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 had four surgeries in a 6 year time span (including an ACL replacement in my right knee), and I 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).
Cross-Fibering
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 to bend the middle and ring fingers and use the second knuckle (closest knuckle to the hand-but not the knuckle joining the hand) on the middle and ring fingers, to get into the muscle fibers of the quads/calves, while the second and pinky fingers are straight and 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.
Nutrition is important.
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.
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.
Be patient!
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