Stretching during rehabilitation is both important and tricky. Important because properly incorporating stretching can help produce functional scar tissue and help maintain and improve mobility, etc. Tricky because improper use of stretching can cause re-injury and set you back.
This is why I always recommend that patients see a physiotherapist or other rehabilitation specialist, especially during the initial stages of recovery so that common problems can be avoided or treated as quickly as possible. Because the kind of stretching and mobility exercises you need while recovering from injury are different than the ones you need when your tissue is healthy.
To understand this, we need to understand the different phases associated with tissue healing so we can best plan what kinds of interventions are useful during those phases. What I want to say about these phases is this - I’m using very general guidelines only here in this example. The degree of the injury - is there a broken bone? Is this a grade 1 or 3 sprain or strain? - and the specifics of the injury itself have more to do with the timelines of when you begin incorporating stretching into the rehabilitation regime, the same way that when to begin using heat instead of ice has a lot to do with the degree of damage. So keep in mind that the following guidelines are for mild injuries - grade 1 - so you may need to adjust timelines accordingly.
The Acute Phase
An important thing to understand about inflammation is that the inflammatory process is a cascade event that once started, has to go to completion. That process takes 3-4 days minimum. The more tissue damage there is, the longer that process continues because the chemicals that create the cascade are continuously being released into the surrounding tissue from the damaged areas until those damaged areas heal and are no longer releasing the chemicals. Think of it like a giant water tank that springs a leak. Water continues to leak out until the hole is plugged, and the amount of mess created and how long it takes to plug it depends on how big a hole you had to begin with. And then even after you plug the hole, it still takes 3-4 days from the last drop of water that came out of that hole to fully clean up the mess. So, during this time, you don’t want to heat up the metal around that hole because that will just make it expand, causing it to get bigger and more water will leak out faster making a bigger mess. That’s why using ice/cold therapy at this time is important. Cold constricts the blood vessels to the area, which limits the ability of the body to bring more blood flow to the area, meaning less leaks out, meaning less mess to clean up later.
One thing I want to mention about the application of cold, however, is that you want to limit it’s application to around 10 minutes at a time. Longer than that and you cause what’s known as the ‘Hunting Response’, which is when the body actually dilates the blood vessels in response to prolonged cold to prevent tissue damage. It varies from person to person but this response typically kicks in every 12-15 minutes in response to prolonged cold. So keep your applications of cold under that and you’re golden. Also, you want to, you know, prevent tissue damage. So ten minutes on, take it off, let the tissue warm up on its own, then put it back on, repeat.
Which brings me to a quick run down of RICE versus MICE, meaning either Rest versus Movement, Ice, Compression and Elevation. There’s a post here about the debate between rest versus movement and which is better. This, again, comes down to the degree of injury. Is there a broken bone or full thickness tear involved? Then rest so that consolidation can occur properly is the general rule of thumb. Dealing with a grade 1 sprain or strain? Then movement within the pain-free range is beneficial.
The most important thing to remember, even with those ‘kinked muscles’ is NO STRETCHING during this time. Think about it - you have damaged tissue. Do you really want to pull the edges of those damaged fibres further apart? Think about a cut on your knuckle that you keep reopening every time you bend your finger. How long does that take to heal versus a cut that isn’t constantly being reopened? How much bigger is the scar? Stretching during this time will only cause more damage and force your muscles to contract to ‘splint’ and ‘guard’ the area, causing more pain.
The Sub-Acute Phase
The sub-acute phase is when the initial inflammation phase is winding down, scar tissue is forming, bone is mending, etc. There is still swelling and inflammation, but the tissue is repairing. This tends to be the period of time from day 4 post injury to 4 weeks post injury, depending on injury and severity. If you’re dealing with a broken bone, not moving the affected limb or the muscles crossing the break is still important until your doctor tells you otherwise, but for lesser injuries, moving within the pain-free range of motion is important. You’ll want to start including contrast heating during this phase - see the post on that here. Depending on the severity of the injury, stretching still may not be indicated at this point, but range of motion is important to help create functional scar tissue and keep adhesions from forming. If the injury was minor you can try testing how your body responds to gentle static stretching, but only go to the first sensation of stretch and stay within pain-free range. But again, the more important thing at this point is movement. Movement helps your body to get ‘communication’ to the affected area going again. It creates a feedback system of ‘okay, I’m okay, I’m healing’ between the injured area and your brain, which will help your nervous system to not become over-reactive. However, if you push it during this stage you can create a situation where you can habituate your nervous system to over-respond to innocuous stimuli. Which is why I typically recommend to patients not to begin stretching at this point and focus on movement. Two weeks post-injury is when patients are at the greatest risk of re-injury because they are beginning to feel better but the tissue is still fragile and prone to further breakage, so a gradual return to activity is important. Otherwise, again, you can get into a situation where you train your nervous system to expect further damage, which means it will begin to react sooner to stimuli than previously because it becomes habituated to injury. So take it slow.
Chronic Stage
Chronic here refers to a phase of healing and not to chronic, repetitive injuries. This is the stage, typically anywhere 2 - 8 weeks post injury where the proper rehabilitation regime can be the most beneficial on scar tissue remodelling and strength recovery.
Stretching post-injury becomes important from this phase of injury recovery forward. At this stage, scar tissue is beginning to tighten and patients can experience a resurgence in pain as nerves and blood vessels can become stretched or compressed by said scar tissue. Seeing a physiotherapist or massage therapist who specialises in scar tissue treatment and remodelling can be extremely beneficial at this point. You can have a lot of influence over the scar tissue remodelling process to create functional scar tissue that behaves more like the tissue it has replaced. Stretching, in combination with scar tissue therapy, can help to return the injury to full or almost full function.
You can visit this page here for a great run down of the types of stretching and these sites for how to stretch which muscles.
Til next time, dear Reader!