Healing Timelines
One of the most common questions I get from patients is ”how long will this take to heal”. The answer can be quite complicated due to the fact that it is very rare to only injure one tissue. For example, if you roll over your ankle, you may over stretch one of the ligaments (bone to bone connective tissue) but you will also likely grip as you roll over and thus affect your muscle/tendon. You may also avulse part of your bone, thus now affecting a third tissue. You can see from this example that injuries are complex and never as straightforward as we would prefer.
Let’s start with muscle tissue. When you injure a muscle we call it a strain or a tendinopathy (depending on if it is in the muscle belly or where the muscle attaches to the bone (tendon). Typically with a muscle injury it hurts to use the muscle, meaning active or resisted range of motion. When stretching the tissue there also can be pain when at end range. Typically the pain is dull, achey, and sharp when using it.//
When a muscle is healing, the first phase is about 1-5 days. When you injure your tissue you rupture the cells and after a few hours, necrosis will finish. A hematoma or bruise will start to form, and the inflammatory process begins. During this phase, you want to avoid aggravating activities, control pain. The idea in this phase is to manage pain, and avoid worsening.
From there, the next phase is called the Post-acute phase. This is your proliferation phase where your body gets rid of the damaged tissue, and starts to regenerate the muscle and nerve tissue. Scar tissue is also being produced as a scar around the area that had the hematoma. New blood vessels are also grown to continue to provide blood supply to the area. This phase typically lasts 2 days to 6 weeks depending on the extent of the tissue damage. During this phase (under licensed supervision), you want to start with pain-free range of motion exercises and start some manual therapy to avoid contracture.
The final phase of myofascial tissue healing is the remodelling phase. The muscle fibres that were added in the last phase are now maturing, and the scar tissue is being reorganized. During this phase you want to continue your rehab towards functional recovery, adding in some proprioceptive exercises, properly warming up your tissue before doing any work. Strength exercises should slowly increase, while maintaining some manual therapy.
Although the above makes these phases seem separate there is much overlap during myofascial healing. Next let’s move onto ligament healing.
Ligaments connect bone to bone. They cannot contract but are very strong and have some flexibility to them. When a ligament is injured, it is called a sprain. Sprains are typically graded as mild (no bruising, mild swelling), moderate (bruising, mild to moderate swelling, unable to run or hop, and severe, severe bruising and swelling and unable to bear weight. When a ligament is injured it will feel painful to do active and passive range of motion, but will be painless typically for resisted range of motion. There may be pain when palpating the ligament and there may be some instability felt when testing out range of motion (clunk).
The first phase (acute) for ligamentous healing is about 1-5 days in length depending on severity of the injury. Typically the area is immobilized for a very short term and re-injury is avoided. The next phase (post-acute) typically lasts 2 days to 6 weeks (similar to muscle injury). During this phase pain free range of motion should begin, and some healing and pain modalities are typically utilized. Mobilization can also be used to prevent contracture and reduction in range of motion. During the last phase (remodelling) this can last one week to 12 months or more. The goal in this phase should ble ramping up rehabilitation exercise to lead to functional recovery, and address any secondary issues from the injury. Isometric exercises and pain free range of motion slowly move towards isometric and then eccentric exercises.
The final tissue we are going to discuss are bones! Bone damage may be in the form of a fracture or a bone bruise (still structural integrity damaged). When there is bone injury, all ranges of motion (active, passive, and resisted) are painful. The pain can be dull but when the area of damage is challenged, the pain will be quite sharp. Sometimes there’s also a very deep, gnawing pain that comes with a bone break.
The first phase (inflammatory/reactive) lasts up to 3 days. Blood cells fill the area causing a hematoma, and then quickly fibroblasts create what is called granulation tissue. Granulation tissue is like the first layer of rebuilding that will lead to bone repair. In the next phase, the reparative or proliferation phase, this can last 3 days to 6 weeks. This is where your bone makes a soft callus, and the granulation tissue is slowly moving towards growing new bone. The callus starts as hyaline cartilage and woven bone, eventually turning into hard callus formation. The final phase, the remodelling phase, can take 4 to 6 weeks typically. During this phase the bone remodels back to the original bone contour.
Bone healing is affected by a few key principles. The first being re-injury. If you aggravate a fracture, it will heal much more slowly. The younger you are, the faster you heal. You also need adequate nutrition while healing. Your hormones also play a role in bone healing as corticosteroids tend to slow healing times. Finally other diseases (comorbidities) can affect healing time like diabetes or even people who smoke.
Whether you have injured your bone, ligament or muscle, it’s important to seek out professional care and make sure you are following the guidelines when healing. Often patients who have injuries with no care find later down the road that their motion or biomechanics are affected and then undoing all of that scar tissue can be quite a challenge. Take care of your bodies and give yourself the proper time to heal and the proper tasks to perform while healing.
