When Am I Gonna Get Better?

By Justin Banks, PT, DPT, CSCS

The most common injuries seen in active people are tendonitis, muscle strains and ligament sprains. These could come from overuse, overstretching or overstraining situations. All of these are classified as connective tissue injuries and they all heal in the same way.

The acute inflammatory phase of healing happens first. This typically lasts for the first 7-10 days after an injury has occurred. During this time, the body sends inflammatory cells to the site of injury and removes damaged or impaired tissue. The result of this influx of cells is increased sensitivity to touch, stretch and activity of the impaired tissue. Redness and swelling may also occur. This reaction is beneficial from a standpoint of forcing the body to favor the area to prevent further injury. The clearing out of the area sets up for new tissue to be formed. However, the “clean out” is finished within 2-3 days at which point the benefits of this phase of healing stop. It is at this point where one should be icing, avoiding activities that recreate pain, and (if appropriate) taking anti-inflammatory medication such as ibuprofen.

Following the acute inflammatory phase of healing is the rebuilding phase. This typically lasts from day 11-21 following the injury. This is the time when scar tissue is laid down. Under a microscope, connective tissue such as muscle and ligaments has a linear appearance. It looks like what you see when you open a box of toothpicks, every fiber lined up nicely next to each other. Scar tissue has the appearance much like what would happen if you poured that box of toothpicks onto the floor and they scattered in every direction on top of each other. Scar tissue development happens this way because the body wants it done fast and it will sacrifice that linear orientation for speed of healing. At this time, the injury will start feeling better and it is quite tempting to return to full activity or “test it out.” It is not the best idea to jump back into full activity at this time. However, moderate activity that does not re-inflame the area (make it feel like it felt in the acute-inflammatory phase) is okay. Care should be taken during this phase to come back slowly and gradually. This is the time to transition from ice to heat and start stretching the area in an effort to promote a more linear healing of the new tissue.

Finally comes the remodeling phase. This lasts through the 42 day mark following the injury. This is the window of time where the newly formed scar tissue matures and is reoriented into the most ideal fashion to handle the demands of desired activity. Heating and stretching the tissue remains appropriate during this time. Massage therapy is also beneficial at this time if muscle tissue is involved. Strengthening should be performed in and around the injured area within the tolerance of the tissue. Again, care should be taken to not to get carried away with coming back too quickly. The newly formed tissue is at risk during this window and can be re-injured with too much stress. A good starting point would be 50% of the level of activity performed prior to injury whether one is measuring by duration of activity (volume), amount of workouts per week, or intensity. Once a 50% level of activity is established, using the 10% rule is a safe way to increase activity when this is desired. This means that one would have to keep track of their activity and increase their numbers measured in weekly increments.

What has been described above is the typical process that injured soft tissue (tendonitis, muscle strain or a ligament sprain) goes through on the way to recovery. There are things, however, that can alter or slow the healing process. Re-injury, or aggravating the tissue causes one to move backward on the continuum or even start the cycle completely over. Tobacco, alcohol, and steroid use prolongs the healing time. Also, there could be an underlying movement dysfunction, a muscle strength imbalance or tightness affecting the injury and its ability to perform the natural workload. If a soft tissue injury takes longer to heal than has been described above, one should be suspicious of an underlying problem and consider being evaluated by an appropriate professional.

One last thing to remember is that scar tissue is never 100% as strong as the tissue prior to injury. This means that injured areas are at risk to get hurt again. The risk can be reduced by taking care to continue with a stretching and strengthening program, even after the effects of the injury have stopped.

Justin Banks PT, DPT, CSCS is a Doctor of Physical Therapy practicing at Kentucky Orthopedic Rehab Team's (KORT) Springhurst location. He is also a Level 1 Certified USA Track and Field coach. He ran track and cross-country at the University of Louisville from 2000-2002 and continues to compete for the Fleet Feet Louisville/Brooks Elite Development Club.