Healing Process
 Three Phases
 Inflammatory response
 Fibroblastic repair
 Maturation remodeling phase
Inflammatory response
 Begins immediately after injury
 Signs of inflammation
Redness (rubor)
Swelling (Tumor)
Tenderness (dolor)
Increase in temperature (Calor)
Loss of function (functio laesa)
Inflammation Response
 Very important to the healing process
 If does not accomplish what it is supposed to or does
not subside healing cant take place
 First 48 hours after injury
Inflammation response
 Chemical mediators
 Histamine- released from the injured mast causes
vasodilation and increased cell permeability
 Leukotrienes and prostaglandins cause margination
(leukocytes adhere to cell walls ) Also increase cell
permeability and exudate (accumulation of fluid that
penetrates through vessel walls into extravascular
Inflammation response
 Chemical Mediators continued
 Vasodilation and active hyperemia important brings
neutrophils (leukocytes)
 As swelling increases vascular and lymphatic flow
Inflammation response
 Vascular reaction- immediate response is
vasoconstriction causing local anemia in the area.
This increase causes leukocytes to slow down and
adhere to the injured cells
 Function of platelets- platelets normally don’t adhere
to vascular walls. However, injury exposes collagen
and platelets adhere to collagen
Inflammation response
 Formation of clot- thromboplastin to prothrombin to
thrombin to fibrinogen to insoluble fibrin clot.
 Begins around 12 hours after injury complete within
48 hours
Chronic Inflammation
 Occurs when the inflammatory response does not
respond sufficiently to eliminate the injuring agent
and restore tissue to its normal physiological state
 This low grade inflammation causes tissue damage
to connective tissue, prolonging healing and repair
Inflammation Response
Injury to cell
Chemical mediator liberate
Histamine, leukotrienes,
Vascular reaction
Vasoconstriction to Vasodilation to
Exudate create stasis
Platelets and leukocytes adhere to vascular wall
Clots formation
Inflammation response
Inflammation Response
 Treatment during this phase is RICE.
Treatment during the
inflamation phase
 Rest Ice- 20 mins per hour
 Compression- Ace wrap
 Elevations- above the level of the heart
Repair phase
 Regenerative activity occurs during this stage
 Fibroplasia- period of scar formation. Begins a few
days after injury any last 4-6 weeks.
 Granulation tissue breaks down the fibrin clot.
 Collagen- a strong fibrous protein found in
connective tissue
Repair phase
The normal sequence of events in the repair phase leads
to the formation of minimal scar tissue
Occasionally persistent inflammatory response will
cause fibroplasia and excessive fibrogensis that lead to
irreversible tissue damage
Maturation Remodeling
 Long term process
 Purpose of the phase is to realignment or remodeling
of collagen fibers that make up scar tissue according
to the tensile forces
 Ongoing breakdown and synthesis of collagen occur
with a steady increase in tensile strength
 Increased stress and strain realign collagen for
maximum efficiency
 Rarely as strong as the normal uninjured tissue
Maturation Remodeling
 Rarely as strong as the normal uninjuried tissue
 End of three weeks firm strong contracted
nonvascular scar exist
 Complete maturation phase may require several
years to be complete
Maturation Remodeling
 As the remodeling phase begins aggressive active
range of motion and strengthening exercises should
be incorporated
 Pain dictates the rate of progression
 If swelling increases need to decrease activity
Factors that impede
 Extent of injury
 Edema
 Hemorrhage
 Poor vascular supply
 Separation of tissue
 Muscle spasm
 Atrophy
•Humidity, Climate, oxygen
•Health, Age and Nutrition
•Hypertrophic scars
Soft tissue Healing
 Cartilage healing- poor lack of blood supply so no
 Ligament healing
first 72 hours loss of blood from damaged vessels.
during next 6 weeks new capillary growth begins
Initially scar is soft and viscous
Over next several months scar continues to mature.
Take as long as 12 months
 Limit immobilization
Soft tissue healing
 Muscle Healing- Least 6-8 weeks and considerable
amount of patience
 Tendon Healing- 2 weeks adheres to surrounding
tissue. 3 weeks tendon separates tensile strength is
not sufficient to permit a strong pull on the tendon
for 4-5 weeks.
 Nerve healing- can not regenerate once the nerve cell
dies. Peripheral nerves can heal be slow process
Soft tissue healing
 Antinflammatory drugs -NSAIDS- Nonstreroidal
antiinflammatory drug
 Therapeutic Modalities- Ultrasound, electrical
 Exercise Rehabiliation
 Cutaneous- sharp, bright and burning
 Deep somatic pain- pain in tendons, muscles, joints
 Visceral pain originates from internal organs
 Psychogenic pain- emotional causes
 Referred pain- occurs away for sight
 Myofascial pain- Trigger points
 Sclerotomic, Myotomic and dermatomical-
Pain Control
 Gate control theory- pain is blocked by gate
preventing message from getting to the brain.
 Gate control theory
Descending pathway
pain control
 Previous experiences, emotional influences and
sensory perception influence the transmission of
pain message and thus the perception of pain
Release of B endorphins
 Stimulate the release of opiate like chemical called
endorphin from the hypothalamus and anterior
Treating pain
 Therapeutic modalities, medications, massage,