Healing 101

When we injure ourselves, whether it’s a broken bone, a sprained ankle or a simple skin cut, all of our tissues follow the same stages of healing; inflammation, repair and remodeling. The stages overlap, one stage flowing into another, with elements of different stages happening at the same time. How well the tissue heals depends on many factors including which tissue has been injured, how you manage pain and inflammation and how and when you start to use the tissues again.


Stages of Healing:


1. Inflammation: 

Inflammation seems to be the new buzzword in medicine and has been linked to all kinds of health issues. And it’s true that inflammation in the intestines from food sensitivities and in the joints from arthritis is destructive and should be managed. This is not the kind of inflammation we are talking about here. What we are referring to here is the inflammation that begins with injury and lasts anywhere from four days to three weeks. Immediately after an injury, the damaged tissue is bleeding and without oxygen. This activates your immune system, causing an inflammatory response in the injured tissue. A clot quickly forms and many different kinds of inflammatory cells are attracted to the injured tissue. Over the next several days, debris is removed and cells that are more anti-inflammatory in nature are attracted to the area. These cells will transform into the blood vessels and tissues of the healed injury. It is during this phase that many of the cells that you will need in the next two phases are attracted to the area, called in by the injury and inflammation.


2. Repair:

This phase begins as early as day four and lasts until about day 28. In this phase you begin to make the basic structure of tissue. Basic blood vessels form. You form a matrix, which is sort of like a gel. Into this gel you lay collagen, the fibers that provide structure. The gel gradually firms, trapping the collagen and beginning the healing of the tissue, closing the gap and reconnecting the edges of the injured tissue.


3. Remodeling:

Remodeling is the longest phase and can last as long as two years, depending on the tissue. During remodeling, the basic tissue formation that began in the repair phase is refined. The tissues gradually transform further into the tissue they are meant to be. The ratios of cells and vessels normalize. The collagen fibers become the type that normally occurs in that tissue, the fibers line up along the lines of the forces applied to the tissue and the structural strength of the tissue gradually improves.


Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) After an Injury

Non-steroidal anti-inflammatory drugs (NSAIDs), such as acetaminophen, ibuprofen and aspirin (e.g. Tylenol, Advil, etc.), are often used after an injury to manage pain and inflammation. But many studies indicate that the use of NSAIDs in the inflammation phase impairs healing in the repair and remodeling phases. NSAIDs interrupt the inflammation phase by inhibiting certain enzymes. This interruption limits how many and which cells you have for use in the repair and remodeling phases. (Remember that many of the cells you will use during repair and remodeling are attracted to the area during the inflammation phase.) So you might want to minimize the use of or avoid using them altogether during the first one to two weeks after an injury. On the other hand, studies of NSAID use during the repair and remodeling phases indicate that use during these later phases is not detrimental to healing. In fact, NSAID use during repair and remodeling of ligaments and tendons may in fact improve the quality of the tissue and decrease formation of abnormal scars.

Using ice for inflammation and pain does not interrupt the inflammation phase in the way that NSAIDs do. Cold numbs sensation on the skin and constricts the vessels, decreasing the amount of fluid in the area temporarily, thus providing some relief of pain and inflammation.


Tension and Forces through the Healing Tissue

Providing the correct tension to the repairing tissue can assist healing and improve the final quality of the repair. How and when to apply tension through the healing tissue will depend on which tissue is involved and which phase of healing it is in. During the inflammation phase, correct movement will help reduce swelling and prevent abnormal scaring and loss of muscle mass. During the repair and remodeling phase, tissue specific tension will assist with proper bone formation and healing of muscle, ligament and tendon. It does this by providing the stimulus for reorientation of the collagen fibers in the proper direction and encouraging thicker, stronger collagen fibrils that can withstand greater forces. Knowing just how to do this properly is complicated, so get some help. Have your doctor and physical therapist guide you through the phases and tell you how and when to use the tissues, so you can recover from your injury strong and well healed.


Interested in learning more? Join us for our upcoming Healing 101 lecture on Thursday, September 21st at 6PM. Click here for more details. 

