The following concept map represents the repair phase for a 20-year old baseball pitcher
with a Type II SLAP lesion. A Type II SLAP lesion occurs when the superior part of the labrum
is damaged and involves the detachment of the biceps insertion.1 A SLAP lesion usually results
from the high eccentric activity of the biceps muscle during the deceleration and follow through
phase of throwing.1 The repair, or proliferative, phase is the second part of the healing process
and can last from 3 days to 3 weeks. The main events of the repair phase include lymphatic
drainage, capillary budding, collagenization and construction of the scar tissue.2 Electrotherapy,
exercise, ultrasound and massage can all facilitate these events to optimize the healing process.
Electrotherapy can be used in the repair phase as a safe and effective way of managing
pain.3 Electrotherapy decreases pain through the gate control theory by stimulating A-beta
sensory nerves which stimulate the substantia gelatinosa at the dorsal horn of the spinal cord and
decrease the number of painful stimuli making it up to the brain stem and back down to the
effected tissue.3 By reducing pain, exercise can be performed to increase range of motion and
functional performance and decrease joint stiffness.4 Electrotherapy can also be used to prevent
and retard disuse atrophy, increase local blood circulation and re-educate muscle.3 A high
enough frequency can cause a muscle contraction that, when used during the early repair phase,
can prevent atrophy.3 For the shoulder, an IFC treatment should be used as it is able to cover a
large area and penetrate deeply.3 For pain control, settings should include a beat frequency of 90130 pps and a pulse width of <100 µsec for 20 minutes.4 For atrophy reduction, settings should
include a beat frequency of 50-85 pps, a duty factor of 5 sec on/5 sec off and the patient should
be encouraged to perform 25 percent of a maximal voluntary isometric contraction.5
Exercise is important in the construction of the scar tissue. Collagen fibers are first laid
down in a haphazard arrangement leaving the scar weak.2 The scar tissue can gain strength
through moderate stress.5 As a body part moves, the collagen fibers align along the lines of
tensile force and increase in number and size.5 This is very important to the formation of the scar
because as the fibers rearrange into a parallel formation, the scar becomes stronger and the edges
of the wound are better kept together.2 Exercise also stimulates circulation, increasing oxygen
and nutrient delivery to the healing tissue, which increases fibroblast activity and
collagenization.5 The right amount of exercise is important, as too little will not provide the scar
tissue with adequate direction, and too vigorous of exercise can tear an immature scar.5
Appropriate stresses include active range of motion and strengthening exercises like external
rotation, internal rotation, lateral raises and bicep curls.2
Activity during this phase also promotes lymphatic drainage and therefore the reduction
of effusion. Macrophages drain away liquefied cellular remains through phagocytosis in the
lymphatic system.2 This drainage is important because the more free protein that remains in the
joint, the bigger the scar will be that develops.5 The lymphatic system is passive because vessel
walls do not contract and there is no pressure to cause fluid to move through it. Thus, external
forces such as muscle contractions help to squeeze the lymph vessels and force their contents
upstream.5
Ultrasound, another appropriate treatment during the repair phase, produces vibrations
that are created by electrical energy that is converted to acoustic energy. Ultrasound transmits
waves through molecular collision and vibration and results in cavitation and microstreaming.6
Cavitation occurs when gas-filled bubbles expand and compress due to the pressure changes in
the tissue fluids and results in increased flow in the surrounding fluid.6 The movement of the
bubbles increases macrophage activity, which stimulates fibroblasts to produce collagen, and
assists in the removal of dead cellular debris.5 Acoustic microstreaming is the unidirectional
movement of fluids along the cell membranes as a result of mechanical pressure changes within
the ultrasound field. This movement may stimulate fibroblast repair, collagen synthesis, and
tissue regeneration.6 The movement of the ultrasound head promotes the alignment of collagen
fibers to increase tensile strengths.
Ultrasound heats up the tissue to increase blood flow, increase extensibility of collagen
fibers, provide analgesia to local tissues, increase fibroblast mobility, and promote angiogenesis.7
In order to see these thermal benefits, the tissue must be heated to 40-45°C for at least five
minutes.8 Settings for an ultrasound treatment on the shoulder should include a duty factor of
100% at 3MHZ for 10 minutes.7 To optimize treatment by decreasing resistance at the surface, a
150º hot pack can be placed on the shoulder for 20 min before the ultrasound treatment.5
Massage is another tool that can facilitate the events of the repair phase. An effleurage
massage will activate the lymphatic system and promote drainage of cellular debris.5 The
movement of the strokes can aid in the alignment of collagen fibers to increase tensile strength.5
The mechanical manipulation during massage will increase blood flow, increasing oxygen and
nutrient delivery, fibroblast activity and collagenization.5 Massage will also decrease pain by
stimulating A-beta sensory fibers and activating the gate control theory.5
As part of the healing process, the repair phase includes lymphatic drainage, capillary
budding, collagenization, and scar formation. Exercise, electrotherapy, ultrasound and massage
are all treatment choices that will facilitate the events taking place in this phase and aid the
athlete in their recovery.
References
1. Mihata T, McGarry MH, Tibone JE, et al. Biomechanical Assessment of Type II Superior
Labral Anterior-Posterior (SLAP) Lesions Associated With Anterior Shoulder Capsular Laxity
as Seen in Throwers. American Journal of Sports Medicine. 2008;36(8):1604-1610.
2. Herzog. The Body’s Response to Injury. In: Cummings N. Perspectives in Athletic Training.
Mosby; 2008: 48-64
3. Tiktinsky R, Chen L, Narayan P. Electrotherapy: Yesterday, Today and Tomorrow.
Haemophilia. Jul2010 Supplement 5;16:126-131.
4. Dolan MG, Mendel FC. Clinical Application of Electrotherapy. Athletic Therapy Today.
2004;9(5):11-16.
5. Knight and Draper. Therapeutic Modalities. Baltimore, MD: Lippincott Williams & Wilkins, a
Wolters Kluwer business; 2008.
6. Baker KG, Robertson VJ, Duck FA. A Review of Therapeutic Ultrasound: Biophysical
Effects. Physical Therapy. 2001;81(7):1351 -1358.
7. Speed CA. Therapeutic ultrasound in soft tissue lesions. Rheumatology. 2001;40(12):1331 1336.
8. Draper DO, Edvalson CG, Knight KL, Eggett D, Shurtz J. Temperature Increases in the
Human Achilles Tendon During Ultrasound Treatments With Commercial Ultrasound Gel and
Full-Thickness and Half-Thickness Gel Pads. Journal of Athletic Training. Aug2010;45(4):333337.