Pulled Muscles, Scar Tissue and Re-Injury
What is scar tissue and how does it affect recovery & re-injury of pulled muscles and sports injuries?
by Brad Walker | First Published September 8, 2005 | Updated October 30, 2018
Have you ever had an injury that just won’t heal? And then when you think it has healed, you go and re-injure it again. You may have a problem with scar tissue.
So you’ve pulled a muscle? Over-stretched it, torn it, strained it, sprained it. Call it what you want. From an injury point of view, the initial healing process is all the same.
Sprains (ligament) and strains (muscle or tendon) are the most common type of soft tissue sports injury and are often caused by activities that require the muscles to stretch and contract at the same time. A lack of conditioning, flexibility and warm up can also contribute.
Before we start!
Let’s have a quick look at the type of injuries I’m talking about. The type of sports injuries I’m referring to here are the soft tissue injuries, which are very common in most, if not all sports. Examples of common soft tissue injuries would include things like hamstring tears, sprained ankles, pulled calf muscles, strained shoulder muscles and tendons, corked thigh, etc. These injuries include sprains, strain, tears and bruises that affect muscles, tendons, ligaments and joints (the soft tissues of the body). Remember a sprain refers to a tear or rupture of the ligaments, while a strain refers to a tear or rupture of the muscles or tendons.
Side note: The sort of injuries I’m NOT talking about here are injuries that affect the head, neck, face or spinal cord. Injuries that involve shock, excessive bleeding, or bone fractures and breaks. The treatment of these type of injuries goes way beyond the relatively simple soft tissue injuries that I’m discussing here.
The First 72 Hours
While most people are well aware of the importance of applying the R.I.C.E. regimen to a sprain or strain in the first 48 to 72 hours, it’s after this that most people get stuck. Let’s start by having a look at what happens during those first 72 hours and then move onto what’s needed for a full recovery.
Without a doubt, the most effective, initial treatment for soft tissue injury is the R.I.C.E.R. regimen. This involves the application of:
- (R) rest;
- (I) ice;
- (C) compression;
- (E) elevation; and obtaining a
- (R) referral for appropriate medical treatment.
Where the R.I.C.E.R. regimen has been used immediately after the occurrence of an injury, it has been shown to significantly reduce recovery time. R.I.C.E.R. forms the first, and perhaps most important stage of injury rehabilitation, providing the early base for the complete recovery of injury.
The diagram below is a comparison of the same injury treated with the R.I.C.E.R. regimen and without. The top row of pictures show the effects of a soft tissue injury when the R.I.C.E.R. regimen is not used. While the bottom row of pictures show the effects of a soft tissue injury when the R.I.C.E.R. regimen is used.
The first diagram in the series shows a rupture in the soft tissue immediately following an injury. 24 hours later, when R.I.C.E.R. has not been used, there is a large amount of uncontrolled bleeding and swelling. However, in the bottom diagram, the application of rest, ice, compression and elevation has significantly reduced the amount of bleeding and swelling, and most importantly, scar tissue formation.
Picture courtesy of Dr. Barry Oakes, MB, BS, MD, F.A.S.M.F.
Senior lecturer in the department of Anatomy, Monash University, Victoria, Australia
How to apply ice
Crushed ice in a plastic bag is usually best. However, blocks of ice, commercial cold packs and bags of frozen peas will all do fine. Even cold water from a tap is better than nothing at all.
When using ice, be careful not to apply it directly to the skin. This can cause “ice burns” and further skin damage. Wrapping the ice in a damp towel generally provides the best protection for the skin.
How long, how often? This is the point where few people agree. Let me give you some figures to use, as a rough guide, and then I will give you some advice from personal experience. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours.
These figures are a good starting point, but remember they are only a guide. You must take into account that some people are more sensitive to cold than others are. Also, be aware that children and elderly people have a lower tolerance to ice and cold. Finally, people with circulatory problems are also more sensitive to ice. Remember to keep these things in mind when treating yourself or someone else with ice.
Personally, I recommend that people use their own judgment when applying ice to themselves. For some people, 20 minutes is too much. For others, especially well conditioned athletes, they can leave ice on for up to an hour at a time. The individual should make the decision as to how long the ice should stay on.
