The Stages of Tissue Healing

There are 4 primary stages of healing which occur flowing injury;

  • Bleeding (hours)
  • Inflammation (0-72 hours)
  • Proliferation (2 days – 3 weeks)
  • Remodelling (3 weeks – up to 6 months)

*In reality each of the phases overlaps, and can act as a stimulant/inhibitor for the following phase

Bleeding Phase

  • Occurs following trauma
  • Last no longer than a few hours in most circumstances
  • Type of injury/type of tissue will determine characteristics e.g. if tissue is well-vascularised or not

Inflammatory Phase

  • Essential initial component of tissue repair
  • Recognised by heat, swelling, redness and pain
  • It is undesirable when caused by other factors such as repeated mechanical irritation or repetitive trauma
  • Onset is within a few hours of injury, and maximal reaction is 1-3 days
  • Can take a few weeks to fully resolve
  • Onset and resolution and quicker in more vascular tissues

Proliferation Phase

  • Refers to the generation of the ‘repair material’ – usually collagen (referred to as scar tissue)
  • Onset is 24-48 hours, but peak activity is 2-3 weeks post-injury
  • The more vascular the tissue, the shorted these times
  • The process typically continues for 4-6 months after its peak

Remodelling Phase

  • Essential for the organisation of scar tissue fibres to form a functional scar
  • Functional = able to behave in same way as ‘parent tissue’
  • Previously thought to start from 2-3 weeks post-injury, recent evidence suggests that it starts within the first week post-injury
  • Can continue for up to 1 year post-injury

*Therapies must be aimed at facilitating each stage if required – not changing the process

*Bear in mind most clinical presentations are due to impaired/abnormal healing following injury

The healingprocess following muscle injury;

Some phases overlap, dependable on the individual response to healing and the type of injury. Not every patient undergoes all phases to achieve a full rehabilitation.

1. Acute Phase (1-7 days)

  • RICE method can be applied
  • Aim is to minimise inflammation and pain
  • Flexion/extension exercise can be utilised but must be pain free (to avoid re-injury)

2. Subacute Phase (3 days – 3 weeks)

  • Inflammation is reducing
  • Muscle action is important to prevent atrophy
  • When patient has FROM without pain, concentric strength exercises can commence
  • If pain occurs, exercise intensity must be reduced

3. Remodelling Phase (1-6 weeks)

  • Stretching exercises can be used to prevent a loss of flexibility
  • Eccentric strengthening exercises can be carried out
  • These must be pain-free as if regeneration has not reached a peak, re-injury is likely

4. Functional Phase (2 weeks – 6 months)

  • Aim is to return to pre-injury activities
  • All components of movement need to be considered; strength, flexibility, endurance, proprioception etc.
  • Exercises should focus on what is relevant to the patient
  • Psychological issues should always be considered

Rehabilitation Protocol Following Meniscus Repair

General considerations

  • Weight-bearing as tolerated
  • Use crutches if necessary
  • Regular assessment of gait to avoid compensatory patterns
  • No resisted leg extension machines (isotonic or isokinetic)
  • No high impact or cutting/twisting activities for at least 4 months post-op
  • Driving is permitted once leg is strong and coordinated to react safely to avoid an accident. Driving is often resumed after the first week or two and when pain medications are no longer needed.

During the first 4 weeks

Twice per day: without brace, allowgravity only to bend knee back as tolerated but no more than 90° for a good kneestretch without increase in pain. Relax knee and stretch for 60 seconds

Week 1 (inflammatory phase):

  • Regular ice and elevation. Aim for 5x per day, 15 minutes each time
  • Cold/compression therapy as instructed
  • Aquatic exercise once surgical wounds are healed(8-10 days)
  • Soft tissue treatments for oedema/pain control and to posterior musculature, patella,and incisions.
  • Knee extension range of motion should be full

Exercises:

  • Quad-sets - 10 sec. holds every 30 minutes
  • Straight leg raise exercises (lying, seated, and standing): quadriceps/adduction/abduction/gluteal sets
  • Ankle pumpsthroughout the day
  • Well-leg stationary cycling
  • Upper body conditioning and core strengthening

Weeks 2-4 (sub-acute/proliferation phase):

  • Continue upper body/core strengthening (*all exercise must pain-free)
  • Continue with pain control, range of motion, soft tissue treatments, andproprioception exercises.
  • Non-weightbearing aerobic exercises (i.e. unilateral cycling, swimming)
  • Weight-bearing as per surgeon guidelines
  • Gait training 5-20 minutes during this phase using hydro treadmill (chest level to begin)
  • Week 2 approx 50% WB (treadmill speed 3-3.5mph) *50% = hip level at low speeds
  • Week 3 approx 75% WB (treadmill speed approx. 4mph)
  • In particular avoid twisting/deep squatting/stooping
  • Mini/wall squats ok if tolerated (less than 450)

Weeks 4-6 (remodelling phase – up to 1 year):

  • Aim for full WB by week 4
  • Stretching, exercises and manual treatments to improve ROM (especiallyflexion)
  • Incorporate functional exercises (i.e. partial squats, calf raises, mini-step-ups,proprioception)
  • Stationary bike and progressing to road cycling as tolerated
  • Slow walking on land treadmill for gait training
  • Week 4 jogging (e.g 6 kph at chest level)
  • Week 5 jogging at wait level
  • Week 6 add resistance jets

Weeks 6-8:

  • Increase the intensity of functional exercises (i.e. cautiously increase depth ofclosed-chain exercises,Shuttle/leg press). Do not overload closed or open-chain exercises
  • Progression to walking without a limp and flexion range of motionshould be at 80%
  • Exercises include lateral step-ups, squats (60-700), leg press (70-00)
  • Gradually increase speeds on hydro treadmill, using chest level initially, then waist level

Weeks 8-12:

  • Introduce more progressive closed chain and agility leg exercises
  • Knee flexion range of motion should be equal to other knee
  • Exercises include;
  • Light hamstring curls
  • Toe-calf raises
  • Side-step-ups
  • Theraband resisted side-stepping
  • Lateral stepping

Weeks 12-16:

  • Low-impact activities until 16 weeks
  • Begin running – straight lines/soft surface initially
  • Deep squatting
  • Front lunges
  • Increase the intensity of strength and functional training for gradual return toactivities

5 months

  • Pivoting/cutting and agility work
  • Sport-specific drills (bowling/fielding)

NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.