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Scar Tissue 101

Posted by john h on 6/21/04 at 21:41 (153664)

By Jonathan Kraft, CMT

First off, let me congratulate you that you are trying to do your own healing!  So many people go to their MD/DO/physical therapist/chiropractor/massage therapist, etc. and expect that that person is going to be able to heal them completely.  I often tell my clients who have chronic conditions (health related issues which last a long time) that even if they come for massage three times a week, they won't see the kinds of improvements they want until they're willing to do their own work to improve (be that stretching, doing their own massage, eating right, ice/heat, etc.).  So congratulations on your willingness to do your own healing!

While I have never had multiple surgeries on the same area, I have had four surgeries over the past 8 years (including an ACL replacement in my right knee), and understand the pain that often accompanies scar tissue.

I was fortunate with my ACL injury in that I had a surgeon who believed it was important to keep the knee moving and stretching.  When I came to (from surgery), my knee was already moving in a machine called a CPM unit (Continuous Passive Movement – delivered by Colorado Professional Medical), which allowed me to set the speed and degree of the angle which my knee was moved to.  It constantly moved my leg up and down, bending the knee each time.  When I got home, I automatically started using the CPM unit again, which had been delivered to my house and which the delivery person had taught me how to use prior to surgery.  I increased the speed and angle of degree every day and stopped using the CPM unit one week after surgery, because I had gotten back the full range of movement which the CPM unit allowed for (120 degrees).  It was about 6 months after my knee surgery when I learned that some orthopedic knee surgeons believe in keeping the knee immobile for up to a month after ACL surgery.  I was surprised and disappointed to hear this because keeping the knee immobile for that long of a time is setting the person up for a longer (and often more difficult) recovery.

Scar tissue develops all the time in muscle.  When you pull muscles, some amount of scarring can occur.  That scar tissue can be gotten rid of through normal stretching and activity.  However, when serious scar tissue develops (as is often the case in whiplash and surgery) it can take a lot more to get that tissue to be reabsorbed into the body.  If it is not gotten rid of, it can cause numbness of the nerves in an area, decreased flexibility, and ultimately, pain.

Many people think that scar tissue will simply go away after time, but most often, it does not.  It is an injury which needs to be worked with in order to re-heal as effectively as possible.

Healing, depending on whom you talk to, is a complex process.  Some people believe that prayer alone will heal, while others believe that only pills and western medicine will heal.  Some have great success with acupuncture, others with chiropractic, and others with nutrition.  I believe that healing is a combination of all of these things.

What I offer here is advice on how to massage scar tissue, with the hope that you will be able to use it and effectively break up your scar tissue.  I hope this works for you, and hope as well that you will let me know your results.  I hope you'll incorporate whatever else works for you, as that will help speed up your healing.  Also, a point I'll make is that massage is all hands-on, so describing it using a non hands-on medium like email or the Internet is a bit difficult; I'll do my best, but if there's something you don't understand, please email me.

There are two levels of scar tissue which you can address with massage.  One is the skin level, and the other is the muscle level.  I will first address the skin level, and then address the muscle level.

When scar tissue develops, the brain/nerve connections, which have to happen to detect touch, never develop or develop very weak.  This is because scar tissue develops primarily to heal and protect, and only secondarily to feel sensation.  In other words, the tissue naturally develops a weak ability to notice sensation while it is being created.  Because most people don't use or touch a part of the body which had a kind of trauma to it, (like that which comes from surgery or a car accident,) the tissue doesn't receive any stimulation.  This means that in many cases (after surgery or other trauma), the secondary function of scar tissue, sensation, never or barely develops.  Over time, this lack of sensation causes an area to be touched less (after all, why would a person touch an area that had no feeling?).  It receives less touch, and because of this, it receives less stimulation, which means that the nerve endings and connections develop less, which means that the area has less feeling, so it is touched less; and the process goes on until there is a thick mass of non-sensory tissue, most of it probably scar tissue.

