Many athletes develop excessive connective tissue fibrosis (scar tissue) or poorly organized scar tissue in and around muscles, tendons, ligaments, joints, and myofascial planes as a result of acute trauma, recurrent microtrauma, immobilization, or as a complication of surgical intervention (3,5,6,9,10,13). This can lead to soft tissue adhesions, tendinitis, tendinosis, fascial restrictions, and chronic inflammation or dysfunction which in many cases responds poorly to conventional treatments (9,13). Excessive scar tissue contributes to chronic tendinitis and numerous other injuries induced by musculoskeletal abnormalities that cause significant disabilities and time lost from work or training activities (4,10,14,15). These problems are often difficult for the clinician to treat successfully (1,3,16).
This case report involves a 20-yr-old college football player who had failed conservative treatment for his chronic ankle pain and associated functional limitations caused by post-traumatic scar tissue. A new physical therapy modality consisting of an augmented form of soft tissue mobilization was employed in an attempt to improve or resolve the patient's excessive scar tissue. Performance Dynamics had developed a noninvasive, cost effective, portable form of augmented soft tissue mobilization (ASTM). ASTM is a process that uses specially designed instruments to assist the therapist in the mobilization of soft tissue fibrosis.
ASTM originated from and expanded on the concepts of cross-friction massage (16). It theoretically works by allowing therapists to more effectively introduce a specific and controlled amount of microtrauma into an area with excessive or poorly organized scar tissue (1,6,13). This controlled micro-injury causes microvascular trauma and capillary hemorrhage that induces a localized inflammatory response (13). The inflammatory response is the initial step for the body's healing cascade and immune/reparative system (5,9,10,13). This process appears to stimulate connective tissue remodeling through resorption of excessive fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment (13). The purpose of this case study was to determine whether this rehabilitation process could improve a condition in which fibrosis was a major component of the pathologic process.
ASTM involves the utilization of specially designed instruments that augment a clinician's ability to perform soft tissue mobilization. The instruments are solid, hand-held devices with angled edges which are guided in a stroking motion along the skin. A lubricant such as cocoa butter is applied before treatment to reduce the coefficient of friction and prevent abrasive trauma to the overlying skin during the treatment. Each of the instruments may be held in a variety of positions depending on the body part being treated, clinician comfort, and the goal of the treatment. The instruments are used to mobilize the soft tissues primarily in longitudinal strokes that are parallel to the fiber alignment of the underlying soft tissue. As the instruments move over an area with underlying fibrotic lesion, a change in texture is palpable through the instruments because of the irregular tissue alignment and the capacity for the instrument to pass that irregularity on to the clinician's hands in the form of increased vibration within the instrument. The strokes for the initial screening purposes are smooth and flowing. Once the fibrosis is located the strokes are shortened, and instruments with progressively smaller surface area are used to increase the pressure per unit area and thereby mobilize the fibrotic lesion. The pressure of the instruments during the treatment needs to be firm enough to locate the fibrosis and cause micro-trauma, but not so hard that macro-trauma occurs. The physical therapist repeats the stroking motion using the instrument progressively over the affected area for approximately 5-10 min. In the case of ASTM, the instruments are used to apply a greater focus of pressure to induce a controlled amount of microtrauma to the underlying fibrotic connective tissues. The technique is somewhat like soft tissue mobilization in which therapists use their hands to manipulate injured connective tissues. Instruments made from the proper materials augment the clinician's ability to perceive the underlying connective tissue fibrosis when the instruments are applied to body surfaces. The clinician who performs this modality can assess the effectiveness of the treatment by assessing changes in the underlying soft tissue texture. This also enhances the physical therapist's ability to adjust the intensity and frequency of the treatment appropriately.
Usually upon completion of the ASTM there is immediate erythema along with the potential for some transient ecchymosis. The patient then undergoes a stretching and strengthening program to maintain flexibility and reestablish muscular balance around the area that is being treated, as well as to influence the structural alignment of the remodeling collagen fibers and soft tissue matrix. Subsequently, cryotherapy is applied to the treated area for approximately 5-10 min to limit any post-treatment soreness.
History. The athlete was a 20-yr-old junior offensive guard from a Division III college who presented on April 15, 1994, to our facility with a chief complaint of right chronic ankle pain with marked decreased range of motion. He complained of pain with activity reaching about 6 on a scale of 10. He also complained of significant pain in the ankle with popping and grinding. He has a long history of recurrent ankle sprains, five for each ankle, dating back to December 1989. Past medical history included two arthroscopic surgeries on his right ankle, with subsequent physical therapy and home rehabilitation exercises. The purpose of the initial arthroscopic surgery in January 1990 on his right ankle was to remove bony fragments. He attended physical therapy for 5 wk with good results (no pain with running and good range of motion). During the fall of 1991, he started having pain again with popping, grinding, and decreased range of motion. Review of systems was unremarkable and they reveal no history of hypertrophic scarring or keloid formation. Orthopedic evaluation with plain x-rays at that time demonstrated additional bony fragments and arthritic changes. Over the ensuing months he continued to have these symptoms and developed locking of his right ankle. He underwent a second surgery in December 1993 for removal of an osteophyte and scar tissue resection. Subsequently, he had physical therapy for 4 weeks (12 sessions) with improvement in symptoms and was released to continue his home rehabilitation. During this time, he also attended the training room at his college for range of motion exercises and ankle strengthening under the direction of a certified athletic trainer, who maintained contact with the treating physical therapist.
