Scar Tissue

Not Breakable, But Changeable

By Catherine Ryan

There are a few manual therapy idioms that persist without merit. Such things provoke me to come out swinging—in a clinician/science-nerd kind of way. Breaking down mature scar tissue is one of those phrases. “Breaking” implies severing, akin to surgical lysis (cutting scar tissue within the body). There is no evidence that manual therapy is capable of such a thing—it’s physiologically implausible. Also, such a phrase can evoke client recoil, and that alone is enough reason to stop saying it, but I’ll add some evidence to support my position.

Regardless of etiology (surgery, burn, sport injury, overuse/repetitive strain), tissue insult is reconciled by the four overlapping stages of wound healing. Remodeling is the final stage of that process. In the tissues we commonly address, collagen constitutes the physical fabric of remodeled tissue. Collagen has the tensile strength of steel. I’m no delicate flower, and my hands are pretty strong . . . but not that strong. Attempting to manually break steel-like collagen—ouch!—is not only futile, but also does not seem to fit with a client-considerate approach to care. Further, dense collagen (e.g., dense fascia, like the IT band) is only deformable (i.e., stretch or alteration of shape) under extreme forces1—again, strong hands, but not that strong. Gil Hedley, PhD, and founder of Somanautics Workshops, demonstrates beautifully the strength of collagen in his video “Fascia is All Around Us!”2

That said, while collagen may not be breakable by manual methods, it does appear to be changeable. What, then, are physiologically possible changes that underlie the outcomes we facilitate in our clinical practice when working with scar tissue?

Evidence-Informed: Physiologically Plausible Changes

Before we dive into how our work works, let’s go a bit deeper into what scar tissue is. Understanding what it is—what we are working with—is paramount to delivering safe and productive care.

Tissue Interrupted

Scars are not obligated to be problematic. Scars “construct” us back together when tissue integrity has been interrupted. The renovation may not be totally homogenous. Even normal scars (nonpathological) may look, and the tissue function, somewhat differently than the original material.

Regulatory mechanisms ensure that remodeling—the laying down of new collagen—terminates once tissue homeostasis is reestablished. If these mechanisms fail, unchecked/anomalous collagen proliferation ensues (i.e., fibrosis), typified by chaotic organization, pathological cross-links, stiffness, and abnormal crimp. Irrespective of etiology and scar type (surgical, burn, axillary webbing, frozen shoulder, or repeat strain), fibrosis constitutes the characteristic physical attribute of abnormal (pathological) tissue remodeling in response to insult.

Fibrosis can impact a person’s function and quality of life in several ways. For example, it can cause interference with tissue sliding, muscular stretch, strength capacity, and organ, blood, lymphatic, and nerve function.

In a nutshell, fibrotic collagen is the “what” in the question: “What is going on in there?” Therefore, manual therapy scar tissue management should aim to temper fibrogenesis or facilitate meaningful change once fibrosis has been established.

Labor of Love

In 2013, I had the great pleasure of meeting Mary Law of Handspring Publishing and Nancy Keeney-Smith, LMT, MLD, at the International Massage Therapy Research Conference in Boston. Knowing our professional interests, Mary suggested Nancy and I partner up to coauthor a book.1
Nancy and I are often asked what it was like to write a book. For us, it was a labor of love . . . giving birth through our brain, heart, and hands. The love was working with Handspring Publishing and all the talking, thinking, and writing about massage therapy and scars. The labor was accumulating, reading, and trying to make sense of current research (wound healing, lymphatic, fascia/connective tissue, and manual therapy).
We felt it vitally important to honor the credibility of our profession by providing an evidence-based body of work and to develop a deep understanding for—and to clarify—what truly is the issue, what needs to change, and how we can best use our hands to facilitate the needed changes to provide the best possible care for our clients. After reading a ridiculous amount of research, we found ourselves at the juncture of plausible and not, and this is how we arrived at the conclusion that mature scars/adhesions are not breakable by manual methods. Which brings us to: what is going on in there? Any of you who work with scar tissue in your practice know that your hands are doing something to improve your client’s situation.
1. Nancy Keeney-Smith and Catherine Ryan, Traumatic Scar Tissue Management: Massage Therapy Principles, Practice and Protocols (Pencaitland: Handspring Publishing, 2016).

