The 5 Phases of Muscle and Tendon Injury Repair

Welcome to the Performance Place Sports Care podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. I'm Sebastian Gonzales, Dr. Sebastian Gonzales. I'm your host on the Performance Place Sports Care podcast. And this is a question I got today that I think will really, really help you guys in regards to learning how to get control of your injury and get control of knowing how to deal with your injury and be able to digest the information that you're finding all over the internet, as well as from your doctors and PTs and chiros.

And just to assess your risk reward based upon how old your injury is, all the information I'm doing today is, it was based upon a whole period of my life, actually, where I was researching tendon repair time or tendon muscle repair time. And I was actually putting on a course for it. So I really wanted to find the best up-to-date information that I could. And I actually wrote a whole manual. And we only did this seminar one time. And it was really, really hard for me to get people to want to come to it. And I say that from not from a point of view, not that I had an issue with getting good information. It's just, I know I'm not very good at marketing stuff. And this, I mean, podcasting has been something that it's nice that people listen to it and you guys share it and listen to it where I don't spend a lot of time pushing things on social media and so on.

Because this is something which apparently you guys like already and you already listen to and share and so on. So I think that's why the seminar didn't get off the ground. But who knows, maybe I'll actually start sharing it again one day. It was intended for trainers and other sports injury professionals to be able to learn how to rehab these conditions. So what this is going to be on is a timeline. A repair timeline for tendon and muscle injuries. And just, again, guideline of this is what your body is doing under the surface, theoretically. So can you do certain things? What should you do in those time frames and so on?

Now, the question I got is, if you have tendonitis from an injury, how soon should you start these exercises for rehabilitation? Can you do more damage if you start them too soon? So, the first thing we have to consider when we go through this, first I'll tell you the phases, but also to remember, this is based upon low grade 2 tears of muscles. So, grade 2 is where you actually bruise. You can see a visible bruise on the skin. And that means there's been enough damage to really get the blood to come to the surface. And lower than that is a grade 1. And grade 1s are, obviously, you can't see a bruise.

And I guess, technically, we can call these strains. Whether it's a fresh strain or not is a whole different story. And let's just say you've never had this condition before. And this is something that popped up because you stepped off a curb, because you had a hamstring tear, or anything like that. And if it's an older injury, we can theoretically jump past through the first couple phases. So, phase 1 is what I call the vulnerability period. Phase 2 is the mobilization period. Actually, let's take a step back. The vulnerability period is the first 5 days after the initial injury. Mobilization period, which is phase 2, is 7 to 21 days post-injury.

And then we have the early strength period, which is about 21 days till 6 weeks. Then we have the mid-strength period, which is 6 to about 10 weeks after injury. And lastly, we have the late strength period, which is about 10 weeks to about a year and beyond. So, these phases are actually not published anywhere else but on my material. And I came up with the names for them, mainly because I thought it would be descriptive of the things that you should know during each phase. And I didn't make all this material up. It was actually based upon, if you've heard of any of my other podcasts or you've seen my YouTube videos, you'll know that I've had a couple hamstring tears.

And it was really hard for me because I like playing baseball. It happened playing baseball. And I was around, I think, 29 at the time when I had my first hamstring tear. And it was really, really frustrating. And I was at home, not playing, because I like to play once a week at least. And it was frustrating just to sit here and just not know what to do or not have any control of my injury. And so I started looking things up. And I did a lot of research. And these are the things I came up with. And I started realizing that, oh, shoot, it's been three months. I haven't done any of this stuff yet.

It would have been nice to know this stuff ahead of time. What I can do productively during each phase of the repair process of the muscle and tendon, where I can give myself the best chance to play again well and not have this injury linger for the rest of my life. Because I definitely have known people. And there's one guy on my team that he keeps claiming that he used to be as fast as I am. And I'm like, well, what happened? You know, you get a pinch runner all the time. He's a 50-year-old guy. And he's like, I tore my hamstring. Just can't run anymore. And I'm like, when's the last time you've really sprinted?

Because a lot of times he'll come in and play second base and so on. And yeah, he's like, yeah, it's been about 20 years. Just haven't done it. And I didn't want to be that. I didn't want to be, I didn't want to disable myself from fear. I'd rather know I've taken every step I possibly can to be able to repair my injury so I don't live in regret. So here we go. We're going to take this vulnerability period as number one. And I have this conversation with many people that come into my office. So I'm really, really thankful actually that this question came up because I didn't think about having this topic yet.

