Working with scars
"Scars are just another kind of memory.” ― M.L. Stedman, The Light Between Oceans
When you think about massage therapy, scars may not be one of the areas that first comes to mind. In fact, we may cover them up, avoid looking at them and touching them ourselves, and often not think that they are important to mention to our massage therapist. Perhaps we intentionally don't mention them, or make a point of mentioning that we don't want them touched at all during massage. I've encountered all of these situations as a massage therapist and they are all completely understandable. Depending on the scar and the situation surrounding how it came about, scars can represent painful or traumatic events, a loss of some sort, memories that we want to forget. They can also represent survival and strength. Whether a scar is related to a childhood injury, c-section, major surgery, cancer treatment or burns, scar tissue has some differences to normal tissue.
A scar is a collection of fibrous tissue that forms to replace lost epidermal and dermal tissue. Scar tissue is comprised of less elastin and more collagen fibres. This means it lacks the elasticity and flexibility of normal tissue. It's role is repair, to cover and provide a barrier. As such, it may not have the same amount of strength or functionality as normal tissue. There are a number of types of scars. Atrophic scars are flat and depressed with an inverted centre below the surrounding skin, they often occur as a result of acne or chickenpox, being caused by inflammation which destroys collagen and leaving an indent. Contracture scars result from contractile wound-healing where new tissue shrinks and shortens, causing tightness and restricted movement due to the tissue contracting over the area. Contracture occurs before the scar is fully matured and is often associated with burns. Contracture scars can be shiny, raised, irregular and hypertrophic and if deep, can affect muscles and nerves. Widespread (stretched) scars appear when fine lines of surgery scars become stretched and widened in the weeks following surgery. They occur as a result of the tissue around the wound being under tension while healing. A scar may become more widespread over a period of months. Keloid scars result from a healing process that has become dysfunctional. They are smooth, elevated, widespread overgrowths of tissue and extend beyond the original injury and can be thickened. They can continue to grow, with extensions in to normal tissue and can be associated with an inflammatory skin disorder. Keloid scars can result from acne, burns, cuts and other types of skin trauma. They are most common in people with dark skin and can be painful, itchy and restrict movement. Hypertrophic scars are raised, red scars similar to keloids but remain within the boundary of the original injury. Over time they become flatter and lighter. The tissue is generally thicker than normal tissue and can restrict movement. A good visual overview of scar types can be found here and here.
Research indicates that, when comparing normal tissue to a number of scar tissue types (keloid, hypertrophic, normotrophic), the orientation of collagen fibres in scars is in a more parallel manner, which may account for it's more rigid structure. Where a scar heals in a more disorganised arrangement, this is considered to be fibrosis. For scars that form as a result of burn wounds, these can be more contracted causing functional impairment. These differences in scar tissue can affect flexibility and functional range of movement and also quality of life. Some scars can be numb or painful, due to nerve damage, compression or some sort of impingement.
I have worked with a number of clients with scars over the past few years - treating a range of scars including hip and knee surgery scars, abdominal, spinal surgery and mastectomy scars. With a number of clients who I worked with over a number of sessions, my clinical observations were of changes to the texture and mobility of the scars, improvements in movement and flexibility of the areas/limb affected, reduced pain in the area(s) affected, and improved confidence and attitude (acceptance) in relation to the scar. Recently I attended a 3 day workshop on working with scars with Marjorie Brook from Marjorie Brook Seminars. Besides getting a thorough overview of scar tissue - what it is, how it differs from normal tissue, causes and types of scars and effects of scars, the scar tissue release techniques taught by Marjorie in her S.T.R.A.I.T course were instantly applicable in clinic. What I observed from the hands-on work we got to do on a group of volunteers with a variety of scars, was that the scar tissue slowly softened, appeared and felt smoother and took on a broader and less ridged/risen appearance. Feedback from the volunteers themselves was positive, with many reporting a felt difference to the scar in terms of restriction and physical quality of the scar. It would be interesting to know how this plays out over time and if the felt changes remain.