Therapeutic Loading

The application of mechanical or manual force can influence neurophysiological and integrin-mediated responses. It appears that effects can differ depending on the type of therapeutic loading (e.g., tension, compression, bending, shear, and torsion/rotation). For example, fibroblasts, which play a prominent role in wound healing, are responsive to tissue tension and stretch—when stimulated, fibroblasts in skin and connective tissue down-regulate agents associated with fibrogenesis;1 and fasciacytes, which regulate hyaluronan, appear to have an affinity for shearing type methods—hyaluronan plays a key role in fascial sliding, including sliding within neural interfaces.2
1. Helene M. Langevin, “The Science of Stretch,” The Scientist 27, no. 5 (May 2013): 32.
2. Carla Stecco et al., “The Fasciacytes: A New Cell Devoted to Fascial Gliding Regulation,” Clinical Anatomy 31, no. 5 (March 2018): 667–76,

Learn more and see Catherine Ryan’s and Nancy Keeney-Smith’s hands in motion. Check out ABMP’s three-part video series in the ABMP Education Center ( Additionally, you can find their “Scar Tissue Management” chapter in Fascia, Function, and Medical Applications, edited by David Lesondak and Angeli Akey (CRC Press/Taylor & Francis), due to publish August 2020.

More Than Skin Deep: The Iceberg and Octopus Effects

Scars are like icebergs—what you see on the surface is not always an accurate representation of what is happening below. According to Jean-Claude Guimberteau, MD, with irregular or abnormal healing, even though the surface tissue looks normal, below the surface is another story—tissue can be fibrotic (thick/dense) and devoid of loose connective tissue serving a sliding function. When viewed endoscopically or during cadaver dissection, octopus-like tentacles of scarring can be seen reaching out from the region of original injury—exerting far-reaching effects.

Carpal Tunnel and Camitz Opponensplasty

Patient X is a breast cancer survivor with ongoing lymphatic issues. Surgery was performed on the edematous side. Patient X was initially seen by Nancy Keeney-Smith one week postsurgery (left). Treatment consisted of lymphatic drainage and gentle scar tissue work—one-hour sessions, provided 1–2 times per week for six weeks (right).

"Where you think it is . . . it ain’t.”—Ida P. Rolf
Scarring in a seemingly unrelated region can impact function elsewhere. For example, following mastectomy, restricted shoulder range of motion can be related to fibrotic tethering or restriction around the surgical drain site, well below the glenohumeral joint. Surgical drain-site scarring is commonly problematic. Any midstream interruption in the healing process increases the risk of fibrosis. If standard protocols of care (e.g., joint mobilizations and range-of-motion exercises) are not achieving expected outcomes, look beyond the local area of complaint.

Manual Therapy and the Early Stages of Healing

“Manual therapy is certainly, at the moment, one of the best options to improve the new recovering subcutaneous and cutaneous structures and to diminish the tissular retraction and rigidity.”
—Jean-Claude Guimberteau, MD3

Part of the impetus for writing Traumatic Scar Tissue Management (Handspring, 2016) came from our observation that manual therapy education and protocols for working with scar tissue are largely directed to after the fact—dealing with mature scars: an important part of client care, but not of optimal comprehensive care.
Evidence supports that in addition to addressing problematic mature scars, timely and skillfully applied manual therapy can augment the wound-healing process, thereby reducing the risk of pathological scar formation and consequent issues (e.g., movement restrictions, undesirable scar characteristics, pain, and sensory disturbances, such as pruritus and altered proprioception and interoception).4

Fibrosis can be a challenging issue to reconcile, so prevention is key. Two primary drivers of profibrotic activity have been identified: excessive or prolonged inflammation and premature or anomalous tissue tension. Other important factors to consider are neural hyperactivity/sensitivity, immobilization, and the client’s psychological state.

