Updated: Jan 20, 2019
Our bodies are really good at healing themselves IF we give them the chance to do so. In this article I explain the three phases of the healing process and what you should do in each one to get the best results. Understanding this is the key to a speedy and successful recovery. Remember, you can join my Facebook group to watch livestreams about injury prevention and ask your injury related questions.
In this article:
How injuries heal
Why understanding the phases of healing is important
How injuries heal
This may sound like a strange thing for a physio to say, but you really don’t need anyone to rub, poke or zap your injury better. Our bodies have evolved over millions of years and are very capable of healing themselves. In fact, getting a strong massage during the wrong phase of healing can actually make your injury worse!
Treatments like massage, acupuncture, electrotherapy etc. can help to alleviate the symptoms e.g. pain and stiffness that you experience, but they don’t actually affect the healing processes that happens inside your cells. What your body needs to recover is the right mixture of rest and exercise. It will all make sense when you read the sections below.
There are 3 phases in the healing process of injuries.
The Inflammatory Phase
The Proliferation Phase
The Remodelling Phase.
How long these phases last for, depends on how badly you’ve injured yourself. There’s also always some overlap between when one phase stops and the next one starts.
Why understanding the phases of healing is important
Your body’s most important mission in this world is survival. It is always worried about the possibility of starvation and as a result won’t waste energy on things it thinks that you don’t need.
For example, you may want big muscles but just “wanting” them is not enough to actually develop them. You have to tell your brain that you need them to be stronger and you do this through giving it a stimulus. In the case of bigger muscles, the stimulus is when you pick up heavy weights. The brain registers that your muscles are currently struggling with the job at hand and that acts as the stimulus to produce stronger and bigger muscles.
Most injuries (sprains, tears, breaks etc.) are associated with cell damage. These damaged cells have to first be removed (inflammatory phase), new cells have to then form (proliferation phase) and these new cells then have to grow stronger to match the original ones (remodelling phase).
This is the reason why you need to use a carefully graded treatment programme consisting of the right amounts of rest and exercise to allow your injury to heal back to full strength. If you exercise it too vigorously too soon, you’ll just break the weak new cells down. If you just rest the injury and don’t do any exercise, the cells will likely not regain their full strength because you’ve not indicated to the brain (through graded exercise) that it needs to rebuild it back stronger please.
This will make more sense when you read my explanations under each of the phases.
The inflammatory phase starts as soon as you injure yourself and usually lasts between 4 to 6 days.
Simply put: when you injure yourself cells, fibres and blood vessels are torn or disrupted and you get some bleeding. This signals the start of the inflammatory phase.
First a clot forms in the wound to stop the bleeding. The clot also provides scaffolding for other cells to attach to during the healing process. This is in a way similar to the scab that forms on your skin when you cut yourself.
The injured cells then send out a distress signal which calls all the ‘cleaner’ cells needed for the process of inflammation to take place. Inflammation has been given a bad name over the years and patients are often keen to take anti-inflammatory drugs as quickly as possible after an injury to “stop the inflammation”.
Thing is, inflammation is extremely important for wound healing and research suggests that you can delay or hinder your recovery from muscle and bone injuries by taking anti-inflammatory drugs, e.g. ibuprofen or naproxen, within the first few days of sustaining an injury.
SMOKING and CORTICOSTEROIDS (cortisone) also interfere with wound healing and can either cause non-healing or poor healing. Corticosteroids may have a role to play in chronic injuries, but should be avoided during the acute stages of any sports injury.
You should see inflammation as the body’s way of cleaning the wound and preparing it to rebuild strong tissue. During this time certain cells migrate into the wound and destroy bacteria and cell debris. They are preparing the cell for the next phase, the proliferation phase.
The inflammatory phase is characterised by:
Warm to touch
What to do during the inflammatory phase
Treatment during the inflammatory phase should be aimed at protecting the injured area to prevent further injury of the weakened tissue and also to limit how much it bleeds.
Stop what you’re doing. Continuing to train or play your sport when you’ve injured yourself, will worsen the injury and bleeding and your recovery will take much longer.
Limit the bleeding. Apply ice and gentle compression for 10 minutes after sustaining the injury. It may also help to elevate the body part if possible. This helps to limit the internal bleeding without decreasing the inflammatory response. Excessive bleeding can cause lots of pressure in the muscle or joint. This increased pressure can cut off the blood circulation and oxygen supply to adjacent cells and you can end up with more damage than what the original injury actually caused. WORD OF CAUTION: applying the ice for longer than 10 minutes or applying very strong compression, may have the opposite effect.
