Scar-Tissue Massage Research

This technique effectively reduces adhesions in the scar-tissue matrix resulting in accelerated return to full muscle function and freer range of motion. Research on wound healing supports the efficacy of scar-tissue massage and points toward the benefits of the inclusion of this technique in post-injury and post-surgical situations.

Scar-tissue formation, while absolutely necessary to the healing process, can be a significant impediment to the recovery and rehabilitation of injured muscle and connective tissue. Effective scar-tissue massage can speed up the time it takes the body to regain pre-injury or -surgery range of motion not otherwise attainable. Scar-tissue massage is also gaining recognition as an asset in reducing health-care costs[1].
Scar tissue can inhibit range of motion by adhering connective tissue of the wounded and adjacent structures together. This often affects associated joints and presents a formidable barrier to attaining comfortable body function and useful range of motion. Circulation problems can be caused by reflexive muscle tightness in the wounded area. This often becomes chronic, and the resulting reduction in movement interferes with blood circulation allowing waste to become trapped in the dense collagen network, blocking out nutrients. Add to this the adhesion and circulation problems in referred areas due to the pain reflex response, and scar tissue can indeed be considered a significant clinical problem. Research supports the use of scar tissue massage in resolving these functional problems.
“Analysis of various disorders resulting from abnormal deposition of collagn indicates that it is not the volume or amount of collage that accumulates in the tissue lesion, but rather the physical properties (maturation, polymerization) of the collagenous matrix that are responsible for the dysfunction of the affected tissue organ,” write M. Chvapil and C.F. Koopman. “Once collagen is stabilized, it is more resistant to degradation by tissue collagenases. The dense, rigid scar of mature collagen binds less water.” [2] When collagen binds less water it is more dense and thick, therefore the movement and migration of collagenase to and through the tissue is impeded.
Newer scars are more malleable and more easily affected by scar tissue massage, although any scar can be worked on for greater function. Optimally, best results come from beginning work on scar tissue eight to sixteen days after injury or surgery, at which point the scar is in the maturation/remodeling phase.
Inhibition of free, or at least reasonably functional, range of motion is a particularly insidious problem with scar tissue. To have full range of motion the muscles must be able to slide in relation to each other in order to be independent in their motion. Scarred muscles adhere to and pull adjacent connective tissue and muscle with them when they contract or lengthen. Thus one of the functions of connective tissue, to provide a sliding surface for the muscles, is inhibited. This function is apparent in the separation of muscles by intramuscular septa and into fascicles (fiber bundles). Since every muscle fiber is surrounded by connective tissue, conceivably any motor unit could need to slide in relation to adjacent motor units for dexterity and graceful movement.
Scar tissue can bind muscle and connective tissue together so that they cannot move independently but must pull on each other when muscles move. If the injury or surgical cut is deep, scar tissue can bind many layers of muscle and connective tissue causing varying degrees of limited movement and pain. A physiological problem connected with scar tissue is that the collagen fiber network is reticular in orientation, meaning it goes in all directions and so has limited range of motion in any one direction. Consequently, the surrounding area’s flexibility and circulation are affected. If the collagen network is large and extensive, functional movement will be decreased. The advantage of treating scar tissue is that no matter how thick and tough it is, it maintains some pliability. Collagenase is always present in connective tissue. All scars can be loosened to some degree, and usually to a great degree. Scar tissue massage allows the scar’s collagen fibers to increase movement in a greater and more comfortable range.

In many cases, full use of areas of the body, especially limbs, can be impeded by nerves and muscles bound up by the fibers of scar tissue. Scar tissue massage is a simple and straightforward solution to achieving freer movement.

Scar tissue is connective tissue, and so it has the ability to arrange its fibers in a variety of ways in response to the pressure and movement it is under. When connective tissue is stretched, like elastic its fibers recoil to their original state. However, the fibers incorporate some of the stretch, lengthening the fiber net. If the stretch is applied slowly, steadily and repetitively, the increase in the elastic quality can be effectively controlled. “The permanent changes result from breaking intermolecular and intramolecular bonds between collagen molecules, fibers, and cross links,” write A.J. Grodin and R.I. Cantu. [4]
“All connective tissue seeks metabolic homeostasis – the tendency of chemical reactions involved in cellular metabolism to occur in a manner that leads most efficiently to stability of the cells’ metabolism – equal to the outside stresses applied to it. Carefully controlled stresses may positively change the metabolic and physical homeostasis of the tissue. For example, collaen production is less haphazard, more organized and laid down in a quality and direction more suited to optimal tissue function.” [5]
It is evident that in many cases full use of areas of the body, especially limbs, can be impeded by nerves and muscles bound up by the fibers of scar tissue. Scar tissue massage is a simple and straightforward solution to achieve freer movement. But like most tissue injuries, every scar carries its own special circumstances and skilled, individualized adaptation of technique is required. Effectively worked, the reticular fibrous network of scar tissue can be coaxed into functional movement.