But it's really important for you guys to know because you can know how much you can do during each phase from a theoretical standpoint even. So the vulnerability period, God, I should have called it something else because I obviously can't say the word. The first five days, it's the first five days of the injury. And let's just say we had the hamstring pop, right? The bruise started to come to the surface, a really small one. For the first five days of the injury, it's really important to get the rest that you keep hearing about. So rest is important, but also it is severely overly used. And the reason why you want rest during this period is because your body is working really hard to repair that damaged tissue.

And there was a study done at least in 1941 where Mason and Alan had described the injury, at least this was to a tendon that was repairing itself. It was producing like a gelatinous spider web of connective tissue. So almost like a jelly in there. And during this period of time, you don't want to tear this jelly apart. You want the jelly to form because it's forming a scaffold or scaffolding, a framework for your soft tissue to repair. So during this period of time, you can do things like immobilization. If you turned your ankle, possibly go into a walking boot or an air cast. Start things like the rise or price method with protection, rest, ice, heat, compress, and even elevate.

And too much activity at this point can actually tear this gelatinous stuff apart and it actually can set your recovery back. So this is the period that I see a lot of people thinking they should stay in for a long period of time. And honestly, I think the reason why they do that is because they're avoiding doing activity again. It's the fear that they have. And again, when I came up with this concept to present this idea to people, it was because I wanted them to feel empowered during this period of time. Not be afraid of their injury. Sorry, I had to get a swig of water. The phase two, mobilization period.

This is where you actually get to start doing a little bit of stuff. And it's from 7 to 21 days. And it is the prime time to start moving and adding some isolated stretching into the area. And the goal of this period is not to stretch the heck out of it because it is still starting to harden into some tissue which can transfer load. So that is the important part of the next phase is that it can start transferring load. But this one, the new scar tissue is starting to form. And what you want during this phase is to be able to decrease the amount of relative tightness that you're going to have going forward.

So I like to call this, this is active stretching or even what we call reciprocal inhibition stretching. Or you can do very light massage work or manual therapies. Or even passive modalities are good such as ultrasound, e-stem and so on. So active stretching though, if you don't know what it is, it's where you start to, let's just say if you injured your bicep, you don't go into a doorway and rip the heck out of the bicep and stretch it to the max. You basically just sit here and pump your arm. It's like you're doing air bicep curls. And people might be looking at you and wondering what's going on.

But you can definitely feel below the surface that this thing is starting to tug on that little section which has been torn. And that's all it takes. If we're talking about a hamstring, I might sit into a chair and extend the leg a little bit and flex it and extend it and flex it. And it's really, when I'm flexing my quad, that's as far as I want the hamstring to stretch. It's as far as it will tolerate with quad contraction. But I'm not going to have someone lay me on my back and just rip into the hamstring. It's a little bit much because it's just a little bit too early. Not that this isn't something you can do later.

You just can't do it right now. Now, adding some light manual therapy is important to help align the scar. And we call this making the scar more functional. And I think based upon what grade you had, this still might even be an early time to do it. And it's funny. I've actually had people come into the office that have gotten them in the first phase, the vulnerability phase. And they're just a few days out of the injury. And I can see the things all bruised and so on. And they really want soft tissue work. And I actually, I told someone, I told one of my colleagues about this, that I remember this one person came in.

And I knew that if I didn't do something that they were going to leave and probably go to someone else who was going to do something with them and stretch the heck out of the area. So kind of part of the thing that I needed to do the best was do something so that they'll stay under my care. Because the misunderstanding of my not doing the thing they asked was mean I, I don't want them to think I didn't care or that I didn't think it would be helpful in the long run. But I needed to do something else so they would stay under my care, so they would build some trust, so then we could do this part later.

But when you do it softly, at least in the mobilization period, you can get the scar to start to become more functional in the long term. And scar tissue is something that will form during this period. Again, scar tissue, if you have heard any of my conversations about scar tissue before, scar tissue is normal. But you don't want it to mat down and cross bridge and start to attach to structures around it, which can happen later on. So deep tissue work, it starts to separate these tissues, and that's really all we're really looking for so it can heal properly over the period of time. But other modalities like ultrasound, E-STEM, TENS unit, those are good.

Those are what we call passive modalities, and they're things that can be incorporated around this period of time because they are things that will help you control pain. Because it does hurt, it hurts a lot, and these things can make it so you're a lot more comfortable. Now remember, the point of this period of time is to minimize the amount of scar tissue forming, but we want to have some, but to be quality scar tissue. So I actually found in one study in 1999 that, actually there's another one in 2000, that scar tissue was shown to be of inferior quality and greater risk for future injury than regular tissue.