Getting Back to Gardening

By: Gema Sanchez, PT

If you are a gardener in Portland, February is the longest month of the year. You wait for those rare sunny days and bundle up to finish the fall clean up, admire the hellebores and hunt around for the first signs of Spring. And while all that fresh air and sunshine is good for the soul, your body may be a little stiffer than it was in the Fall, putting you at risk for injury. Here are some recommendations to prevent injury as you transition back to the gardening season:


  1. Alternate light and heavy tasks: Analyze what you have to do and determine if it is a light task such as stacking tomato cages or a heavy task such as clearing awkward branches. Give your body a break from the heavier tasks by alternating them with the lighter tasks. For example, take a break from taking out dead shrubs by spending some time tidying up plastic pots from last year’s garden. After moving heavy pots, rest your back and arms by doing a light task such as starting seeds. When you alternate heavy and light tasks, you use your body in different ways, thus reducing overuse.
  1. Take frequent breaks from repetitive tasks. Early spring cleaning often involves repetitive tasks such as clearing debris and weeding. Staying in these forward bent positions for long periods or repeatedly reaching down and coming back up can be very hard on your back. Remember to take frequent breaks to stretch your back and legs and walk around a bit. A good place to start is to take a 10 minute break for every 30 minutes of work.
  1. Sharpen your pruners and saws: Dull blades are not only dangerous but very hard on your hands and arms. Pruning is much easier, more precise and better for you and your plants with sharp tools in good working order. Pruning can also be a repetitive task, so take frequent breaks to rest your hands and arms, especially if you are pruning thicker branches.
  1. Remember your biomechanics: All the basics of proper lifting and carrying very much apply in the garden. Bend your knees, carry objects close to you, alternate sides when you are carrying buckets or watering cans and get help for awkward or very heavy lifting.
  1. Bring your work to you: Whenever possible, bring your work to your level. Use a waist level surface for potting, transplanting, seed saving, tool maintenance and any other task you can easily lift onto the surface.
  1. Cool down with some stretching: After a day in the garden, take a few minutes to stretch out, especially your back, shoulders and hips. Your therapist can help design a program that is right for you. Hold stretches for at least 20-30 seconds and remember stretching should never be painful.
  1. Start out slow: As tempting as it is to spent the entire day working in the garden, consider limiting your time to a few hours the first day. Or at very least, take a good long lunch break, put your feet up and admire you work.

Treating Painful Tendons – Tendinopathy and Its Real Cause

By: Gema Sanchez, PT

tendinopathy, tendinitis, physical therapy
Pain relief and increased strength are a few of the benefits of treating tendinopathy with Physical Therapy.

Pain and tenderness in a tendon, sometimes lasting for many months, is a fairly common occurrence. Many people would still call this tendon pain tendinitis, which means inflammation of the tendon. But when researchers began looking more closely at the structure of chronically painful tendons 20 years ago, they found that many of the painful tendons did not have inflammation. Instead, the tendons showed signs of degeneration without inflammation. These findings indicate that there is much more going on than just inflammation, so the diagnosis of tendonitis was no longer accurate. In an effort to more accurately describe the state of the tendon, a chronic painful tendon is currently diagnosed as tendinopathy, meaning a disorder of the tendon.

Tendinopathy is diagnosed using clinical findings. These include:

  • tenderness/pain with palpation of the involved area
  • pain with activity, stretching and contracting the muscle
  • decreased function
  • gradual onset of stiffness in the tendon
  • sometimes localized swelling and palpable crepitations (a crackling sound or feeling)

An ultrasound or MRI could be used to confirm clinical findings, but these tests are not accurate for diagnosing tendinopathy.

Tendinopathy affects both athletes and non-athletes. The most commonly affected tendons are the Achilles, kneecap, shoulder rotator cuff and elbow extensor tendons. Pain can be debilitating, leading to the inability to perform work and sport activities.

Causes of tendinopathy are not yet fully understood.  It is believed that it occurs due to a combination of intrinsic factors (such as muscle tightness/imbalance/weakness, age, joint hypermobility and systemic disease) and extrinsic factors (such as occupation, physical load and overuse, inadequate equipment and environmental conditions).

Treatment of tendinopathy has influenced and been influenced by the evolving understanding of tendon pathology and healing. Various forms of intervention aimed at decreasing pain and promoting tendon healing have been used. These include: extracorporeal shock wave therapy, low level laser, glyceryl trinitrate patches and injections. Surgical intervention has been shown to be successful in non-responsive cases, but is in general considered a last option.