Case Histories
The following two client case histories show the benefits of scar tissue massage.
A 42 year-old lawyer, who plays soccer on weekends, tears an Achilles tendon completely in half about three inches above the heel. Five days after surgery he began receiving our scar tissue massage. Since the wound was so fresh, the massage began with gently moving the skin over the underlying tissue to develop independence of the superficial fascia. As the skin became free of the repaired tendon, the massage went slowly deeper into the underlying layers. The goal of the deeper work was to feel for the integrity of the collagen fiber network, and continue to influence the scar fibers in a longitudinal orientation. Also, getting the Achilles tendon and its tendon sheath independent of each other and the structures deep to them were a subsequent goal. This protocol continued twice weekly for four weeks, for approximately twenty minutes duration. The rest of the hour massage addressed the sacro-iliac joints, neck and shoulders.
At that point the tendon could be stretched into almost full range of motion. Massage treatments were changed to once a week, slowly increasing independence in the tendon sheath and surrounding connective tissue. After three months the client resumed jogging, and at five and a half months post-injury the client was playing soccer at full speed, cutting and pivoting without holding back. The client’s post-operative prognosis was nine to twelve months to regain full functional use of the Achilles tendon excluding participation in sports. This occurred four years ago. Today the client remains active in sports and has had no Achilles tendon problems since.
The second case involves a 52 year-old woman who fell on Thanksgiving Day, 1996. The client fell forward, breaking her fall with her hands, and broke bones in both her forearms, requiring the radius to be pinned twice with a rod inserted. She had two surgeries ten days apart. She wore casts for two months and had 16 weeks of physical therapy. The client stopped PT at that point due to lack of insurance coverage.
Upon completion of physical therapy, the client could not close her fist, could not drive a car, and could not sleep through the night because of the pain. Even light pressure or movement on her shoulders was extremely uncomfortable. Pre-treatment assessment for massage revealed permeating scar tissue networks throughout the houlder girdle, rib cage, neck, and left forearm.
Her massage program began with slowly and gently moving the shoulder girdles, assessing for areas of more movement and independence between shoulders and rib cage (freedom of movement of the rib cage is crucial for sustained change in the range of motion for the shoulders arms and neck). After two scar tissue massage sessions, the client reported her first full night’s sleep since her fall. Treatments began in April 1997 and stopped in February 1998. There were numerous lapses in treatment due to financial constraints. In all, the client had 26 treatments of 45 minutes each. Currently, the client reports less pain, the ability to drive a car and sleep through the night, full range of motion in her left hand, and increased power in her grasp. The client returned to work Jan. 12, 1998. the remaining scar tissue in her left forearm is extensive due the fact that one pin inserted during surgery had to be removed and another reinserted. A significant amount of tissue is bound up in scar tissue in that area, which would require further sessions to release. At the same time, the client has enough integration of scar tissue into her movement to be fully functional in her work and everyday life. The remaining symptom is mild/moderate pain in her left wrist and forearm with certain movements.
These two cases required different uses of the scar tissue massage techniques. The pressure, movement, and rate at which tissue was manipulated, and the levels of movement explored, were quite varied. The application of individualized techniques is of primary importance to the effectiveness of this (and, truly, all) kind of massage.

