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Scars: The Octopus and the Iceberg

Updated: Nov 4, 2023

Caring for scars with the right therapy can help wound healing, detect emerging issues, and evaluate and treat existing issues. In short, client-focused scar tissue management contributes to better outcomes and mitigates costs and burdens associated with pathological scaring. That's a mouthful!

Ok James, what the hell does that mean?

First the Octopus and the Iceberg: Scars are misunderstood structures in our bodies. They perform an essential job and we all pick up a few in our lives. But in poorly healed scars 90% of a scar is unseen by the human eye. Apart from the most superficial scars, 90% of scars are unseen below the top layers of the skin. That's the iceberg. Scars, especially, larger, deeper scars, often form fibrotic tentacles of tissue reaching beyond the site of the original injury, "Where you think it ain't", Ida P Rolf, causing problems far removed from the original injury site.

Most people with scars view them as a necessary evil when it comes to healing from traumatic events, such as surgery, accidents, and other related trauma. Additionally, because the majority of issues caused by scars are beneath the skin it never occurs to people that some or all of their issues (such as chronic pain, and tightness) could be caused by scar tissue. Even if they do come to this realisation, they often have no idea that there is a way forward.

I'm going to begin by putting to rest at least one misconception. Very commonly you will hear the term, "breaking down tissue". This is a reference to the collagen that is incorporated into every part of your soft tissue structure. Take it from me, you can't 'break' collagen. It has the tensile strength of steel and in the denser tissue areas such as fascia, there is no way someone is breaking that down, (check out the amazing Gil Headly if you want to go down that rabbit hole: Does Fascia Stretch?: Learn Integral Anatomy with Gil Hedley - YouTube). What collagen is, is changeable. 90% of the remedial work I do involves supporting ongoing tissue change through ongoing, but time-limited, therapy. What does this mean for scars?

What is a scar? Without getting into physiology, a scar binds us back together when tissue integrity has been interrupted. All scars look somewhat different from the original tissue, but this is normal and nothing to be concerned about. It is our body performing regulatory processes ensuring that new collagen is being laid down and our body's homeostasis is back on track. Unfortunately, these processes sometimes break down for numerous reasons such as multiple injuries, continuous damage being taken, not enough rest, genetic conditions forming poor collagen, and many more. This type of scarring causes crosslinks between different tissues, crimping of muscles or nerves, stiffness, and general pain, often in a completely different part of the body than the offending scar. This is referred to as fibrosis.

It can stop tissues from sliding over each other, reducing stretching, strength, and organ, blood, and lymph function.

“Manual therapy is certainly, at the moment, one of the best options to improve the new recovering subcutaneous and cutaneous structures and to diminish the tissular retraction and rigidity.” Jean-Claude Guimberteau, MD

Manual Therapy is often used in the early stages of healing to reduce the formation of fibrotic scar tissue, and when it is the client often heals faster and better than without the manual therapy. Early intervention reduces excessive inflammation and premature or anomalous tissue formation, the two primary causes of fibrotic tissue. Unfortunately, it is not used nearly often enough.

This means that manual therapists are often left to deal with mature scar tissue that has been left to form and cause problems. Fibrotic tissue is often seen to be an inactive scaffold. This is not true. Fibrotic tissue, like all tissue, is under constant change, just at a much slower pace, often too slow to cause improvement. So what does manual therapy do?

Fibrotic tissue is often dense, stopping fluids from entering and surrounding it. manual therapy focuses on ensuring fluids enter the tissue, allowing sliding and also allowing increased healing and change by allowing more oxygen and nutrients into the tissue. This further allows the tissues to begin aligning, becoming more organised, which eventually means they stop pulling and crimping, and become smoother and more supple.

A win for anyone suffering from scars.

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