My personal recommendation is that people should apply ice for as long as it is comfortable. Obviously, there will be a slight discomfort from the cold, but as soon as pain or excessive discomfort is experienced, it is time to remove the ice. It is much better to apply ice for 3 to 5 minutes a couple of time an hour, than not at all.
During the first 72 hours after an injury, be sure to avoid any form of heat at the injury site. This includes heat lamps, heat creams, spas, Jacuzzi’s and saunas. Avoid all movement and massage of the injured area. Also, avoid excessive alcohol. All these things will increase the bleeding, swelling and pain of your injury. Avoid them at all costs.
To Stretch or not to Stretch
During this phase of the rehabilitation process NO STRETCHING should be used at all! This is not the time to start stretching. Concentrate on the R.I.C.E.R. regimen and avoid all stretching or any activity that puts stress on the injured area. Stretching during this early stage of the rehabilitation process will only cause more damage to the injured tissues. Avoid stretching during the first 72 hours. Click here for a more detailed article on how to use stretching for injury rehabilitation.
The Problem with scar tissue
When a muscle is torn, you would expect that the body would repair that tear with new muscle. In reality, this doesn’t happen. The tear, or rupture, is repaired with scar tissue. As you can see with the final diagram on the right hand side, when the R.I.C.E.R. regimen is used, this limits the formation of scar tissue.
Now this may not sound like a big deal, but if you have ever suffered a soft tissue injury, you’ll know how annoying it is to keep re-injuring that same old injury, over and over again. Untreated scar tissue is the major cause of re-injury, usually months after you thought that injury had fully healed.
Scar tissue is made from a very tough, inflexible fibrous material. This fibrous material binds itself to the damaged soft tissue fibers in an effort to draw the damaged fibers back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. In some cases it’s even possible to see and feel this bulky mass under the skin.
When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished, but flexibility of the tissue is also compromised. So what does this mean for the athlete?
- A shortening of the soft tissues, which results in a loss of flexibility.
- A weak spot forms within the soft tissues, which could easily result in further damage or re-injury.
- A loss of strength and power. For a muscle to attain full power it must be fully stretched before contraction. Both the shortening effect and weakening of the tissues means that a full stretch and optimum contraction is not possible.
How to get rid of scar tissue
So, how do we put the finishing touches on your recovery? How do we get rid of that annoying formation of scar tissue?
Firstly, you must keep active! Don’t listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity.
Light activity promotes blood circulation and also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system.
To complete your recovery and remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is commonly used by physical therapists (or physiotherapists), and it primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.
Physical Therapists accomplish this aim by using a number of treatments to stimulate the injured area. The most common methods used are ultrasound, TENS and heat.
Ultrasound uses high frequency sound waves to stimulate the affected area, while TENS (or Transcutaneous Electrical Nerve Stimulation) uses a light electrical pulse to stimulate the injured area. And heat, in the form of a ray lamp or hot water bottle, is also very effective in stimulating blood flow to the damaged tissues.
Secondly, to remove the unwanted scar tissue it is vital that you start a course of deep tissue sports massage. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that.
Either find someone who can massage the effected area for you, or if the injury is accessible, massage the damaged tissues yourself. Self massage has the advantage of knowing just how hard and deep you need to massage.
To start with, the area will be quite tender. Start with a light stroke and gradually increase the pressure until you’re able to use deep, firm strokes. The more you massage the effected area the harder and deeper you will be able to push.
Use deep, firm strokes, moving in the direction of the muscle fibers. Concentrate your effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue.
A few final points before finishing up. Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body.
Also, I recommend you purchase a special ointment to use for your massage called Rub-on-Relief. This special ointment is extremely effective in treating soft tissue injuries, like sprains, strains and tears. It includes all-natural ingredients, has zero side effects and best of all, it’s quite cheap. You can purchase this ointment from the link above.
You’re not done yet!
If you were to follow the advice so far, your injury would have healed to about 80% of its’ original capacity. You may even feel that your injury is fully recovered. Your treatment so far may have stopped the swelling and bleeding, it may have reduced the amount of scar tissue at the injury site and it may have even started to heal the soft tissues that were injured. But there is still one more important thing to do.