So scar tissue, you do want some because it's going to mat the stuff together and help repair the tissue, but also we have to be very careful of how we manage that area as well going forward and how you can load it and so on. Now, the third phase, which is called the early strength period, is from days 21 to roughly six weeks. And this is the time where things start to become really, really fun. And you also have crossed the bridge to not tear the tissue back up again, or tear that tear up again, and separate the two ends. And the reason why it's important is because some research has shown that there's a crossbridge that forms between the two ends or the two sections of the muscle or tendon which has been damaged.

The reason why it's important that these two ends are now have the crossbridge between them is that it has the ability to transfer load. And what I mean by that is that you can do light exercise or rehab on it. Now, there's a principle for muscles and soft tissues called the SED principle. It's called specific adaptive force to implied demand. Let me say it again because I'm stuttering around a little bit today. So specific adaptive force to implied demand. This is kind of this principle that bodybuilders use to get really big. But obviously, we're finding the balance of that and just loading the tissue lightly during this period of time.

But if you don't make the muscles do something, they won't. And grandma used to say, if you don't use it, you lose it. And this is the period of time where it's best to start using some type of load to get those muscles to repair. There's actually, studies show also too, there's cells in the area called satellite cells. Satellite cells are what we call early stage myogenic cells. They become muscle. They become the tissue that needs to repair. And the major way that they're stimulated is through damage to an area, but also to mechanical load. So exercise or loading the air is important to make sure these satellite cells are being activated and they're going to repair the site as well.

So some exercise, at least that I did some research on with hamstring stuff, for me personally, was eccentric exercise. And this is why I kind of developed this whole thing that we're talking about today. Eccentric exercise is the lengthening contraction. So it's not the shortening one. Say we're talking about a bicep curl. It's not the one where the weight goes to the sky. It's the one where the weight goes down. And you can do it really, really slow. And at least with hamstrings, there was a study in 2004 where it found that hamstring strains showed that eccentric training strengthened the hamstring significantly and decreased the amount of further strain in compared to concentric exercise.

So that's the shortening contraction. So it showed that the lengthening contraction significantly reduced future strains in compared to shortening contraction exercises. Now that's not to say we can't do both, but it means that we should do, or it means we should do both. We can't ignore them both. So eccentric exercise is something also that's been shown really, really well to help out jumper's knee in patients. In fact, there was one study in 2005 which showed a satisfactory rating of around 90 for jumper's knee, which is almost like patella tendonitis. It's pain around the kneecap or just below it.

So eccentric exercise, at least according to my research, was something you can do during this period of time. But again, it should be lightly loaded. Just like everything else, it has a progression upward. And eccentric exercise, again, to clarify, it is a lengthening contraction. And there has been some studies that show that the lengthening contraction can cause more damage if done quickly and also heavily loaded. So you have to really, really do this slowly. And I would strongly suggest you see somebody to make sure that you're doing the right one for you. Also too, I didn't do a disclaimer yet, but I need to.

If you have a muscle tear, this is all just theory. You can't manage your own. I can't stress that enough. Don't manage your own condition. Get some ideas from a strength coach, a PT, a chiropractor, or an MD, or someone who knows how to manage these cases. Actually, athletic trainers would be great as well. So phase four, now we're getting into really, really fun stuff. So we call this, or I call this, the mid-strength period. And this is around six weeks to ten weeks after the initial injury. And it starts to look more like normal exercise. And you'll probably have a couple specifically recommended isolated exercises for an area.

But you'll start to do some normal movements. Okay. Oh, by the way, I didn't talk about it in the last phase. There is isometric contractions, which is a non-movement contractions, which are really, really safe to begin on as well. We do start some muscle strain and tendon injury people on isometric stuff, more so than eccentrics now. But eccentrics are important as well. So in the mid-strength period, back to what we were originally talking about, we can start to reintroduce exercise using multiple types of contractions. So concentric, eccentric, and isometric. So that's shortening, lengthening, and holds.

Also, you can introduce more deep tissue mobilization to combat the formation of excessive scar tissue on that side of injury. So our tissue work can get much harder and more frequent. Now, something I run into a lot with people during this phase is since we're only about six weeks out or 10 weeks out of the injury, they're really scared to start doing normal activity. And we might get them to do, say we're talking about hamstring injuries, you might have them start to do deadlifting or even Romanian deadlifting or single leg RDLs. And these are all things that there's a lot of hesitation on. And understandably so, because it feels like the injury is going to tug away and tear again.

