Injuries and RehabTell us where it hurts! Do a quick search before asking about your shoulder injury to make sure your question hasn't already been answered (about 50 times), and read the sticky post first.
You've heard it. I've heard it. You've used it. I try not to. The term "scar tissue" gets thrown around in musculoskeletal health professions like it's going out of style. Yet, if you ask (at least in my experience) any of these people to define the term "scar tissue" no one is able to produce a satisfactory answer. "What does this machine do?" "It breaks down scar tissue." "What does this technique do?" "It breaks down scar tissue."
My argument for this debate is that, with the exception of muscle tissue and fibrin clots, "scar tissue" does not exist. If you look at the structure of a "scar", its composition is relatively the same as the surrounding tissue. Is it the same? No. On a structural level, it may not be as strong as the surrounding tissue, depending on the molecules in the repair zone. However, that structure may never be the same again, and yet produce no functional impact or pain. And as far as diagnosis is concerned--no pain, no dysfunction=no disease, regardless of what that site might look like under the microscope.
So my question is what exactly does, "breaking down scar tissue" involve? I've heard many explanations, from "encouraging collagen to remodel properly" to "breaking down the collagen fibres that are laid down improperly", none of which actually makes any sense. Collagen is remodelled on a constant basis, in healthy and repairing tissue. It remodels according to chronic stress and parallel to the direction of stress. It is impossible to clinically determine whether collagen is "disorganized" or not. So how on earth does one justify the use of "breaking down scar tissue" to "remodel collagen" when it's impossible to know if that collagen needs to be remodelled or not?
Now, I'm perfectly fine with people saying, "We don't know why it works, it just does." provided there's evidence to back that up. Heck 80% of medicine is "We don't know why it works, it just does." But I, for one, having to talk to people everyday about their therapist who says they should have such-and-such done because it will "break down scar tissue", want to know what, exactly, this phrase actually means.
I just want to chime in before Bill rolls in with his more technical follow-up... I don't think that when they use the term "scar tissue" when referring to muscle that it technically means that it has the same properties of a real scar. I think that they are referring to "adhesions" in the muscle that occur. Here is when my knowledge drops off though. What exactly those adhesions are I do not know, but I think that they just use the term scar metaphorically.
The last paragraph of your post really made me laugh though, because that is why I have "active release therapy" done on me... to break up these supposed adhesions to help with chronic knee and shoulder problems. Why do I do it? Can I explain it in technical terms? Nah, but it sure seems to work. [img]smile.gif[/img]
Good post...most of what we say or do IS based on theory, conjecture, educated guesses, and bullshit (hopefully it’s pretty good bullshit, meaning it works).
It’s commonplace to discuss the repaired area as a scar or scar tissue to differentiate it from the non-injured area, especially during healing stages. The area that fills in a cut on the skin is a scar. What’s the difference in any other tissue? Tear a muscle. It heals with the same mechanism as the scar on your skin. There are also textural differences that separate the “good” tissues from “bad”.
(My aside…It kinda bugs me at ART courses when the only talk about effects to adhesions/scar tissues and ignore the neurologic effects of pressure, tension, and movement in the results that are shown. This has to account for some of the immediate improvements in function we see with many soft-tissue and manual techniques.)
That being said here’s a thought or two…
Are we breaking up the collagen fibers? Most likely not (unless they’re really young). But we can affect the extracellular area which affects the crosslinking of collagen fibers between themselves and other tissues, thus altering the visoelastic properties of the connective tissue and movement of the surrounding tissues. The crosslinks are sensitive to temperature, chemical changes, and tension (why is a properly cooked filet mignon tender? Low collagen content and the heat destroys crosslinks.) This can in effect restore movement between tissues, improve restricted blood flow, and reduce tension or chemical irritation to nerves.
The process can be done with exercise, manual techniques, application of heat/cold, combination of all, etc.
True enough, and perhaps in muscle tissue, the "low-collagen" argument works--though if you tear a muscle, the scar isn't muscle tissue at all (which is why I excluded muscle tissue from my above note).
But in the case of connective tissues, in particular tendons and ligaments, the collagen content is relatively higher. And is it particularly in the tendon pain area that this terminiology is used.
The fact of the matter is that no one really knows what exactly is the source of pain in individuals affected by overuse-related tendon pain--though there are clues pointing perhaps to something promising that may actually answer this question in the near future. But, "breaking down scar tissue", "increasing blood flow", "mobilizing soft tissue", "removing adhesions" are all characteristics that can't be measured through clinical means (i.e. without biopsy and microscopes). And despite the textural differences between the two regions, if there's no pain and no dysfunction, then diagnostically, there's no disease, regardless of how different the two areas may appear to be.
We know certain therapies work when they are put to the test in randomized control studies. We may not know why, but a collection of strong studies of this type is a good indicator that these therapies work. Are they affecting extracellular molecules? I don't think we actually know that. And while this answer is seldom satisfying to clients, I think it is much more "ethical" (if I can be a bit judgemental) to present these therapies as such until such a time when we do know.
I often get questioned about treatments especially when they work quickly, like ART. More frequently than not (depending on my mood) when someone asks why it works, I say "I don't know exactly...but it could be [long explanation]". Then my patient either nods in agreement and says "Oh" or falls asleep from boredom.
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