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Take home points:
All body tissue follows a predictable sequence of healing whether that tissue is bone, tendon, or ligament. Understanding this pattern can help us to devise intelligent and rational methods of approaching these injuries. This pattern is easy to understand even for someone without a medical background. It is also important to understand that in long-standing injuries that all of these stages may be occurring in different areas of the injury. I find that there are three distinct stages to healing a foot injury.
The first step is injury. Some might call this inflammation, but it is important to stress that inflammation from a cellular or chemical standpoint is a brief and minor part of this stage. During this stage, there is mechanical damage to the tissue. Bleeding and bruising may or may not be present. The tissue damage incites white blood cells to come into the area of the damage and breaks down the damaged tissue. The chemicals that are released also increase blood flow into the area so that large concentrations of oxygen and other nutrients are available for the repair process. The tissue strength weakens considerably during this stage. This stage can last from several days to several weeks.
The pain during this stage is usually sharp and throbbing. Immobilization of the extremity or protection from the extremes of motion can be helpful. A fractured bone may require casting as could a ruptured or strained tendon. While anti-inflammatory medications can help with the pain, it is unclear how these medications affect the progression of healing. There is some evidence that these medications may interfere with bone healing in animal models. The effect on the repair of other soft tissues is unknown but, in my opinion, probably there is very little positive or negative effect.
The next step is consolidation. During this period, an immature scaffold or scar develops that begins to stabilize the injury. This scaffold does not have the mechanical properties of the original tissue. While it may, in many ways, function in the same ways that the original structure did, it is weaker and will be prone to overuse, possibly even rupture. This stage can last from a couple of weeks to a couple of months.
Protection of the injured structure is important during the consolidation stage. In a bony injury such as a fracture, a brace would be appropriate. Ruptured or repaired tendons should be moved to prevent scarring to the bed of the tendon. Exposure to limited amounts of stress is helpful in strengthening and reforming the tissue, preparing them later for normal usage. Excessive stress or motion at the injury site may retard the formation of some types of tissue such as bone. Exercises should emphasize flexibility in the joints and limited amounts of strengthening. Protected weight-bearing can often be resumed. Often, in foot injuries, protective shoes or boots may be helpful in providing protection.
The final stage is maturation. In this stage, the injured structure begins as a relatively disorganized scaffold and becomes more organized and reforms itself along the lines of stress. Tendons begin to have fibrous structure. Bone spicules begin to form along the axis of stress. The mechanical strength begins to approach normal.
Gradual resumption of normal activities begins in this stage. This should proceed in a stepwise fashion. An example is walk before you jog. Jog before you run. Run before you return to sports. There should be many sub-steps between these milestones and multiple degrees of endurance. Pain, especially pain that increases with the activity, is a useful signal that the return to activity is too rapid. To some degree, this stage can continue for years. Much of the maturation continues even after the injury is asymptomatic.
Understanding this process helps to make the recovery process easier to fathom. It also clarifies the use of various braces for protection. Feet, like other musculoskeletal parts of the body, were not designed or did not evolve to be protected or supported. While certain irreversibly damaged feet may require protection indefinitely, the use of protection should ideally be limited. The modern usage of orthotics and high-tech “supportive” shoes, while helpful in the early stages of healing, should be gradually discontinued. It is my belief that usage of these devices in healthy feet has the potential to increase the possibility of injury by protecting the feet from normal stresses. This is much the way that an astronaut protected from gravity looses bone mass and strength when in space for long periods. Stresses stimulate the bones, ligaments, tendons, and joints to make themselves stronger (Wolff’s Law). Remember, the goal is to return to normal.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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