In the early stages of wound healing, manual therapy is aimed at managing these factors and any of their instigators. Lymphatic drainage, autonomic nervous system (ANS) balancing, and neural sedation methods reign supreme during this time frame. For any stage of care, dosage variables are important determinants of safety and effectiveness. The amount of pressure applied; the expanse of tissue engaged; and the direction, speed, and angle of contact all matter, as does the type of therapeutic loading.5

The treatment of scars and adhesions cannot be described as a set modality. As Willem Fourie wrote in Fascial Dysfunction: Manual Therapy Approaches, “Treatment could be rather defined as a management strategy using combinations of different massage and manual techniques to constitute a therapeutic approach aimed at improving tissue quality and mobility.”6

Mature Scars: Change Agent, Not Break Agent

Although fibrotic tissue is often considered an inactive scaffold, precluding potential for change, fibrosis is neither static nor irreversible but a continuous remodeling process and thereby susceptible to intervention.7 If problematic mature scars or adhesions are in an ongoing state of flux (remodeling), then it seems reasonable that change is possible. What then does this influx tissue need in order to change into something that functions better? Current fascia research is the primary purveyor of physiologically plausible (positive) collagen changes mediated by manual therapy and the types of therapeutic loading that will achieve the desired changes.8

What is Changing? Fibers and Fluid

Simply put, when treating any type of mature (fibrotic) scar or adhesion, manual therapy methods are directed at facilitating collagen (fiber) and ground substance (fluid) changes. Evidence-supported manual therapy-mediated collagen fiber changes include improved hydration and organization; disruption of pathological crosslinks; and promoting favorable features, such as crimp, suppleness, and smoothness. Fluid environment changes include shifts in volume and/or viscosity within and around tissue fibers, including loose connective tissue serving a sliding function. The mechanisms by which various methods facilitate fiber and fluid changes involve interrelated responses within multiple systems.9

A Scar, is a Scar, is a Scar

A significant realization we came to when writing the book is that a scar is a scar. From the manual therapy perspective, whether the scar or adhesion is related to a new knee (arthroplasty), oncology treatment (e.g., mastectomy, radiation induced fibrosis), or an accidental injury, scar management protocols are essentially the same. That said, the severity and stage of injury, the anatomy involved, and the person themselves warrant consideration.

Client-Centered Care

Getting all science-y is my jam. Reading research has changed the way I use my hands—supporting my evolution over 30 years of practice. Equally, my jam is client-centered care: the harmonious marriage of what my hands can facilitate while being present with the human on my treatment table. A dear friend and massage therapy colleague Pamela Fitch exemplifies the perspective of myself and my Traumatic Scar Tissue Management coauthor Nancy Keeney-Smith: “We are not just treating scars; we are treating people with scars.”

Working successfully with problematic scars or adhesions requires expert navigation, not only of the physicality of the scar material but also inclusive of the whole clinical presentation and the whole person. A meta-analysis of massage therapy research suggests that some of the positive responses to treatment are attributable to the positive regard of the therapist toward the client and the development of a professional alliance between the therapist and the client. According to Fitch, “Our clients are often seeking meaningful professional/interpersonal experiences, such as caring, connectedness, and compassion, along with facilitating productive treatment outcomes.”10

The Inclusion Conclusion

Over the last several decades, advancements in medical technology have led to improved surgical techniques and emergency care. More people are surviving injuries that would have been fatal even 20 years ago. An increase in survival rate means an increased need for knowledgeable and skilled professionals to assist with prevention and treatment of problematic scars or adhesions.

Postsurgical client self-care instructions commonly include a recommendation to self-massage the scar, for the purpose of improving the scar quality and function. However, there is a paucity in clients receiving direction to seek out early treatment administered by an manual therapy professional, constituting an important missed opportunity in patient care.

Knowledgeable and skilled manual therapy professionals can assist the medical management team with augmenting the wound-healing process (which in turn can reduce the risk of pathological scars or adhesions), early detection of nascent issues, and evaluating and treating existing issues. The inclusion of manual therapy into an interprofessional approach to client-centered scar tissue management will contribute to achieving better outcomes and mitigating cost and other burdens associated with pathological scarring.

