The Essentials
The body's remarkable healing process
The human body has the fascinating ability to heal itself! At least to a certain degree and extent. But when you look at the state of a house or a machine after 50, 60, or 80 years, this ability is truly mind-blowing!
And yet most people put quite a heavy strain on their bodies, though often not in the right way… because it is not movement that harms the body, but rather incorrect movement, or none at all!
“It’s not movement that destroys a Machine, it’s friction”
As osteopaths and physiotherapists, we must know the exact sequence of wound healing and its processes to design our therapy for maximum impact and effectiveness. This means that depending on the phase of wound healing our patient is currently in, we as manual therapists must select correctly dosed techniques and applications to plan the therapy accordingly.
The ultimate goal of wound healing is the complete functional restoration of the injured structures. And the more optimally physiological stimuli act on the injured tissue, the more flawlessly healing progresses – with minimal scar tissue.
Wound healing in the human body (whether this involves an injured intervertebral disc, a torn or operated cruciate ligament, a strained joint capsule or ligaments, or even a fractured bone) always occurs in distinct phases. In physiotherapy and osteopathy, these wound healing phases are divided and distinguished as follows:
Inflammatory Phase
Proliferation Phase
Consolidation Phase
Organization Phase
Further, more detailed subdivisions are possible and are sometimes used.
Healing process of a heel surgery after 2 days, 15 days, 20 days, 6 months, Kaspar1892, Surgical suture, healing process, CC BY 3.0
These phases can overlap and vary depending on the tissue involved. Crucial to the duration of the individual phases is the blood circulation of the injured tissue, as well as the extent of the damage. This also influences the turnover time of the tissue: all tissues in the human body are replaced and renewed sooner or later. If the tissue has good blood circulation, the turnover time and healing time are relatively fast. A great example of this is the skin: after a cut, nothing is visible within a few weeks (the turnover time is around 3 weeks, meaning our skin is renewed every three weeks).
An intervertebral disc, however, which can be responsible for back pain or discomfort, does not have such a rich blood supply and has a turnover time of around 400 – 500 days (meaning it takes over a year for the tissue of an intervertebral disc to renew itself).
Depending on the level of activity (which in medicine describes the current state of the tissue, meaning even a chronic condition can be in a highly active state, e.g., activated osteoarthritis, not to be confused with acute), which a therapist must identify, different therapeutic options and techniques with varying goals are applied.
Abrasion of the hand – 32 minutes after injury, Jpbarrass, marked as public domain, Details on Wikimedia Commons
Inflammatory Phase of Wound Healing
The inflammatory phase lasts, depending on the tissue, between 3 and 7 days after the injury. It is characterized by pain and swelling partly caused by the inflammation itself.
The inflammation creates optimal conditions to activate the body's own cells (e.g., macrophages, leukocytes, lymphocytes), substances, and enzymes (similar to a fever).
Through the oxygen-rich blood and the proteins within it that leak into the injured tissue, the body and connective tissue cells are guided, activating a mutually influencing chain of events. The released proteins also cause more fluid to accumulate, which triggers the swelling. This makes the tissue looser, allowing body cells to migrate more easily into the injured area.
The tissue begins repairing the vascular system, and the body initiates emergency first-aid care and repair using temporary tissue (Type III collagen) to close the wound as quickly as possible. Although collagen synthesis has already begun, the formation of new fibroblasts and myofibroblasts dominates during this phase.
Pain relief and decongestant measures are the main focus during this phase. Appropriate rest and unloading of the injured tissue are indicated. Compression bandages may be used if necessary. The sympathetic-vegetative nervous system should be calmed. Pain-free movements within the matrix range of the tissue (passive or active mobilization) are nevertheless indicated in most cases and are essential to stimulate the connective tissue. However, physical loads should be approached with great caution, as the tissue remains highly unstable due to the lack of ground substance production.
Electrotherapy or ultrasound can be an excellent complement to the therapy during this phase.
The body should complete the inflammatory phase as quickly as possible, and your therapy should actively support this process.