But if you know how to do your exercise, you know how to load the area slowly, you'll probably be okay. Make sure your form is really, really good. And you should be with an exercise or qualified professional to do this with you. Now, remember, the reason why it's relatively safe to do during this period of time is because that crossbridge has already formed at 21 days, usually. Again, it depends upon the grade that you have. But that crossbridge has formed. So we need to start loading these areas. And if there's any gaps in your loading process, like say you went out of town for two weeks and didn't do anything, you almost need to restart back again.

You cannot jump in where you left off. You need to restart and you need to make sure you have consistency of loading the area because the muscles will only accommodate to the load you're putting upon it. And it has to be consistent. Okay. The last part is the late strength period. And this is 10 weeks out to about a year. And honestly, we can say even further than that because it really depends on how long it takes for the athlete to be comfortable. Okay. The tissue continues to change for easily all the way up and towards the year. But I've seen some studies which say a couple of years. But during this period of time, we start to load the movements that we have in the mid-strength period more so.

And we can even isolate things down a little bit more so too. So an example would be during the mid-strength period, perhaps we've gotten the person to start box squatting with a hamstring injury. Now we want them to increase the amount of weight on it. Or we push them to a more strenuous type of lift, which would be deeper than a box squat. Okay. We might get them to do a single leg activity, such as a Bulgarian split squat. And these are all based upon the premise that they had proper strength within the stabilizer groups of the hip. Also the proper amount of core or trunk strength. There's a lot of things, a lot of variables that pivot on how much we can load the person.

But again, this is all theoretical. If we're talking about the exact muscle that got injured, we can start loading it heavier. So I hope this was helpful. Again, this is something I really talk to my clients about because they wonder what they can and can't do at the gym and is there any risk of re-injuring it. And back to that original question, how soon can they start the rehab exercises and can you do more damage? You can do them probably pretty soon, but it depends on what your injury was. Okay. Can you do more damage? Well, yeah, you could. But also too, there's a possibility of you doing a lot of long-term damage if you don't start them as well.

Are you starting them too fast? Are you loading it slowly? Do you have proper trunk or local stabilization to accommodate the load for the exercise? Are you doing your movements properly? Can you squat and deadlift properly? Can you pull and push properly? There's a lot of things pivoting on what this person can do or cannot do. So I would strongly suggest get evaluated. But learning the phases of the underlying injury and how it repairs will be helpful in regards to you knowing what you can and can't do probably during that phase of time. So, again, if you guys want to have your questions answered on air, we do have a speak pipe button or a voicemail button on the website.

Please don't leave them on our office line because we won't take them. I have the p2sportscare.com site. Also, too, I strongly believe in education. Like I always tell you guys, I want you to learn the most about your injuries so you can take control of your rehab. You might need help here and there about your diagnosis and your image and form and so on, just like everybody else does. I do, too. I know that when I start doing things like cleans or even deep squats, I start to round. So I kind of want to have someone watch me and make sure that they're coaching me through the proper techniques to make sure I don't hurt myself.

But we do have some courses online that are helpful in regards to learning the basic amount of rehab, local stabilization of, let's just say we have a rotator cuff one currently. The rotator cuff one is the most common exercises that I need to recommend for each shoulder condition. And it is something that most PT offices or even sports injury offices will recommend you anyways. So you might as well know them anyways. It'll really accelerate the things that they're teaching you. And it talks about how injuries happen, how to combat them from happening again. And we have an advanced course, too, where it talks about how to increase ball velocity if you're a pitcher, how your lower body, your trunk, and all these other parts of your body come into play when you're trying to improve injuries as well as prevent them.

So we have other ones coming for runners as well. And just check that out. So we're going to have links to it on the show notes below, but also, too, on the P2 Sports Care site. You should be able to find courses, as well as the Performance Place HB site, which is the one we are building specifically for the courses. But right now, both those websites are doing some construction. We're trying to make the user experience better for you guys. Because I know in the past, when I put these sites together, especially the P2 site, it was almost like my journal. It was all of these stuff that I wanted to remember, I wrote in article form, and then I put it up there, and it's a big jumbled mess.

And it's hard for people to find. So we're trying to make it so you guys can find the articles you want, specific to what you're interested in. So again, check me out. And please go into iTunes and share this with other people. And if you can rate it for me, that would be honestly so, so awesome. The best way I can share information is if you guys share my voice for me, and that's why I formed the podcast. So talk to you guys soon, and see you next week.