I can’t help it. Every time I think scar, I think… Scar (and yes, I used to have a much better picture of Scar from The Lion King for you…but I had to remove it in my attempt to make sure I’m not violating anyone’s copyright laws!) I was going to try to think of some funny way to explain why scars and Scar are the same… but I can’t… I relate it to the 50,000 times I have watched The Lion King... so I’ll leave it at that.
Scars can be a big pain though– literally! I have treated women who even after several years cannot tolerate pressure on a c-section scar. Men who have nice huge abdominal scars that ultimately contribute to problems with constipation. And moms who have discomfort near their perineal tears every time they have sexual intercourse. The truth is that scar tissue is often something skilled physical therapists will evaluate and treat as part of a comprehensive program in men and women with pelvic floor dysfunction(and really, with any type of problem!). And the best part– treating scar tissue can make HUGE differences!
So, what is a scar?
When there is an initial injury (and yes, a surgical incision is an “injury”), the body goes through three phases of healing: Inflamation, Proliferation and Remodeling. Through this process, the body creates scarring to close up the initial injury. Scars are composed of a fibrous protein (collagen) which is the same type of tissue that is in the tissue the body is repairing (i.e. skin, etc). The difference, however, is that scars are not quite organized the same way as the tissues they replace, and they don’t really do the job quite as well. (i.e. scars are much more permeable to UV rays than skin is). Scars can form in all tissues of the body– even the heart forms scar tissue after someone has a heart attack (myocardial infarction).
How do scars lead to problems?
After the inflammation and proliferation stage of healing, comes the remodeling. This stage can take months to years! During this time, the body is slowly adapting and changing the scar to the stresses on the tissue. Have you ever noticed that some scars initially are pink and raised and then over time become light/white and flat? That’s remodeling. Ultimately, there are a few major reasons why a person might develop pain from a scar:
- Adhesions: Scars are not super selective when it comes to tissues they adhere to. So, sometimes, scars will adhere to lots of tissues around them and this pull can lead to discomfort.
- Sensitivity: Scars can become very sensitive for a variety of reasons. Sometimes, small nerves can be pulled on by the scar which can lead to irritation. Other times, people themselves will have a significant amount of fear related to the scar. This fear, can often make people avoid touching the scar, and that, along with what we know about how our brain processes fear and pain (See this post, this one, and this one), can lead to a brain that is veeerrrryyy sensitive to the scar. Along with this, muscles near scars can become tender and sensitive. This can occur due to the scar pulling on the muscle or due to the sensitive nerves in the area.
- Weakness/Poor Muscle firing: So, we know that when our tissues are cut, the muscles around the tissues are inhibited (have you ever seen someone after a knee replacement? It can be quite a bit of work to get those muscles to fire immediately after surgery). That’s why it’s important to get the right muscles firing and moving once a person is safely healed. Moving the right muscles improves blood flow too which promotes healing.
- Changing Movement: Painful scarring can lead to altered movement. We can especially see this with postural changes after c-sections or other abdominal surgeries, but movement patterns can change with scars all around the body. We also know that abnormal movement patterns over time can lead to dysfunction and pain.
What can we do about it?
There are several ways physical therapists can help decrease pain from scars. Can we actually break-up/melt/eliminate scar tissue? I don’t really think so– honestly, scars are made from strong material and truly breaking up the scar is typically something that has to be done surgically– but most of the time, that is not necessary. We can decrease pain from scars by:
- Improving the mobility of the scar: Gentle techniques to massage the scar and the tissues around the scar can facilitate blood flow to the area and decrease some of the pulling on the tissues around it. There is a thought as well that scar tissue massage can disrupt the fibrotic tissue and improve pliability of the scar (basically, help the scar organize itself a little better, and ultimately move better), and help to promote decreased adhesions of the scar to the tissues around it. Unfortunately, there really is not a lot of great research out there about scar tissue massage. However, this review published in 2012 found that 90% of people with post-surgical scars who were treated by scar massage saw an improvement in either the appearance of the scar or their overall function–which is very promising!
- Desensitizing the scar and the nervous system: This is where I think we can make huge changes–both by improving someone’s worries/fears about the scar (calming the nervous system) and by slowly desensitizing the scar and the skin around the scar to touch. This is a slow process, but over time, many people who initially can barely tolerate pressure on the scar can be able to easily touch and move the scar without discomfort.
- Promoting movement: So, we talked about how muscles can become inhibited or tender after a surgery? Part of improving scar tissue related pain is helping the muscles around the scar move well and learn to fire again. This can include some soft tissue treatment to the muscles to reduce the tenderness of the muscles, but ultimately leads to learning to use the muscles again in a variety of movement patterns. Movement is amazing for the body and can not only improve blood flow, but decrease pain too!
Wanna learn more?
Several of my colleagues have written wonderful information about scar tissue! Check out this great, article and free handout by Kathe Wallace, PT on abdominal scar massage! My colleagues at the Pelvic Health and Rehabilitation Center have also written a few blogs on scars, which you can find here and here.
Have a great rest of your week!