I have larger scars on two of my fingers (from surgery).  While sitting in class or somewhere where I only need to listen to what's going on, I will take a sharpened pencil, paper clip, nail file, or even a needle (something with a small point), to see what kind of feeling I have in a specific spot on the scar.  I will really pay attention to what kinds of sensations I'm having in the spot that I'm touching.  I don't pierce the skin, as that would only cause further injury to a healing area, but I do test to see how much sensation I have.  I have done this since having surgery over 8 years ago.  Over time, the sensations have become stronger and more definite in the scar tissue itself, and as the sensation has come back, the scar tissue has been reduced (not gone away), and become much less painful.  It probably also helps that I am a massage therapist, and while working on a client, I use the sensations coming from my hands to understand when a muscle is tight, or when it has knots, etc.  I pay a lot of attention to the sensations coming from my fingers.

For the skin level on a knee, you will want to work on the scar itself.  Touch it with an object with a small point in several specific spots on and around the scar.  Can you feel the sensation?  If not, start by going around the edge of the scar.  Can you feel that sensation?  Notice what it feels like.  Does it make a difference if you press hard or light?  What about if you move it around a little?

Set an intention that you want to feel sensation in that specific point you are touching.  By doing this, and focusing your attention on it, you are forcing your brain and your body to focus in on the sensory information you should be receiving from those nerves.  Just like working to develop more flexibility by stretching the same muscles over an extended amount of time, you are working to develop those nerves on a daily basis by using different kinds of touch.  Over time, you will redevelop more feeling in the area than you previously had.

Moving on to the deeper layers, it is important to know that just as scar tissue develops on the outside layers of the skin, it develops in the muscle.  Muscle can be divided into two groups with regard to scar tissue; areas which can be worked through direct massage, and those which are much more difficult to work with using massage.  Most massage therapists have developed an ability to work at a deep level within the muscle that most non massage therapists have not.  For the areas which are difficult to get to when doing massage yourself, I would recommend getting into a regular stretching program and getting regular massage.  Most recreation/fitness centers now offer Yoga classes.  If yours doesn't offer Yoga or another kind of stretching program, ask them why they don't, and consider joining one that does.  Also, consider getting regular scar tissue massage for a while.  If you don't know a good massage therapist, ask a friend who gets regular massage, or even look up a CMT in the phone book.  You can find criteria for selecting a massage therapist by clicking here.  You may have to take some time researching, but it will be worth it when you find a therapist with whom you feel comfortable, and schedule an appointment.  Massage can range from $20 to upwards of $300/hour.  The cost doesn't necessarily determine the quality of the massage, so don't think you have to pay an arm and a leg to get a great massage. Let the therapist know your wants with regard to getting your scar tissue broken up, and they should be able to help you.

Another thing to consider (when getting massage for a trauma area) is that the muscles around the area will be tightening up in protection of the injury.  In the case of a knee surgery, this would be the quadriceps, hamstrings muscles, calf muscles, and all the muscles on the anterior (front) side of the lower leg.  A therapist should know to work these muscles, and you can rub them yourself as well to help keep them loose.

On to the level of scar tissue in the muscle that you can work yourself, cross-fiber technique can be very effective.  If your scar tissue is right over the knee cap you'll probably have to lift it up off of the knee and squeeze it between your thumbs and forefingers to get to it.  However, if it is in a more substantial set of muscle (lower quads), you will be able to work your fingers across the muscle and use a cross-fiber technique on the muscle (or have someone do this for you).


Start by using a cream, lotion, or oil (I personally recommend Lotus Touch cream, available from http://www.lotustouch.com) and use it on the area you want to work.   Skinstore.com also sells a few creams and gels, which have been reported to help considerably to diminish the tightness and the overall thickness of scar tissue.  Remember that you are using the massage cream to allow your hands or a tool to more easily move across the skin, so if the skin soaks all of it up, you may need to reapply.  You will then want to work across the muscle fibers.  In the case of the muscles around the knee: as you are standing, most of the muscle fibers go up and down, so you will want to work across the leg.  You can use massage tools and/or implements to get into the muscle deeply and work across the muscle, or you can use your hands.  One good hand position is shown in the picture.  Using this hand position, use the second knuckle (closest knuckle to the hand) on the middle and ring fingers, to get into the muscle fibers of the quads/calves, while the second and pinky fingers glide across the leg.  Move up and down the muscle, making sure to focus on areas where it feels like there is more binding of the tissues.  You can finish by doing a gentle massage on the area to calm it down.  This is one possibility for cross-fibering.  