The most widely used and favored treatment for tendinopathy is eccentric exercise, which has been shown to reduce pain, improve function and normalize tendon structure. Eccentric exercise refers to a specific type of muscle contraction. There are two types of muscle contraction, concentric and eccentric. A concentric muscle contraction is when a muscle contracts while getting shorter. This is what you normally think of as contracting a muscle to move a joint, for example, flexing your biceps to bend your elbow. An eccentric muscle contraction is when a muscles contracts while getting longer. When you are relaxing your elbow back down to straight, the biceps works eccentrically to slow and control the motion.

 In order for an eccentric exercise program to be effective for treating tendinopathy:

  • loading must be customized to the particular tendon involved, taking into account length of tendon, load, and speed
  • exercise program should be as similar as possible to the usual mechanical stressors that the person experiences
  • exercise must be gradually progressed
  • exercise progression must last for at least 12 weeks

Physical therapists have the correct training and knowledge to design, monitor, instruct and progress a customized eccentric exercise program.. They will provide you with a program that stresses the tendon in the right way to promote healing and help you return to your normal work and sport/recreation activities safely and without pain.

Flourishing During the Holidays

By: Gema Sanchez, PT

Fall and winter are upon us, bringing with them our most active and intense season of holidays and celebrations. The short days and long nights of winter are mother nature’s rest period after the long days of spring and summer. We, like the plants and animals, are meant to use the dark and cold to rest and rejuvenate in preparation for warming in the spring. But, humans are social creatures, and the long dark days are also the perfect time to spend intimate time with our loved ones and enjoy the stored abundance from our summer gardens. So, how do we handle this flurry of activity and responsibility at the very time when our minds and bodies are ready for rest?  Stress management. Recognize and nurture your stress management techniques and you will emerge from the holiday season joyful and at peace. Taking good care of yourself is the key. Here are some tips:

  1. Rest. Aim to keep rest and activity in balance, too much of either won’t serve you. You will be tempted to skip sleep, but don’t. Invest in this and everything will be easier. Make rest and sleep a priority and schedule it in as just as important as all the other things you are trying to accomplish. If you are rested and alert, you will be able to move through the season peaceful and focused. And don’t forget to rest your mind. This is the time when those mundane tasks like washing dishes and folding laundry can give you the microbreaks your mind needs to function well. Try practicing mindful meditation whenever you are performing these tasks. Clear your mind and focus only on the task at hand. When you are washing the dishes, be aware of the soap and the water and the fork in your hand. When your mind wanders, just gently bring it back to the task. Try to let go of the endless to do list and let your mind go blank. You will emerge with more energy and clearer thinking.


  1. Eat well. Yes, we all love the richness and decadence of holiday food, and by all means indulge! But the remainder of the time, use food to nurture and nourish your body. Make a simple, healthy pot of soup to eat during the week. Pile up on the abundance of healthy winter veggies and citrus fruits. Drink lots of water and healing teas. Think of it as your training and rest period prepping you for the marathon of delicious decadent food and alcoholic libations of the season. This goes beyond the holiday parties and dinners; how to manage that ever present barrage of temptation in the lunch room at work? Try this tip: make a small plate of all the tempting goodies in the kitchen and bring it to your desk. Go ahead, pick all you favorites. Snack from this plate instead of the plates in the kitchen, you’ll be less tempted to overeat and still get to sample all the fun!


  1. Be realistic. Don’t overextend yourself. Aim for quality, not quantity. Prioritize. You have a lot to do normally, and now in addition to your normal work and household chores and responsibilities, your events calendar ramps up. You have guests or you are traveling, managing children during the holiday breaks and hosting or attending parties. This is not the time to schedule you annual dental and eye appointments. Clear your schedule and make room. Have lunch with your friend in January, not on the day you are picking your parents up from the airport. Take a moment to really look at your invitations, and balance those that you need to attend with those that you want to attend. You don’t have to attend them all. Allow yourself to leave early if you are not enjoying yourself and stay late if you are.


  1. Accept help when it is offered and ask for help when you need it. If you are hosting parties and guests, and someone offers to help, say yes! Cooking prep is so much more fun when you have help and companionship. Let your guests help set and clear the table and do the dishes. If you are finally off your feet and resting and someone offers to fill your glass, let them! Set food up as self-serve whenever you can. Rely on your loved ones. Make holiday meals potluck or at least ask for help with food prep. If you are a guest, help in any small way you can like making your bed, tidying up after yourself and entertaining the kids. If you don’t have plans during the holidays, reach out and offer to help. Your help can be a welcome gift to those who have too much to do. Many hands make light work.