The photo below is of a right clavicle scar originating 4.5 years ago as a result of a medial and lateral fracture of the clavicle, followed by a subsequent medial refracture 6 months later. The fracture required 4 surgeries, one initial surgery to plate the fracture, followed by three subsequent surgeries to clean and debride the wound due to problems with infection as a result of the plate, and finally surgery to remove the plate and close the wound. As a result, the scar tissue is irregular, with a widespread (stretched) section at the lateral aspect of the scar which also has a dip or divet in the tissue, there was also a small round drain scar at the end of the main scar. Hypertrophy has reduced over time. There is a numb area at the outer edge of the scar, extending slightly below the clavicle and to most of the anterior deltoid. There is also a small area barely visible to the eye which has a single bristley, fibre-like texture to it, dissimilar to a hair. At the course, there were two instances where remnants of stitches that had not completely been removed 5-10 years prior, came to the surface and emerged during the scar work. This is not uncommon during this work and I have since heard that at the other New Zealand workshop taken by Marjorie Brook, one student had a staple emerge from a 6 year old scar they were working on.
Scar treatment was done on the scar for 10 minutes, using seven different techniques to see what differences might be made to the tissue. By the end of the session, the appearance of the scar at the lateral edge was flatter and wider. The small dip/divet was not a palpably noticeable and the scar felt softer. There was no pain or tenderness in the area as a result of the treatment, i.e. the area did not become hypersensitive. The recipient did not find the work uncomfortable. The photo below shows the scar after treatment. Further sessions will be carried out to see if any other changes are possible and if the textural changes from the first session remain.
I'm continuing to look at research on scar tissue and manual therapy. While there does not appear to be extensive research is this area, anecdotally it appears to be clinically effective, with greater efficacy in the area of post-surgical scars. The problem is that at present there is no consistent treatment approach and outcomes are not measured in a standardised way. Perhaps this area has not attracted a great deal of research funding, however it is an area that warrants more research.
Some research indicates that stretching of scar tissue may cause a change in tissue from fibroblast to myofibroblast which contributes to wound healing and tissue repair. If this is the case, this may in part reveal why manual therapy may be useful for addressing scar adhesions, fibrosis and reduced extensibility of scar tissue. There may well likely be other factors as well, perhaps body image, self efficacy, attitude and confidence related to the scar. One of the volunteers at the course who had undergone ankle surgery 6 months prior stated at the end that the scar work she had received from the course participants had given her a sense of hope (for recovery). Things like this can be just as important as physical changes.
I'm now incorporating this scar tissue work into my soft tissue and nervous system approach in my clinic work. If you have scars which bother you and would like to see if this approach could benefit, contact me. It is slow, gentle work and the work is carried out in a way that works respectfully and with the individual's tolerance levels. Some people may tolerate 30 minutes working on an area, while for others 5 minutes may be enough. The work can also very easily be combined with more general massage therapy. As always, it's about what works for the individual client.
Brook, M. (2010). The S.T.R.A.I.T Method: Scar Tissue Release Foundations. Wantagh, NY: Turning Leaves Productions, LLC.
Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology (5th ed.) St. Louis, Mo: Elsevier.
Fourie, W. J., & Robb, K. A. (2009). Physiotherapy management of axillary web syndrome following breast cancer treatment: discussing the use of soft tissue techniques. Physiotherapy, 95(4), 314-320.
Junker, J. P., Kratz, C., Tollbäck, A., & Kratz, G. (2008). Mechanical tension stimulates the transdifferentiation of fibroblasts into myofibroblasts in human burn scars. Burns, 34(7), 942-946.
Sexton, P., & Chambers, J. (2006). The importance of flexibility for functional range of motion. Athletic therapy today, 11(3), 13-17.
Shin, T. M., & Bordeaux, J. S. (2012). The role of massage in scar management: a literature review. Dermatologic surgery, 38(3), 414-423.
Verhaegen, P. D., Van Zuijlen, P. P., Pennings, N. M., Van Marle, J., Niessen, F. B., Van Der Horst, C. M., & Middelkoop, E. (2009). Differences in collagen architecture between keloid, hypertrophic scar, normotrophic scar, and normal skin: an objective histopathological analysis. Wound Repair and Regeneration, 17(5), 649-656.