The last 20% can be the most crucial to your complete recovery. If you’ve ever suffered from a sporting injury in the past, you’ll know how annoying it is to think you’re recovered, and then out-of-the-blue, you’re injured again and back to where you started from. It can be one of the most frustrating and heart-breaking cycles an athlete, or anyone else for that matter, can go through.
What is Active Rehabilitation?
Most people refer to this phase of the recovery process as the active rehabilitation phase, because during this phase you will be responsible for the rehabilitation process. You will be doing the exercises and activities required to speed up your full recovery.
This phase of the injury rehabilitation process should only be implemented after the initial healing process has been completed.
The aim of this phase of your rehabilitation will be to regain all the fitness components that were lost during the injury process. Regaining your flexibility, strength, power, muscular endurance, balance, and co-ordination will be the primary focus.
Without this phase of the rehabilitation, there is no hope of completely and permanently making a full recovery from your injury. A quote from a great book called “Sporting injuries” by Peter Dornan & Richard Dunn will help to reinforce the value of active rehabilitation.
“The injury symptoms will permanently disappear only after the patient has undergone a very specific exercise program, deliberately designed to stretch and strengthen and regain all parameters of fitness of the damaged structure or structures. Further, it is suggested that when a specific stretching program is followed, thus more permanently reorganizing the scar fibers and allowing the circulation to become normal, the painful symptoms will disappear permanently.”
The first point to make clear is how important it is to keep active. Often, the advice from doctors and similar medical personnel will simply be; rest. This can be one of the worst things you can do. Without some form of activity the injured area will not receive the blood flow it requires for recovery. An active circulation will provide both the oxygen and nutrients needed for the injury to heal.
Any form of gentle activity not only promotes blood circulation, but it also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products that accumulate in the body following a serious injury. Activity is the only way to activate the lymphatic system.
Warning: Never do any activity that hurts the injured area. Of course you may feel some discomfort, but never push yourself to the point where you’re feeling pain. You’ve come a long way from first being injured; don’t take a step backwards now. Be very careful with any activity you do. Pain is the warning sign; don’t ignore it.
Now it’s time to make that injured area strong again. The main areas you’re going to be working on are your range of motion, stretching & strengthening, and co-ordination. Depending on your background, and what sport you’re involved in, these elements should be your first priority. As you start to regain your strength, flexibility and co-ordination, you can then start to work on the more specific areas of your chosen sport. Let’s start with range of motion.
1. Range of Motion Exercises
Regaining a full range of motion is the first priority in this phase of the rehabilitation process. A full range of motion is extremely important, as it lays the foundation for more intense and challenging exercises later in the active rehabilitation process.
As you work through the initial stages of recovery and your injury begins to heal, start to introduce some very gentle movements. First bending and straightening the injured are, then as you get more comfortable with this simple movement, start to incorporate some rotation exercises. Turn the injured area from side to side, and rotate clockwise and anti-clockwise.
When you feel comfortable with these range of motion exercises and can perform them relatively pain free, it’s time to move onto the next phase of the active rehabilitation process.
2. Strength Exercises
Now it’s time to add some intensity to the range of motion exercises. The aim here is to gradually re-introduce some strength back into the injured muscles, ligaments and tendons.
When attempting to increase the strength of the injured area, be sure to approach this in a gradual, systematic way of lightly over-loading the muscles and tendons. Be careful not to over-do this type of training. Patience is required.
The use of machine weights can be very effective here, as they provide a certain amount of stability to the joints and muscles as you perform your rehabilitation exercises.
Another effective and relatively safe way to start is to begin with isometric exercises. These are exercise where the injured area does not move, yet force is applied and the muscles and tendons are contracted.
For example: imagine sitting in a chair while facing a wall and then placing the ball of your foot against the wall. In this position you can push against the wall with your foot and at the same time keep your ankle joint from moving. The muscles contract but the ankle joint does not move. This is an isometric exercise.
3. Stretching Exercises
It’s also important at this stage to introduce some gentle stretching exercises. These will help to further increase your range of motion and prepare your injury for more strenuous activity to come.
Remember, while working on increasing the flexibility of the injured area, it’s also important to increase the flexibility of the muscle groups around the injured area. In the example above, these would include the calf muscles, and the anterior muscles of your shin.
4. Balance and Proprioception
This phase of the rehabilitation process is often overlooked and is one of the main reasons why old injuries keep re-occurring. When a soft tissue injury occurs, there is always a certain amount of damage to the nerves around the injured area. This, of course, leads to a lack of control of the muscles and tendons, and can also affect the stability of joint structures.