Limit swelling by applying ice and elevating the body part. Excessive swelling can also cause increased pressure in the surrounding tissue which, as explained above, can lead to a more severe injury. You can apply ice every two hours during the first 3 to 5 days of recovery.
Protect the body part. You may find that using a crutch or sling for a day or two after injury can help speed up your recovery in severe cases. The cells and fibres are very weak immediately after an injury and you will help their recovery if you can decrease the load on them for a few days. Crutches, splints and slings should never be used for more than 2 days without consulting a physiotherapist of medical professional, since prolonged use can also hinder your recovery. NOTE OF CAUTION: Being over-protective of an injury can lead to poor recovery outcomes.
Gentle movement. Moving the body part within its pain free range can help to decrease your pain and help recovery. I usually tell people to start doing this on the second day after injury depending on how bad it is. So, if you injure it today, start moving it from tomorrow.
The body has used the inflammatory phase to clean the injury site and it now uses the proliferation phase to rebuild the tissue. During this phase new blood vessels and cells are formed and collagen fibres are laid down. This phase usually starts around day 4 post injury and can last up to 14 days depending on the severity of the injury.
During this phase the injury is busy healing but the ligament, muscle etc. (whatever you’ve injured) is still very weak. The new cells and collagen fibres do not yet look like they will in healthy, uninjured tissue. They are randomly laid down and not organised to form a strong, functional scar.
For a scar to be strong all fibres has to be aligned in the direction that it has to withstand force in. The scar is thus getting stronger during this period of time but is still very vulnerable. If you load it too quickly, e.g. strong exercise or returning to sport too quickly, you can easily tear it again.
Think of the cells as being a mess of spaghetti in your plate during this phase. For the scar to be strong, all of the spaghetti strands have to align next to each other. This will happen in the remodelling phase.
What to do during the proliferation phase:
Movement but within the limits of pain.This means that movements should be done PAIN FREE. Movement is important since it tells the body to form new cells and also in what direction it should align the new cells and collagen fibres.
You may still have to protect the body part to some degree by limiting how much force you put through it. If for instance your ankle sprain is severe enough to require you to use crutches, you should usually progress from using 2 crutches, to using 1 crutch, to using no crutches within 2 weeks. Again, this is heavily dependent on the extent of your injury and is best discussed with your physiotherapist.
I’m a big advocate of relative rest. Remember that rest alone is not good for injuries? Relative rest means that you continue training but you just cut the aggravating exercises out or you reduce the weight or intensity to a level that you don’t aggravate your injury. This way you can keep some of your fitness while ensuring your injury heals in the best way possible.
This phase can start at 8 days after injury and last up to 1 year depending on the severity of your injury. Lower back injuries can sometimes take up to 2 years to fully recover! Doing the correct rehabilitation exercises during the remodelling phase is extremely important – I’ll explain why.
The first collagen fibres and cells that are laid down are very thin and not aligned in the same way as normal, healthy tissue. (Think of your spaghetti bowl again.)
By moving the body part and doing stretches and exercises, you tug on the scar tissue. This tugging acts as mechanical stimulation to tell the body in what direction it should align the fibres. It also acts as a signal for it to form stronger cells and collagen fibres.
This allows the scar to become stronger over time. Progressively loading the scar tissue is thus key to creating a strong functional scar.
It is important to understand that it can take a very long time for an injured muscle, ligament etc. to get back to full strength. Research has shown that “at 1 week, the wound has only 3% of its final strength; at 3 weeks, 30%; and at 3 months (and beyond), approximately 80%.”
What to do during the remodelling phase
From the above it should be clear why it is so important to go through a carefully graded strengthening programme before returning to your sport. There is unfortunately no one size fits all recipe for rehabilitation. It’s best to seek guidance from an experienced physiotherapist who is willing to liaise with your personal trainer or coach.
I find that my patients recover much better when I can team up with their PT by providing certain parameters for them to work within until the injury is fully recovered. This way my patients loses a minimal amount of their fitness!
You may also be able to play sport before you have gained full strength if you use appropriate braces or taping techniques. I do video consultations via Skype and you’re welcome to contact me if you would like a bespoke treatment programme to help you recover from your injury.
You can make sure that you do not delay your recovery from sports injuries through understanding the phases of healing and doing the correct exercises in each phase.
Broughton, G., 2nd, Janis, J. E., & Attinger, C. E. (2006). Wound healing: an overview. Plast Reconstr Surg, 117(7 Suppl), 32e-S.
Paoloni, J. A., Milne, C., Orchard, J., & Hamilton, B. (2009). Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use. British Journal of Sports Medicine, 43(11), 863-865.
Wheeler, P., & Batt, M. E. (2005). Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. British Journal of Sports Medicine, 39(2), 65-69.