  1. Exercise. You knew this was coming, right? I know, this is when you least feel like you can spare the time, but do. Like sleeping and eating well, keeping your mind and body healthy using exercise is critical to your enjoyment of the season. If you don’t have time to work out as much as you want to, do an abbreviated version of your workout. Maybe attend your class 1x/week instead of 3. Take a twenty minute walk instead of your usual forty five minutes. If one of your houseguests likes to be active, take them on a walk with you and enjoy the conversation. If you are visiting, offer to take on some of the “to do” list so your host can go for their run. Dance while you’re doing the cleaning. Take the dog to the park. And if you don’t have holiday plans, resist the urge to binge and oversleep. Care for yourself especially well and get some form of exercise every day.





How-To Not Flunk Your Exercise Resolution

Written By: Gema Sanchez, PT

By now, you have heard over and over again that regular exercise is essential for happy, healthy aging. But establishing an exercise program, and sticking to it, can be extremely difficult, especially for those for whom exercise has never been a part of their life. As a physical therapist, I have had many people express the desire to start a regular exercise program, or lament that they were exercising regularly for a while but then stopped and have been unable to get back to it.

So, what to do? It’s all about clearing any blocks you might have to getting to the gym, pool, Yoga studio, rock climbing gym or local track and starting.

Here is my advice:

  1. Make it convenient

Choose a location close to work or home or on your daily route. You will find it much easier to get to the gym if you pass it every day than if you have to go out of your way to get there. Make it difficult to give yourself the excuse that it is inconvenient. Every day as you pass the gym, thinking to yourself, “I’m signed up and paying my dues, I should go in there”, remember it will only take a turn of the steering wheel to get you in the parking lot.  First obstacle: Get into the gym. You can’t work out if you aren’t in there.  Also, remember to look for spontaneous and easy to establish ways to exercise.   Walking in the evening, playing with your kids, riding your bike to do errands, taking the stairs when you have time and parking further away from your destination are all really easy ways to get your exercise in without having to carve time out of your schedule.

  1. Find something you really like

You will not stick with something that doesn’t challenge you or is not fun. Sure, you may force yourself to go for a while, but come the holidays, or your vacation or nice weather;  you’ll fall out of the habit and not really want to go back.  Don’t like aerobics, how about swimming? Don’t like the gym? How about dance, or Yoga, or Pilates? Can’t afford the gym or classes? You can walk, or ride your bike or look for free classes for beginners at Yoga studios. The most important thing is that the activity itself motivates you. If you are going by will power alone, it won’t stick.

  1. Get a buddy

Finding a reliable workout partner is hard but worth the effort.  Many people turn to family, friends or neighbors, but sometimes the best workout partners are found right where you work out. Like you, they have summoned the willpower and have the motivation to show up, which is half the battle.  Having a partner helps keep your workout consistent and challenging. You both bring ideas to the workout and when you are having a day when you are less than motivated to go, having someone waiting and counting on you can be just the extra little something you need to motivate you.

  1. Change it up

Many people learn or develop a workout routine and then do the same routine every time they go to the gym. It’s worth it to gradually add to your routine options, learn new machines, try new classes, watch and learn from the people around you. Not only will your workout be well rounded, you will have more fun and never get bored.  I am a regular at the gym in the cool, rainy weather and we rarely do the same workout twice. But come summer, I would far rather go for walks, do gardening or go for hikes. And by the time the rainy weather returns, I am ready and excited to get back to the gym!

  1. Build the habit slowly

It is really important to set realistic, achievable goals at first. Of course the ultimate goal would be to do some kind of exercise at least 3-7x/week.  If you have not been working out regularly, it is REALLY hard to put this in your schedule. You’ll start well for maybe one or two weeks then life will get in the way and next thing you know you haven’t exercised in 2 weeks.  Then it is very discouraging and hard to recommit.  Instead, start with committing to 1-2 days/week. Even if this is all you do for a month or two, it is much better then stopping and starting or doing nothing.  Once it is an easy and normal part of your weekly schedule, try adding more days as you are able.