Fascia and scar tissue are discussed from a variety of perspectives in the medical field. From a physiotherapy point of view, muscles and the systems they work within matter to your function – your ability to live your daily life without limitation, be it pain, leaking, or other negative symptoms. Fascia and scar tissue make up part of the context in which muscles perform, thus they are both worth considering clinically.

Fascia is a dynamic continuum of tissue that is present throughout your whole body. Think of fascia like a spider web – it has primary pathways and smaller pathways, it stretches in response to wind or movement of branches it’s attached to, and it encases prey; yet, it’s all connected. As one author puts it, “Fascia is the philosophy of the body, meaning that each body region is connected to another” (Bordoni et al).

In the human body, fascia varies in thickness, direction, composition, and purpose. For instance, the plantar fascia at the bottom of your foot feels different and performs uniquely from the fascia encasing the small muscles of your hand. Generally, though, fascia serves to help transfer force and load as the body moves as well as to preserve organs and muscles.

Whether or not manual therapy treatment such as myofascial release or self-release techniques like foam rolling make a structural, physical difference in fascia is controversial in scientific research. Some say fascia is too thick and durable to have any clinically significant impact on; others say fascia is the driver behind many pain conditions and goes undertreated.

As far as we understand, direct fascia treatment more likely provides a new or different input to the nervous system than it does alter the flexibility or fluidity of fascial tissue. However, this view doesn’t mean treatment might not be helpful, as new input to the nervous system would result in different nerve signaling, muscle activity, and movement mechanics–likely in a symptom-eliminating way. 

Although opinions differ about direct fascia therapy, what most health practitioners agree on is that movement moves fascia, thus activity, exercises, and flexibility of your body’s tissue are important for your function. As a specific example, certain activities create tension and force through the thoracolumbar fascia, a thick, diamond-shaped web of tissue across your low back and hips. It makes up part of the chain between the latissimus dorsi muscles (under your shoulder blades) and the gluteal muscles (butt muscles). Its ability to connect and transfer these forces during movement is important for pelvic symmetry and control, since activation of the chain provides mechanical compression to the back of your pelvis, which makes it “feel” secure and able to move optimally. Exercises that connect and move this chain can be very helpful for pelvic girdle pain, especially during pregnancy or in the postpartum period.

What, then, does fascia have to do with scar tissue?

Scar tissue is a normal part of the normal healing response after any kind of tissue injury, including surgery. Its formation occurs towards the end of the healing response, and it is made up largely of collagen that is deposited and organized as new tissue. However, compared to normal connective tissue, there are a few things that are different about scar tissue that warrant consideration for treatment.

First, scar tissue is relatively weaker than normal tissue; it can match the tensile strength of normal tissue by a maximum of 80%. Thus, after a surgery or injury, it is important to ensure the scar is as malleable and flexible as possible so that it can endure tension and physical stress during all the activities you want and need to do. For instance, after abdominal or pelvic surgery (laparoscopic or not), it is important to make sure the scar tissue moves well for optimal abdominal and core recovery and function, from lifting groceries to returning to your desired type of exercise.

Second, scar tissue can be sensitized in comparison to normal tissue. Sensitization means that your brain, as a result of injury or trauma, puts up more “alarm bells” than typical in the area, as if the tissue is “on guard” against potential threat. Fortunately, the brain can be trained to normalize the alarm bells that go off when the scar tissue is moved or touched. For example, after muscle injury from childbirth, it is important to make sure the scar tissue responds normally to touch and pressure, such as with sexual activity or pelvic exams.

Given what we know about scar tissue, it is possible for scar tissue formation to interrupt normal mechanics of fascial tissue, as well as other body parts like muscles and organs. Issues related to sensitive or stiff scar tissue in the abdominal, pelvic, or back area include pain with sex, pain with activity, muscle weakness, bladder or bowel urgency or frequency, intolerance to touch or pressure, and more.

Thankfully, these are treatable! If fascia is like a spider web, scar tissue could be considered an extra sticky or stiff part of the web. It doesn’t mean the web doesn’t work or is broken, but it means the mechanics of give and take, push and pull are different than before. Thus, restoring the sticky or stiff part to as close to normal as possible would help the web function more optimally as a whole. 

So, how do you know the state of your scar tissue? Consider the following questions:

• Is it numb? 
• Is it painful or irritating to touch or pressure?
• Are you grossed out or do you feel weird looking at it or touching it?
• Does it look indented or depressed in your skin?
• Do you feel it pull or stretch with certain types of activity, exercise, or movement?

A “yes” to any of the above, while very common, is not normal, and might be a sign that scar tissue is stiff or sensitized. There are a few things you can do on your own to help. First, once the scar is healed, touch the scar. Specifically, use different textures such as a makeup brush, toothbrush, washcloth, cotton shirt, wool sock, or your own hand. Apply gentle strokes in different directions, building from softer and lighter materials to heavier materials with more texture. Second, move the scar. With your finger pads resting at a point along the scar, gently pull the skin upward, downward and in clockwise and counterclockwise circles, and repeat along the length of the scar. You can add gentle pressure to this as tolerated.

Pelvic health physiotherapy can further help by:

• Using manual techniques like scar desensitization and mobilization, which according to research improve skin quality, relieve sensitivity, increase hydration or circulation to the skin, and improve scar quality. 
• Providing you with techniques to change the input of your nervous system to the area of the scar, if needed.
• Assessing the big picture to see how else your body may have been impacted by your injury or surgery, including muscular coordination, activation, and flexibility.
• Provide guidance on building back up to desired activity or exercise.

We at The Mama’s Physio would consider it a privilege to help you optimize your healing.

By Sophia McLean – PT, DPT

Sources:

Atiyeh, Bisara S. “Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods.” Aesthetic Plastic Surgery 31, no 5 (2007): 465-492.

Bordoni, Bruno and Emiliano Zanier. “Clinical and symptomatological reflections: the fascial system.” Journal of Multidisciplinary Healthcare 7 (2014): 401-411.

Britnell, Susannah. “Evidence based management of pregnancy-related pelvic girdle, sacro-iliac and pubic pain.” Rost Therapy. Vaughan, ON. July 2019.

Diegelmann, Robert F. and Melissa C. Evans. “Wound Healing: An Overview of Acute, Fibrotic and Delayed Healing.” Frontiers in Bioscience 9 (2004): 283-289.

Ingraham, Paul. “Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties.” PainScience.com. July 2019. https://www.painscience.com/articles/does-fascia-matter.php

Pergialiotis, Vasilios and M Frountzas, C Siotos, N Karampetsou, DN Perrea, D Efthymios Vlachos. “Cesarean wound scar characteristics for the prediction of pelvic adhesions: a meta-analysis of observational studies.” The Journal of Maternal-Fetal & Neonatal Medicine 30, no. 4 (2017): 486-491.