aim to be able to manage all day to day activities such as lifting, work, stairs, driving distance walking and swimming free from any pain before contemplating general training, weights.
During the remodelling phase there needs to be a focus on lengthening and stretching tissues, strengthening and proprioception work. Close work with the coach at this stage will help you return to a light training programme, with specific attention to key areas which could have predisposed injury . From around 3 weeks after a simple injury a strong and efficient scar exists. However strong activity, ballistic stretching or explosive muscles action can cause this scar to be broken down
Return to full sport should be planned after a reintroduction to full training, power strength and endurance work. The timing of this phase is totally dependent on the athlete, and is different for each athlete
What guidelines should I aim for to be back to full sport ?
When you have :
Full functional range of movement
Your strength measurements are 80% to 85%
You can meet the Cardiovascular Demands of your Sport
and have Passed all Functional Tests
Reference Prentice, W. (2004). Rehabilitation techniques for sports medicine and athletic training(4thed.). New-York: McGraw-Hill.