Whatever hand position or tool you use with cross-fibering, remember that your goal is to break up the scar tissue by going across the muscle, and remember that this isn't going to happen overnight.  By using cross-fibering, you are actually causing minor traumas to an area which promote the healing in that area.  You don't want to re-injure the area to the point where more scar tissue develops because of your working on it.  A generally good way to know how much pressure is enough is that it should be on the level between uncomfortable and painful.  So it should be uncomfortable, but not overly painful.  As far as the time it takes for healing, a good general guideline is that you should give the scar tissue as long to break up (if you're working on it daily) as it did for it to be created.  In other words, if you had surgery two years ago, and you just started working with the scar tissue yesterday, large improvements could take up to two years from yesterday.  Healing doesn't have to take this long, but this should give you an idea of how patient you should be.

In summary:

Work with the scar as often as you think about it. 

It is possible to overwork an area, but not likely that you will with the scar tissue.

Use heat to bring blood to an area, cold to take blood away from an area.

Generally speaking, you will want to take the blood away from an area before you work with scar tissue so that it will hurt less to work with it (the cold of ice will also numb the nerves so you can work with the scar tissue).  You will then want to work with the tissue that is deeper in the muscle, using cross-fibering, while it is cold.  When you are done, you will want to heat the area to bring blood in and carry away the toxins which are released as you break up the scar tissue and open up the area.  (Too much time with the heat can cause an abundance of blood in an area, which can cause swelling and a different kind of pain.  Generally, 20-30 minutes with the heat is a safe bet.)  You will want to use moist heat if possible (i.e. a wet washcloth warmed up in the microwave or something comparable), as it will draw more fluids to the area and encourage the muscle to return to its natural state.  (Don't get the heat so hot that it burns you.)

Working with the scar tissue may hurt initially. 

Pain should decrease over time, but may not fully go away.  Be prepared for this, but don't psyche yourself out.  It does get better.

You can do the work yourself

You can have great results just from working on the scar tissue yourself.  You will be most successful if you will work on it yourself because you are the only one who is with you 24 hours a day, so you can be there all the time to work on it.  However, just like it feels better to get a massage from someone else than it does to give yourself one, you may experience good results from someone else working on you as well.  Just make sure that you communicate with them (and that they are willing to listen) when there is too much pain, or not enough pressure, etc.  Also, there may be cases where you can not reach the scar tissue (i.e. back surgery.  If this is the case, have someone else work with you, and get into a regular stretching program).  Caveat: Make sure you say thank you to the person who is helping take care of you.  They're much more likely to help again.

Be patient.

The human organism is amazing in what it can do, if given the time and resources it needs to do so.  If you re-injure the area by doing more than it can handle (i.e. bungee-jumping two weeks after surgery), don't expect your body to respond well.  Also, eating well can have a huge impact on how quickly the body will heal.  With regard to scar tissue, nutrition plays an important role in how quickly the body will be able to develop feeling in an area and breakdown the scar tissue.  It needs the vitamins and minerals to build tissue, create chemical connections, and carry away toxins.  Make sure you give your body what it needs dietetically.

Skinstore.com has a few great products which have been reported to help considerably to diminish the tightness and the overall thickness of scar tissue.

Re: Scar Tissue 101

Pauline on 6/21/04 at 22:39 (153668)

Good post, but I find people in general people are very hesitant to cause themselves pain, the amount that will actually help them in the long run.
They stop short. I also feel the average person probably doesn't have the strength in their fingers to provide the repetative procedure well enough although it certainly would develop over time.

This is a new doctor to our site with his own idea, but I get the idea from other's posts that we shouldn't trust him. My question is why not at least until we hear back from Goose?

Re: Nice Post

John from MN on 6/22/04 at 09:02 (153684)

John h,

Nice research. The only thing I would add is that their are different levels of scar tissue, and for each level you must push harder inorder to reach the tissue. I hope this works for you.

Re: Scar Tissue 101

john h on 6/22/04 at 09:05 (153685)

Pauline: I welcome Dr. Sandell and his ideas. The more I read the more I realize what he is doing is nothing new it is just something that has not been presented to most of us on the board. I hope very much whoever makes the journey to see him finds help. I took the time to try and find a local PT who used his (or who ever invented it) technique. I am currently undergoing PT using some of his methods but so far the PT is not very much into it. The article I posted on scar tissue 101 makes sense in that he says do not expect resultes in a hurry. It may take months or years. Most of us are looking for a magic bullet and it probably will not ever exist.