Without this information the muscles, tendons and ligaments are constantly second-guessing the position of the joints and limbs around the injured area. This lack of awareness about the position of the limbs (Proprioception) can lead to a re-occurrence of the same injury long after you thought it had completely healed.
Once you feel some strength returning to the injured area it’s time to incorporate some balancing drills and exercises. Balancing exercises are important to help re-train the damaged nerves around the injured area. Start with simple balancing exercises like walking along a straight line, or balancing on a beam. Progress to one-leg exercises like balancing on one foot, and then try the same exercises with your eyes closed.
When you’re comfortable with the above activities, try some of the more advanced exercises like wobble or rocker boards, Swiss balls, stability cushions and foam rollers.
5. Final Preparation
This last part of the rehabilitation process will aim to return your injury to a pre-injury state. By the end of this process the injured area should be as strong, if not stronger, than it was before the injury occurred.
This is the time to incorporate some dynamic or explosive exercises to really strengthen up the injured area and improve your proprioception. Start by working through all the exercises you did above, but with more intensity. For example, if you were using light isometric exercises to help strengthen your Achilles and calf muscles, start to apply more force, or start to use some weighted exercises.
From here, gradually incorporate some more intense exercises. Exercises that relate specifically to your chosen sport are a good place to start. Things like skill drills and training exercises are a great way to gauge your fitness level and the strength of the injured area.
To put the finishing touches on your recovery, I always like to do a few plyometric drills. Plyometric exercises are explosive exercises that both lengthen and contract a muscle at the same time. These are called eccentric muscle contractions and involve activities like jumping, hoping, skipping and bounding.
These activities are quite intense, so remember to always start off easy and gradually apply more and more force. Don’t get too excited and over-do-it, you’ve come too far to do something silly and re-injure yourself.
How to work around an injury
There will be times when you will still need to train while recovering from an injury. Here’s an example of how I re-structured my training while recovering from a recent injury…
I broke my toe a little while back; the long one next to my big toe on my right foot. I was pulling my boat up onto the trailer at a local boat ramp, and my foot slipped forward and my toe caught on something. It didn’t hurt much when I did it, but by the time I’d washed the boat down and put it away, my toe had turned a yellow-ee purple color and it was starting to throb.
I stuck some ice on it and sat on the couch with it propped up on a few pillows. There’s not much else you can do for a broken toe: I’ve broken my toes a few times in the past and the only advice I’ve ever got from a doctor is… strap it to the toe next to it.
I wasn’t too worried. I tend to heal quite quickly, and let’s face it; it’s only a toe. It wasn’t going to stop me from doing much… But it did stop me from doing one of my favorite pastimes; running.
So what do you do when an injury stops you doing the sport you love? Answer: You work around it.
As an “Ex” professional athlete, I’ve had my fair share of injuries, and you learn pretty quickly that you can’t do the same activity day in, day out. You need variety! You need to let your body rest from some activities and give it different activities to keep your conditioning up and work on areas that would normally be ignored.
So, what have I done to keep active and stay in shape while my toe heals? Quite a few things actually…
I like to swim, so I’ve added some deep water running to my usual swim training. I’ve also been meaning to do more core stability exercises, so I’m doing more of those. And I’ve added a few new upper body strength training workouts. And of course, I’ve added some extra flexibility training to work on a few tight spots that I’ve noticed recently.
About the Author: Brad Walker is often referred to as the "Stretch Coach" and has even been called the Stretching Guru. Magazines such as Runners World, Bicycling, Triathlete, Swimming & Fitness, and Triathlon Sports have all featured his work. Amazon (author page) has listed his books on five Best-Seller lists. Google cites over 100,000 references to him and his work on the internet. And satisfied customers from 122 countries have sent 1,000's of verified customer reviews. If you want to know about stretching, flexibility or sports injury management, Brad Walker is the go-to-guy.
Disclaimer: The health and fitness information presented on this website is intended as an educational resource and is not intended as a substitute for proper medical advice. Please consult your physician or physical therapist before performing any of the exercises described on this website, particularly if you are pregnant, elderly or have any chronic or recurring muscle or joint pain.