“Surgeons and manual therapists share similarities,” writes Jean-Claude Guimberteau, MD, and Thomas Hausner, MD. “We are both in direct contact with tissues. Patients would be better served by surgeons and manual therapists working together.”11

1. David Lesondak, “Fascial Syndromes: Emerging, Treatable Contributors to Musculoskeletal Pain,” in Metabolic Therapies in Orthopedics, 2nd ed., eds. Ingrid Kohlstadt and Kenneth Cintron (Boca Raton: CRC Press, 2018), 357–68; H. Chaudhry et al., “Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy,” Journal of the American Osteopathic Association 108, no. 8 (August 2008): 379–90,
2. Gil Hedley, “Fascia is All Around Us,” accessed May 2020,
3. Jean-Claude Guimberteau, MD, Skin, Scars and Stiffness DVD,,inflammation,dvd.php.
4. Justin D. Crane et al., “Massage Therapy Attenuates Inflammatory Signaling after Exercise-Induced Muscle Damage,” Science Translational Medicine 4, no. 119 (February 2012): 119ra13,; L. Berrueta et al., “Stretching Impacts Inflammation Resolution in Connective Tissue,” Journal of Cellular Physiology 231, no. 7 (2016): 1621–27,; Geoffrey M. Bove et al., “Manual Therapy Prevents Onset of Nociceptor Activity, Sensorimotor Dysfunction, and Neural Fibrosis Induced by a Volitional Repetitive Task,” Pain 160, no. 3 (March 2019): 632–44,
5. Sandy Fritz, Mosby’s Fundamentals of Therapeutic Massage, 6th ed. (St. Louis: Elsevier, 2016); Nancy Keeney-Smith and Catherine Ryan, Traumatic Scar Tissue Management: Massage Therapy Principles, Practice and Protocols (Handspring 2016); Leon Chaitow, ed., Fascial Dysfunction: Manual Therapy Approaches, 2nd ed. (Pencaitland: Handspring Publishing, 2018).
6. Willem Fourie, “Management of Scars and Adhesions,” in Fascial Dysfunction: Manual Therapy Approaches, ed. Leon Chaitow (Pencaitland, UK: Handspring, 2014), chapter 18.
7. Thomas A. Wynn, “Common and Unique Mechanisms Regulate Fibrosis in Various Fibroproliferative Diseases,” Journal of Clinical Investigation 117, no. 3 (March 2007): 524–29,; Morten A. Karsdal et al., “Novel Insights into the Function and Dynamics of Extracellular Matrix in Liver Fibrosis,” American Journal of Physiology-Gastrointestinal and Liver Physiology 308, no. 10 (May 2015): G807–G830,
8. Fascia Research Congress, 2020, www.fascia
9. Antonio Stecco et al., “Fascial Disorders: Implications for Treatment,” PM&R 8, no. 2 (June 2015) 161–68,; Gary Fryer, “Integrating Osteopathic Approaches Based on Biopsychosocial Therapeutic Mechanisms, Part 1: The Mechanisms,” International Journal of Osteopathic Medicine 25 (September 2017): 30–41,; Leon Chaitow, ed., Fascial Dysfunction: Manual Therapy Approaches, 2nd ed.
10. Pamela Fitch, Talking Body, Listening Hands: A Guide to Professionalism, Communication and the Therapeutic Relationship, 2nd ed. (Ottawa: Algonquin College Press, 2019).
11. Jean-Claude Guimberteau, MD, and Thomas Hausner, MD, “Surgery and Fasciatherapy” from the 4th International Fascia Research Congress (2015).

Catherine Ryan is a CMTBC-registered massage therapist with a strong interest in patient-centered care, evidence informed practices, and lifelong learning. Over her 30-plus year career, Ryan has engaged in the profession in a variety of clinical, educational, and leadership capacities. An established continuing education instructor, Ryan has presented internationally at conferences, in the areas of scar-tissue management and myofascial pain and dysfunction, which also constitute her clinical practice focus. She has written numerous articles featured in various publications, co-authored Traumatic Scar Tissue Management: Massage Therapy Principles, Practice and Protocols (Handspring 2016), and written a chapter contribution in Fascia, Function and Medical Applications (2020) and Oncology Massage: An Integrative Approach to Cancer Care for Manual Therapists (Handspring 2020). Ryan is also the co-host of the podcast Massage Therapy Without Borders.