A Hypothesized Bio-tensegral Model for Scar Tissue Observed in Anterior Cruciate Ligament Reconstruction and Concomitant Knee Surgeries.  

Brandi N. Higbee, LMT

 Seattle, Washington   Phone: (425)233-0939    Email: Brandinh2002@gmail.com    

Abstract    

Background   

The knee is a complex joint that relies on strength and flexibility. Over 60,000 Anterior Cruciate Ligament (ACL) surgeries are conducted annually [2]. Research demonstrates scar tissue is a contributing factor to a patient’s successful post-surgical rehabilitation [1,2,4,5]. The fascia system is best explained through biotensegrity as a three-dimensional, omni-dependent, Closed Kinematic Circuit (CKC), [3,4,5]. The articulation of the femur and tibia demonstrate biotensegrity principles [3,4]. How can an ACL scar impact the entire knee’s range of motion (ROM)? Is scar tissue three-dimensional in how it impacts the body? This hypothesis suggests a scar’s tissue engagement extends beyond the scar's location. That predictable lines of restriction can be palpated in the circumference of the scar. This case study seeks to identify possible implications of how an ACL scar can inhibit a patient's knee mobility, even years after surgery.   

Methods   

10 Knees were assessed for ROM, scar mobility, and fascia restriction. Concomitant scars were observed if present. Myofascial modalities were applied with light to medium pressure with stretching of local tissue along specific directions according to the hypothesis. Sessions were 50 minutes for 5 sessions.   

Results   

Palpable indentations in the dermis were found along the circumference of the knees. They were in line with the scar's location, even posteriorly, indicating continuity. The width of each line varied from 1/4th to an inch. Adhesions were found along these lines. Patients noted decreased pain, increased ROM (40-60%), as well as improved balance, circulation, and functionality.  

Conclusion   

These channels of tension are deeper than the dermis and superficial to the musculoskeletal tissue. They appear to pin down and moderately restrict all biological structures and tissue in the circumference of the scar, possibly decreasing lymphatic and circulatory flow. This degree of fascia engagement could explain a limb’s restriction of ROM and indicate why manual therapy is helpful for rehabilitation. The restriction indicates a biomechanical compensation that creates a retinacula-type structure for the scar. Potentially enabling new channels for biofeedback, assistance in wound healing, localized protection, omni-directional mechano-transduction, and to re-establishing a pre-tensioned fascia system.  

References

1. Skaria AM. Incision Lines: Active Movement as a Major Biodynamic Factor of Scarring.

Dermatology. J. Jan 23, 2021;237(1):Pg 70-72.

2. S. Brent Brotzman, MD., Clinical Orthopedic Rehabilitation - An Evidence Based Approach. Third Ed. Philadelphia, US: Mosby & Elsevier, 2011 Ch. 4, Pg.211-314

3. Carla Stecco, Warren Hammer, Andry Vleeming, Raffaele De Caro,

Functional Atlas of the Human Fascial System, UK: Churchill Livingstone, 2015,

Ch 1, Pg 1-20, Ch 2, 21-50, Ch 8, Pg 289-366,

4. J. Trewartha, S. Wheeler, J. Avison, L. Blyum, G. Scarr, J. Sharkey, et.al. Scars, Adhesions, and the Biotensegral Body - Science, Assessment and Treatment. Edinburg, UK: Handspring, 2020. Ch 3,4,7,9,10

5. Armstrong C. Unity, Continuity, Structure, and Function. The Ongoing Search for a Deeper Understanding of the Many Roles Attributed to Fascia in the Living Human Body - An Osteopathic Perspective. Grans, France: OBM Integrative and Complementary Medicine 2021;6(3):16.

Disclosure

No conflict of interest. All experimentation involving humans was performed ethically in accordance with the Declaration of Helsinki