At the time of presentation to our clinic on April 15, 1994, the patient was concerned about continued pain with activity, decreased range of motion, and the persistent need for high doses of nonsteroidal anti-inflammatory medication for his pain. He felt he had reached a plateau (approximately 70% improvement in his preoperative symptoms) and was not getting any better.
Physical examination. The athlete's ankle appeared to be bulky with a 4-cm long immature surgical scar located anteromedially. There was tenderness over the surgical scar, as well as areas of tender palpable scar tissue anteromedially. There was significant thickening and adhesions of the underlying soft tissue around both the lateral and medial malleoli, over the anterior compartment of the lower leg, and over the anterior aspect of the mortis. He had marked decrease in range of motion in all planes.
Impression. Chronic right ankle pain with loss of function, decreased range of motion, dysfunctional scar tissue surrounding the right ankle, and an immature post-surgical dermal scar.
Treatment. Physical therapy in the form of ASTM. two times per week for 7 wk (05/02/94-06/16/94) included the following: cryotherapy for 10 min post-treatment; active stretching exercises as prescribed by the therapist; a home flexibility program for the gastroc and soleus muscles; and continuation of inversion, eversion, plantar flexion, and great toe extension range of motion as before.
Imaging studies. MRI imaging of the right ankle was performed with a 1.0 tesla imager (Vista Picker International, Highland Heights, OH), with use of a head coil supplied by the manufacturer. The following pulse sequences were used: 1) T1-weighted coronal sequence: 700/20 (repetition time in ms/echo time in ms), with 4 mm sections and 1 mm intersection gap, 200 × 256 matrix, 20 cm Field of View (FOV), and one signal averaged; (2) multi-echo (proton density, T2 weighted) with axial and sagittal sections; 3) T1-weighted axial sections (slice thickness 6.0 mm). Gadolinium soft tissue enhancement was not used.
Measurements of ankle dorsiflexion, plantarflexion, inversion, eversion, and soleus flexibility were taken on 05/02/94, 05/16/94, 05/25/94, and 06/22/94. Additionally, ratings of pain at rest, pain with sporting activity, and use of nonsteroidal anti-inflammatory medication were recorded (Table 1). The athlete's ankle pain with activity ceased, his range of motion increased, the surgical scar matured, and the excessive fibrotic connective tissue around the ankle softened and diminished. Specifically, dorsiflexion increased from 5 to 10°; plantarflexion increased from 35 to 47°; inversion increased from 20 to 42°; and eversion increased from 15 to 26°. Also, soleus flexibility increased from 10 to 18°. Pain at rest remained at zero and pain with activity decreased from 6 out of 10 to 0 out of 10. The athlete also stopped taking nonsteroidal anti-inflammatory medication for his ankle pain.
MRI scan results obtained on 05/02/94, 07/21/94 (4 wk post-treatment), and 08/09/94 (6 wk post-treatment) demonstrated extensive scar formation around the right ankle, most prominently over the anteromedial aspect and evidence of injury to the talar dome, i.e., osteochondral fragment near the lateral talar dome. There were no significant changes when comparing these scans. Photographs of the surgical scar that were taken before and after treatment demonstrate evidence of scar maturation and a reduction in the soft tissue about the medial malleolus.
Despite significant measurable changes in flexibility and clinically observable evidence of excessive scar tissue regression in the skin surface as well as in the underlying soft tissue, MRI scans at 4 and 6 wk post-treatment failed to reveal any qualitative or quantitative alterations in the soft tissue structures. Failure of the MRI scans to demonstrate any soft tissue changes may result from timing of the scans, lack of resolution, or lack of contrast material. Newer scanners with stronger magnets and more powerful computer software, coupled with soft tissue enhancing agents, may afford better resolution to detect changes in the connective tissue (7,8,11). Further investigation into alternative imaging studies will be needed for future studies.
Despite a massive array of treatment modalities currently available to the physical therapist and certified athletic trainer, many injuries can leave an athlete with persistent pain and dysfunction that prevents him/her from returning to full activity without limitations. Traditional conservative and surgical treatment of post-traumatic scar tissue is often difficult and may produce disappointing outcomes at a significant cost. Also, for many patients surgery may not be an effective or reasonable option. Therefore, hypertrophic scar tissue may leave the affected patients with permanent disability and pain without other viable treatment options. Finding an alternative to surgery or a more effective conservative treatment for excessive soft tissue fibrosis would help reduce medical costs and have a significant impact on the quality of life of individuals with these afflictions. An effective noninvasive treatment would also greatly benefit industrial and factory workers, as well as the recreational and competitive athlete.