Abrasion of the hand – 2 days 22 hours 12 minutes after injury, Jpbarrass, marked as public domain, Details on Wikimedia Commons
Proliferation Phase of Wound Healing
This phase typically lasts between 3 and 10 weeks after the injury. In the proliferation phase, pain decreases significantly while mobility increases. Regeneration of the connective tissue (the initial remodeling of the temporary tissue built earlier) takes place. The synthesis of collagen is highly pronounced in this phase, though the fibers are initially very thin and close together. However, the production of the ground substance is still low during this phase, making the tissue less elastic and only limited in its stability.
Loading should be physiological, functional, and pain-free so that the newly synthesized connective tissue fibers can align themselves perfectly, preventing scar tissue with faulty cross-links. This is absolutely critical in this phase! Neuromuscular facilitation for natural movement and loading is one of the therapeutic goals. Measures that promote blood circulation to optimize metabolism, as well as stimulating the synthetic activity of connective tissue cells, are front and center. Training volume can be increased (but not training intensity, or only with careful adjustments! We want to avoid producing new injuries, and the tissue is not yet fully stable, as explained above). We begin with functional, coordinative exercises in a closed kinetic chain to improve proprioception (exercises in three-dimensional patterns).
Abrasion of the hand – 17 days 11 hours 30 minutes after injury, Jpbarrass, marked as public domain, Details on Wikimedia Commons
Consolidation Phase of Wound Healing
The consolidation phase lasts up to 12 weeks after an injury. The collagen network is remodeled once again, and the fibers become thicker and more stable (Type I collagen). Increased ground substance production by fibroblasts during this phase significantly enhances the load-bearing capacity of the tissue, thereby increasing the space between the fibers. These are the prerequisites for building a strong, stable network of collagen fibers, which also improves the tissue's elasticity.
During this phase, active therapies take center stage, tailored to the patient's goals and demands: what do they need and what do they want to achieve (the difference between an elite athlete and an office worker). The training load can be increased significantly (treatment within the collagen loading range).
Repeated end-range mobilizations should be performed to achieve full mobility and eliminate any movement deficits. Tailored, progressively heavier functional three-dimensional exercises promote further improvement in proprioception and dynamic stability. Speed training can be initiated, such as jump and run coordination. We start closed-chain maximum strength training, as well as strength training with free weights.
Abrasion of the hand – 30 days 4 hours 43 minutes after injury, Jpbarrass, marked as public domain, Details on Wikimedia Commons
Organization Phase of Wound Healing
The organization phase follows the consolidation phase and is closely linked to the turnover time of the tissue. The initially formed Type III collagen has mostly been remodeled into stronger Type I collagen fibers. The original injury site has transformed from a predominantly cellular tissue into normal collagenous connective tissue.
In this phase, activities of daily living (ADL) and the specific goals and demands of the patient take center stage: function shapes structure! Exercises, training, and therapy must be aligned with the patient's daily life, profession, or sport.
Exercises target reactive abilities, speed, and optimization of the stretch-shortening cycle. Eccentric loading, supramaximal, and, where possible, maximal strength training in both closed and open kinetic chains are used, alongside sport-specific drills. Practice matches or competitive scenarios are integrated into the training as well.
The load-bearing capacity of tissue ultimately depends on which cells are active in each phase and which tissue components they synthesize.
Now, it probably makes sense why a cast is usually worn for 6 weeks, or why crutches are often required for 4-6 weeks after leg surgery.
All phases of wound healing actually begin simultaneously right away, as proven by enzyme-histochemical methods, and must be viewed as an interconnected process. The phases overlap, and as therapists, we must recognize when a phase has been largely completed by the body to take the next step in therapy and apply the optimal physiological stimuli to the tissue.
There is no faster healing than optimal healing! At BodyLab, we have the expertise to perfectly support and guide you through injuries of the musculoskeletal system. We aim to relieve your pain and detect or prevent delays and complications (such as infections or long-term deficits) early on. All for an optimal, fast, and ultimate recovery.
If you need us, we are always here for you!
Your BodyLab Team, your experts on the path to recovery
Osteopathy and Physiotherapy | Rehabilitation and Training
Zurich Altstetten
Cover Image Credit
Carsten Niehaus (Lumbar), Wound sewed, CC BY-SA 1.0