Re: Scar Tissue 101

Buck T. on 6/22/04 at 09:42 (153689)

Been looking for tips on massaging scar tissue. This is really helpful. Thanks.

Sincerely, Buck

Re: wonderful !!!!

Marty in SLC on 6/22/04 at 09:46 (153690)

John h,

Did you ask someone to write this up or did you find it on the net? It is great !!!!!!!!!! I won't as much of this knowledge as I can find !!!!!!!!

I'm wondering why this person addressed the knee and not the fascii? Anyway I do believe we can all learn from this. My hat goes off to you John. This is the kind of stuff I thought we were going to see from Dr Sandell.


Re: PS

Marty in SLC on 6/22/04 at 10:08 (153692)

For those of us that have had PF release and or TTS release all the imformation the better, if applied correctly.

Re: Scar Tissue 101

Ed Davis, DPM on 6/22/04 at 10:26 (153697)

Good post. Although, if deep scar tissue was the major issue I would look at other options too. Our body is in a state of flux, building up and breaking down tissue. Our bodies' produce enzymes such as hyaluronidase which breaks down scar tissue. Given the choice between weeks of painful deep massage versus one shot of synthesized concentrated hyaluronidase, I would probably accept the latter if it was my body.

Re: Scar Tissue 101 - for TTS too?

chrisb on 6/22/04 at 10:56 (153698)

John a very useful post, thank you.
My question is - how much/how deep can one use massage on a scar after TTS surgery? Is it a good or bad idea to massage the tarsal tunnel area (here the scar is) vigorously?

Re: Scar Tissue 101 - for TTS too?

john h on 6/22/04 at 11:42 (153701)

Chrisb: Prior to my TTS surgery I had an orthopedic surgeon tell me one had to be very careful when massaging a foot that possible had a trapped nerve as you could do some serious damage. With that in mind I would be very careful massaging a area where TTS is suspected. I had TTS surgery. Some of the area where the surgeon works may be to deep to massage anyway. The big scar that runs up the inside of the ankle about 5-6' has never been a problem area and I cannot palpatate any scar tissue in that area anyway.

Re: Scar Tissue 101

Buck T. on 6/29/04 at 19:32 (154177)

John: Thanks. I have scar tissue from pf incission on side of heal near insertion area. POD pretty sure nerve trapped. Any tips on massaging the area. POD says to keep massaging.

Sincerely, Buck

Re: Scar Tissue 101 - for TTS too?

Buck T. on 6/29/04 at 19:39 (154178)

Hi John, again. Just read last post. So, if nerve is trapped in scar tissue I guess I need to be careful about massaging that specific area. Maybe I should massage around area. I know I do need to talk to POD again about this.

Thanks, Buck

Re: Scar Tissue 101 - for TTS too?

john h on 6/30/04 at 11:25 (154233)

Buck.If you have an irritated nerve and the massage causes further irritation. The Ortopedic Surgeon I talked with said you could do so critical damage depending on just how much you further irritated the nerve. You for example could have something pressing on a nerve in the tarsal tunnel. Something like a vericose vein or what ever. Deep and heavy massage is possible going to cause what ever is pressing on that nerve to further irritate it or worse. It may not be scar tissue at all that is pressing on the nerve so massage may be very counter productive if you have a trapped nerve problem. Massage is and can be good thearpy for many things but there are some things when it is not a recommended procedure. Some years ago I had my PF pain level down to around a 1-2. I went to a massage therapist who's approach was a really really heavy and deep massage to the feet. Her feeling was the more pain the better. After that visit my feet were terrible for at least three months..

Re: Scar Tissue 101

john h on 6/30/04 at 11:29 (154236)

Buck: I am still massaging my feet daily (cross friction type) in the same area where the heel and fascia attach. In doing this I have found some pain spots I did not know existed. I had always had just one spot I thought but doing this daily I have found several and not only on the foot with that had surgery but also the other one. It is not as much fun as a massage therapist but I think I am hitting the correct area better.

Re: Scar Tissue 101 - for TTS too?

Buck T on 7/01/04 at 14:54 (154341)

Thanks, John: Lots of good info to ponder. Think I will only gently massage fascia and leave scar alone for three days. Been massaging scar and pain really getting worse.

Sincerely, Buck