On Collagen
My personal experience indicates that moving the scar-adhered area along the lines of the fascial planes induces the scar-modeling mechanisms to organize the scar tissue along those lines of movement. This observation is supported by H.P. Ehrlich and T.M. Krummel in an article in Wound Repair and Regeneration.
“The arrangement of collagen fibers is by the resident cells, but they are influenced by the chemical composition of the collagen in terms of quantity and quality, as well as the physical forces generated at the healing site as a consequence of its anatomical location.”[6]
Scar tissue massage works by applying controlled physical forces to the healing site. Effective scar tissue massage also normalizes and balances the chemical composition of the connective tissue matrix and interstitial fluid, and simultaneously and consequently improves the function of muscle, connective tissue and nerves.
“The roles of the intra-molecular and extra-molecular contractures in restricting joint motion following prolonged immobilization were studied by the manipulation of previously immobilized rats. The extra-articular pericapsular and the capsular structures resisted most motion. Intra-articularly, manipulation tore the proliferative connective tissue in a plane different from the original joint cleft. The new cleft was lined on either side by fibro-fatty tissue that, with time, came to resemble a synovial membrane (the membrane lining the capsule of a joint),” write W.F. Enneking and M. Horowitz. “The adhesions not disrupted by the manipulation were not affected by the resumption of motion.” [7] The scar tissue matrix, and indeed all connective tissue, responds to pressure and movement. In their absence, the matrix will remain to its current state: tough fibrous connective tissue.
Massage to the scar increases fluid independent movement of the matrix and adjacent tissue, improves muscle function through increased circulation of nutrients and removal of metabolites, and increases range of motion by influencing the effectiveness of the way the wound healing mechanisms remodel the scar. The less movement the connective tissue has, the thicker and denser it becomes, and the pain associated with scar tissue problems usually discourages movement. A 1972 study of knee immobilization reported that, soon after movement resumes, the connective tissue at the site of movement responds by developing a synovial membrane, which is the variation of connective tissue most conducive to movement [8]. Scar tissue massage uses the inherent responsiveness of connective tissue to control scar tissue remodeling. Further, Ehrlich and
Krummel’s work suggests that manipulating the scar changes the nature of the scar’s anatomical construction from immobility toward synovial quality of independence.
“Although soluble collagen can self-polymerize into filamentous fibrils under physiologic conditions (in this case, those in the wound healing process), the organization of these fibrils requires cellular intervention,” the study concludes. “The cellular organization of collagen fibers is important in terms of scar volume, stability and strength… Although collagen covalent cross-links have been shown to correlate with increasing wound-breaking strength (the amount of physical stress the scar tissue matrix can withstand before tearing itself), the amount of collagen deposited, as well as its degree of organization (the alignment of the collagen fibers in the scar tissue matrix, referring in particular to how they function: how much pressure they can withstand vis-a-vis how much movement they allow) may be of greater importance.” [9]
The response of the local fibroblasts is predicated on local tissue chemistry and on the pressures and movements those fibroblasts encounter. My experience indicates that the chemistry and and tissue tension due to local muscle tone can be effectively influenced and altered by scar tissue massage techniques. Scar tissue massage applies movement and pressure through the fascial planes in the surrounding tissue, feeding that pattern into the scar tissue matrix, thereby influencing the fibers’ organization.
The research done by Pins et al and Steffensen et al further supports the relevance and importance of scar tissue massage. They confirmed something that scar tissue massage’s effectiveness suggested: collagenase migrates to movement.[10] That may be the number one anatomical and physiological factor explaining why scar tissue massage works so well. I have come to describe scar tissue massage in its shortest terms as the control of collagenase migration. In fresh scar tissue (less than three months old), collagenase is present in the scar tissue area in great abundance. As the scar tissue matrix ages, the collagenase concentration diminishes, although it is available to all connective tissue always. Middle age scar tissue (approximately 3 months to a year) takes more time to remodel than fresh, and old scar tissue (more than a year) can be tough and take very firm pressure to mobilize. All scar tissue adhesions can be improved no matter how though and resistant. With fresh scar tissue, full range of motion can be virtually guaranteed.

Footnotes

Witte, M.B.; Barbul, A. “General Principles of Wound Healing”, 1997, The Surgical Clinics of North America, 77, (3), pp. 509-528.

2. Chvapil, M.; Koopman, C.F. “Scar Formation:Physiology and Pathological States” 1984, The Otolaryngologic Clinica of North America, 17, (2), pp. 267-8.

Witte, M.B.; Barbul A., p.516

4. Grodin A. J.; Cantu R. “Myofascial Manipulation Theory and Clinical Application, 1992; Aspen Series in Physical Therapy, p.31

Ibib, p.34

Ehrlich, H.P.; Krummel, T.M. “Regulation of Wound Healing from a Connective Tissue Perspective”, 1996, Wound Repair and Regeneration, 4, (2), p.204.

Enneking, W.F.; Horowitz, M. “The Intra-Articular Effects of Immobilization on the Human Knee,” 1972, Journal of Bone and Joint Surgery American; 54-A, (5), p.983.

Ibid.

Ehrlich, H.P.; Krummel, T.M.; p.205

10. Pins, G.D.; Collins, M.E.; VanDeWater, L.; Yarmush, M.L.; Morgan, J.R. “Plasmin Triggers Rapid Contraction & Degradation of Fibroblast Populated Collagen Lattices”; Journal of Investigative Dermatology

and

Steffensen, B.; Hakkinen, L.; Hannu, L. Proteolytic Events of Wound Healing – Coordinated Interactions Among Matrix Metalloproteinases, Integrins, and Extracellular Matrix Molecules

14 comments on “Scar-Tissue Massage Research

  1. Thankyou so much for this article on scar tissue. I have had 3 TKR operations over a 10 year period and still only get about 25 degrees bend in my right knee. The surgeon has told me it is full of scar tissue. I am now going to chase up a local sports massage person and see if he can help me get some more movement and hopefully, less pain.