Currently, at our institution there are ongoing studies comparing standard physical therapy treatments protocols versus ASTM in the treatment of several forms of tendinitis and repetitive stress injuries (12). An animal model on rat Achilles tendon injuries revealed ASTM leads to increased fibroblast recruitment and activation as well as increased fibronectin production (2). Fibroblasts are responsible for laying down new soft tissue matrix and collagen. By increasing fibroblast activity, ASTM was able to enhance the healing process in this animal model. Initial pilot study results, clinical outcomes analysis, and case reports such as this one demonstrate that the ASTM form of physical therapy deserves further investigation as an important adjunct in the conservative treatment of hypertrophic scar tissue. Further studies are needed to determine the depth of ASTM effectiveness into the soft tissues and how ASTM is effected by other forms of manipulation.
In our clinical experience, ASTM has been very useful in increasing the efficiency and effectiveness of conservative treatment for excessive soft tissue fibrosis. This clinical case report provides some additional support for the concept that controlled microtrauma can lead to subsequent regression of scar tissue in and around various soft tissue structures. Many larger controlled clinical and basic science studies are needed to confirm these results and further enhance this modality's efficiency.
Several treatment modalities are available to the physical therapist to treat musculoskeletal injuries. ASTM. was used to successfully treat chronic ankle pain and post-traumatic fibrosis in an athlete after 5 months of conventional rehabilitation failed to alleviate the athlete's symptoms, thus allowing the athlete to resume playing football. ASTM may provide an effective treatment option for the conservative treatment of excessive connective tissue fibrosis.
1. Buckley, P. D., W. A. Grana, and M. S. Pascale. The biomechanical and physiologic basis of rehabilitation
. In: Clinical Sports Medicine.
W. A. Grana and A. Kalenak (Eds.). Philadelphia: W. B. Saunders, 1991, pp. 233-250.
2. Davidson, C. J., L. R. Ganion, G. M. Gehlsen, B. Verhoestra, J. E. Roepke, and T. L. Sevier. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med. Sci. Sports Exerc.
3. Farmer, J. A. and A. C. Pearl. Provocative issues. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds.). Park Ridge, IL: American Academy of Orthopedic Surgeons, 1990, pp. 781-791.
4. Garrett, W. E. and J. Lohnes. Cellular and matrix response to mechanical injury at the myotendinous junction. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds.). Park Ridge. IL: American Academy of Orthopedic Surgeons, 1990, pp. 215-224.
5. Gross, M. T. Chronic tendinitis: Pathomechanics of injury, factors affecting the healing response, and treatment. J. Orthop. Sports Physiol. Ther.
6. Harrelson, G. L. Physiologic factors of rehabilitation
. In: Physical Rehabilitation of the Injured Athlete.
J. R. Andrews and G. L. Harrelson (Eds.). Philadelphia: W. B. Saunders, 1991, pp. 13-39.
7. Herzog, R. J. Efficacy of magnetic resonance imaging of the elbow. Med. Sci. Sports Exerc.
8. Kabbain, Y. M. and D. P. Mayer. Magnetic resonance imaging of tendon pathology about the foot and ankle. J. Am. Pediatr. Med. Assoc.
9. Kibler, W. B. Concepts in exercise rehabilitation
of athletic injury. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds.). Park Ridge, IL: American Academy of Orthopedic Surgeons, 1990, pp. 759-769.
10. Leadbetter, W. B. Cell-matrix response in tendon injury. Clin. Sports Med.
11. Panageas, E., S. Greenberg, P. D. Franklin, A. P. Carter, and D. Bloom. Magnetic resonance imaging of pathological conditions of the Achilles tendon. Orthop. Rev.
12. Sevier, T. L., G. M. Gehlsen, J. K. Wilson, S. A. Stover, and R. H. Helfst. Traditional physical therapy
versus augmented soft tissue mobilization (ASTM.) in the treatment of lateral epicondylitis. Med. Sci. Sports Exerc.
27(Suppl. 1):S52, 1995.
13. Stauber, W. T. Repair models and specific tissue responses in muscle injury. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds.). Park Ridge, IL: American Academy of Orthopedic Surgeons: 1990, pp. 205-213.
14. Walton, W. C. Clinical relevance of sports-induced inflammation. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds). Park Ridge, IL: American Academy of Orthopedic Surgeons: 1990, pp. 149-154.
15. Woo, S. L. and L. V. Tkach. The cellular and matrix response of ligaments and tendons to mechanical injury. In: Sports-Induced Inflammation: Clinical and Basic Science Concepts.
W. B. Leadbetter, J. A. Buckwalter, and S. L. Gordon (Eds). Park Ridge, IL: American Academy of Orthopedic Surgeons: 1990, pp. 189-204.
16. Cantu, R. I. and A. J. Grodin. Myofascial Manipulation: Theory and Clinical Application.
Gaithersburg, MD: Aspen Publications, 1992, pp. 5-20.