tissue tensile strength

tissue overload

maximum tissue loading

remodelling phase proliferation phase

acute phase time

Figure 2: Hypothetical model of the stages of healing in relation to the tensile strength of the healing tissue. For healing to progress, loading must remain within the tensile capabilities of the tissue

exercises during the acute phase. The damaged tissue is fragile: excessive pressure or tension applied during the acute phase may disrupt the fibrin and exacerbate the inflammatory response (Fig. 2). Massage can usually commence approximately 24–48 hours post- injury but not directly over the injury

Figure 3: Massage sequence of “down-the-line” lymphatic drainage.

(a) Drainage of the whole upper extremity and its division into compartments: A, deltoid-scapula; B, upper arm; C, forearm; D, hand.

(b) Sequence of drainage: starting at A, then B–A, C–B–A and finally D–C–B–A.

Tertiary drainage starts at the distal tissue and continues all areas of drainage

distal tissue

Secondary drainage commences at the areas of damage and includes the proximinal area

odema

Initial drainage starts proximally to the damaged area, thus creating a reservoir

proximal tissue DIRECTION OF DRAINAGE

Figure 4: Abnormal cross-link adhesion restricting movement between two collagen fibres

D C B A

site. The affected limb can be elevated to assist with drainage via gravity. The compressive force of massage should be deep enough to deform the muscle in order to affect flow through it. Massage should involve “down- the-line” sequence lymphatic drainage starting proximally, for example with the shoulder (Fig. 3) (24). Evidence clearly demonstrates that enhanced adherence achieved through patient education is vital in enhancing recovery (25,26). Patient education can be enhanced by a simple SWOT analysis to highlight opportunities and threats (27). Water immersion has been shown to reduce peripheral oedema due to the hydrostatic pressure and resulting changes in circulation (28) and therefore is an excellent intervention during the acute and subacute stages.

2) Subacute phase (proliferation) The subacute or proliferation phase is essentially when new generic scar tissue (type III collagen) is laid down and represents the period of the greatest increase in tensile strength (see Fig. 2). Proliferation commences after 2–3 days, reaching a peak at 2–3 weeks post-injury. There are two fundamental processes involved:

fibroplasia (formation of collagen) and angiogenesis (formation of new local blood vessels). Clinically, the subacute phase is when the heat, redness, swelling and pain levels reduce. The range of joint movement improves, skin discolouration and bruising may become evident, and the patient reports improvements. Although a short period of immobilisation following injury is necessary, early controlled movement is essential for decreased healing time, increased vascular ingrowth, and quicker regeneration of scar tissue (29), with stronger mobile tissue (30). Conversely, prolonged immobilisation leads to deleterious tissue effects such as random deposition of collagen, excessive cross-link and adhesion formation (Fig. 4) (24). Adhesions resist normal movement by preventing normal gliding between fibres and adjacent surfaces. During the early and intermediate subacute phase, new tissue is fragile and easily interrupted; consequently, mobilisation too early or too intensively may re- rupture the injured tissue (see Fig. 2) (19). Also, the newly laid collagen fibres are randomly oriented, which can hinder function (31).

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sportEX dynamics 2009;22(Oct):12-17