    • You’re very welcome, Christine. Feel free to contact me for any reason regarding your scar tissue situation.

  2. I have costochondritis, and have had it for many years. I am 25 and am having a hard time doing away with it. I dont know if your familiar but it is a sever inflammation in the costal muscles and ligaments from rib to sternum. I was told that breaking up the scar tissue may help with my rib going back to where it once was and in turn this would help my muscles and ligaments become stronger and hopefully do away with my costo. I am looking for advice from anybody, as I am desperate. How would you recommend breaking scar tissue in an area such as the rib. And how do I go about it not coming back, and healing properly? Any advice would be great

    • I would use a bodywork technique I developed called ‘Floating Joint’. It’s a very subtle technique. Where are you located? I might have a therapist in your area.

  3. Could scar tissue be causing pain after a partial sesamoidectomy? This is 4 months after surgery and I had no pt. I have to walk on side of foot. MRI and X-ray shows structurally that I’m fine. Thanks for any imput.

    • I am curious about Clint’s question as well… It has been a year and 7 months since my sesamoidectomy/bunionectomy/
      second toe fusion surgery, and I have had many ups and downs… I tend to over-produce scar tissue internally, so I realize this is probably part of my chronic pain, though I am now also more prone to bone contusions of the first metatarsal head, now that the sesamoid is no longer protecting it… At any rate, any feedback would be post helpful! I am a still a very active person, but I could never jog again (only uphill on small hikes), jump normally, or walk quite normally, either. I do my best, but I know that my biomechanics have been drastically altered due to the three procedures I had done. I have done a great deal of PT, as well as daily exercise, stretching, strengthening, etc.

      • Scar tissue is the obvious suspect behind your pain & compromised function. An alternative view that you “over-produce scar tissue” is that there is still healing going on, and episodic “bone contusions” suggests that. Scar tissue work here is interesting: you want to keep the dense scar tissue in place where it’s needed for more support, and work into ‘fascial planes’ where movement is required. This will ideally be less stressful to the bones and get a freer blood flow in & out of the area. Remember, all healing is done with fresh blood, so that’s a seriously desirable effect. The work is quite specific & considered; it’s like progress follows assessment as technique is applied, if that makes sense. Same advice as for Clint, hope I can help, Chuck

    • I missed this post, I apologize. I believe scar tissue, more than could be causing pain, is more than likely to be the root of your pain, or at least a sizable portion of it. I hope this gets to you after all this time. My suggestion: find an effective massage therapist, have him/her read this article and the technique piece, call me for any discussion/clarification, and you will more than likely at least improve, and pain-free is a possibility, my opinion. I have worked twice that I can think of on your surgery type, results 80%+ improvement. Thanks, Chuck

  4. Hi, can you send me any links to primary research papers which provide evidence that massage therapy actively reduces /removes adhesion tissue?

    I have access to PubMed and Scopus, but unfortunately, I haven’t been able to find any papers which provide evidencea that massage can successfully reduce scar tissue.

    Regards,
    Aaron

    • The only research I’ve found is a paper titled; “Proteolytic Events of Wound-Healing – Coordinated Interactions Among Matrix Metalloproteinases (MMPs), Integrins, and Extracellular Matrix Molecules”. ain’t that a mouthful. ‘Metalloproteinases’ are what we call ‘collagenase’. The findings by the authors of this research is that collegians migrates to movement. Collegians dissolves collagen fibers, so the introduction of considered movement into any collagen density (scar tissue or adhesions) will attract collagenase. I think it’s apparent that working connective tissue proper with effective massage techniques spreads collagen fibers apart and breaks hydrogen bonds to at least some degree. Thanks for the question.

  5. I don’t know if you are familiar with the tissue left from an involuted deep hemangioma and how similar this is to normal scar tissue but I have one side of my face which has been left much bulkier than the other following the involution of a deep hemangioma birthmark there and would be interested to know your opinion on whether I may be able to reduce it at all through massage in the same way as normal scar tissue? Thanks

    • Scar tissue is universal, so working post-surgery scar tissue is the same in character. That said, the local circumstances for any particular site are unique. So, scar tissue is always ‘normal’ and ‘unique’. And yes, it can be affected as all scar tissue can.

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