First, let me say that I am not trying to equate the back of the 16-year-old male end (in the photos) on the left of the 30-year-old female on the right. I am merely trying to show how the back fascia of the thoracolumbar tissue is similar in both sexes. Furthermore, the picture of "Gordon" --- the escaped Louisiana slave - whose photo was taken at the height of the Civil War in 1863 is simply a different type of scaring. Honestly, the picture on the left does not do justice to what this kid is going through, as it is difficult to convey the fact that the stretch marks are 'welted' off of his back about a quarter inch. As for the scars on the far right; this individual was complaining of chronic low back pain that would not respond to adjustments. Her injuries were utterly "invisible" until I started working on her, and her relief was immediate upon breaking the tissue.
There are two kinds of scar tissue that we need to talk about today, Hypertrophic Scars as we see in the pictures on the left and right, and the Keloids seen in the middle pic. Both involve an overgrowth of something called Granulation Tissue. Granulation Tissue is part of a normal healing process (see diagram below). In a proper healing process, INFLAMMATION gets the ball rolling by attracting the chemicals and compounds that will repair the damaged tissue, which is what it is supposed to do. After the inflammatory phase, the next step is 'Fibroplasia and Granulation Tissue Formation.' The website Advanced Tissue says of Granulation Tissue.
Mere hours after the initial injury, FIBROBLASTS start laying down Granulation Tissue (Type III Collagen --- a weak and inelastic form of Collagen) that will later be replaced by the stronger and more elastic Type I Collagen in a process called 'Remodeling' for more on the process of Tissue Remodeling see the discussion of REMODELING TISSUE. Not surprisingly, research says that Keloid Scars can cause restriction of joint motion if found around joints - besides abrasions, these may also be caused by Surgery. What you have to remember here is that anything that causes restriction has the potential to cause pain via loss of proprioception (perception or awareness of the position and movement of the body.)
Not to overstate this, and I am not saying that the Keloid tissue itself is causing the pain, but that the restriction due to lack of flexibility of the muscle it creates has the ability to increase the workload on the muscles - which potentially causes pain. This is why the combination of restricted movement and/or uncontrolled inflammation can be extremely problematic as far as joint health is concerned.
A March 2016 Medscape article by Dr. Mimi Kokaska (Hypertrophic Scarring and Keloids) went on to say of Keloids,
She also talked at length about the over-expression of various inflammatory mediators (IL-6 and IGF-1) that are thought to cause, "microvascular occlusion and subsequent hypoxia." It's no secret that both hypoxia (inadequate oxygenation) and ischemia (reduced blood supply) is problematic due to the negative influence on the healing process and muscle function. On many levels, they heighten the ability to induce pain in the area around them.
Hypertrophic Scar Tissue is very similar to a Keloid, only less severe in appearance. Part of the difference between Keloids and Hypertrophic Scars is that the later will sometimes improve in appearance over time, while Keloids can actually get worse --- in some cases MUCH WORSE. Despite the fact that such scars are supposed to be, according to many sources, non-painful and merely a "cosmetic" issue, it's easy to find sources and studies that say otherwise. For example, in Dr. Kokaska's above-mentioned article, she says of Hypertrophic Scars; "are associated with adverse wound healing factors..." A 2014 study published in the journal Clinics (Update on Hypertrophic Scar Treatment) had this to say of Hypertrophic Scars...
For those interested, this sequence of posts contains a great deal more information (much of it extremely detailed) about the physiology and pathophysiology of Hypertrophic Scars. If you found the quote above interesting, this site will be going into more detail on the ECM, FIBROSIS, and INFLAMMATION, as related to CHRONIC PAIN. And as for the last sentence - this pertains to burn victims, and unfortunately, Tissue Remodeling treatment does not work for burn scars. These must be treated with distinct therapeutic techniques.
What does the medical community say works for treating Hypertrophic Scars? The only real consensus is that nothing works very well. This is due to the fact that surgical treatment almost always results in more scaring, and most of the non-surgical treatments for these types of scars (silicone spray and CORTICOSTEROIDS) cause their own unique problems. They also tend to stop working once the treatment ceases. What seems to work best - is manual therapy.
A three year old study from Seminars in Cutaneous Medicine and Surgery (Low-level Laser (Light) Therapy (LLLT) in Skin: Stimulating, Healing, Restoring) touted some of the same benefits of LOW LEVEL LASER THERAPY and MULTI-WAVE LIGHT THERAPY that I have been talking about for the past decade. After discussing its mechanism of action (photobiomodulation --- see link), the group of seven medical doctors and Ph.D. researchers stated,
OTHER TECHNIQUES FOR SCARS AS RELATED TO MANUAL THERAPY
Usually, whena small amount of lubrication is topically applied during scar massage. This can be castor oil, lotion with essences of plant extracts, or vitamin E oil. This is used to keep the scar and skin pliable and softens during scar tissue massage. Nothing should be applied to lubricate the area if you have any open sores or incisions. This could be an avenue where the lubricant—and an infection—may enter the body.
Cross Friction Massage
One effective method of scar massage is called cross friction or transverse friction massage. This involves using one or two fingers to massage your scar in a direction that is perpendicular to the line of the scar.
This technique helps to remodel the scar and ensures that the collagen fibers of the scar are aligned properly. Cross friction massage is commonly used in the treatment of tendonitis and muscle strains or ligament sprains - which is a similar tissue density. The technique is performed for five to 10 minutes. When instructed to do so, you may be able to perform scar tissue massage on yourself. It should be done two to three times per week.
Myofascial release (MFR) is often used to manage scar tissue and the adhesions in the muscles that may accompany scar tissue. The technique involves using the hands to massage the skin and underlying tissues around the scar. Motions are slow and the amount of force used is usually light. Your CMT can feel for restrictions of tissue, called fascia, in various directions and work to improve movement in those restricted directions.
Active Release Techniques (ART)
Active Release Techniques (ART) is often used to manage scar tissue and the adhesions in the muscles that may accompany scar tissue. The technique involves ART protocols that identify, isolate, and target the affected area to break up scar tissue. This promotes blood flow and oxygenation of tissue fibers for faster healing of injuries. ART can be used to treat problems with:
Instrument Assisted Scar Tissue Massage
A relatively new technique used in physical therapy is called instrument assisted soft tissue mobilization (ISATM). Based on the Traditional Chinese Medicine techniques called Gua Sha (pronounced: GWA -SHA). This technique involves using special instruments of various shapes and sizes to massage and mobilize tissues through direct pressure in multiple directions. Your PT may use this technique by rubbing your scar tissue with an instrument, thus "breaking up" the tissue present - or scraping. The use of IASTM is new, and thus may lack rigorous scientific study required to decide if it is worthwhile to use in the integrative clinic.
HYPERTROPHIC SCARS AS RELATED TO STRETCHMARKS
What can I tell you about Hypertrophic Scars as they relate to Stretchmarks? Let me first say that I am not an expert on this subject --- I am merely giving my personal experience with Stretchmarks in patients I see with pain. This is not something I see lots of ---, and it isn't common, I've probably seen less than 50 cases.
Thirdly, for whatever reason, the oldest person I have seen with this sort of thing is about forty, with most being much younger.
Fourthly, the cases I have seen are almost always related to a history of severe impact (falling out of trees, off horses, hit by a metal beam, four wheeler accidents, impact with a railroad track, etc., etc., etc.) or connective tissue disorders (EDS, Loeys-Dietz, Marfan). Some of these led to immediate chronic pain, while with others, the pain did not show up until later.
Fifthly, some of these scars are indented into the skin or below the surface like the pic directly above, while some are welted off the surface like the pics at the top.
And lastly, the stretchmarks that I have found thus far have always been located in the area of the THORACOLUMBAR FASCIA and occasionally into the mid-back. TISSUE REMODELING has helped in most of the cases I've treated.
Beyond after-the-injury treatment, if you know you are prone to scarring, what could you do to help prevent it from forming in the first place (or at least slow it down)? Honestly, I would suggest you --- live your life in an as anti-inflammatory manner as is possible even though these pathological scarring issues have been called genetic; due to something called EPIGENETICS (the study of changes in organisms caused by modification of gene expression). The anti-inflammatory lifestyle, which, based on Nutrition, is undoubtedly far more relevant than you ever would have dreamed. As to what some of this looks like, follow this link.
As for other hidden causes of inflammation, you might have many. If this is the case, you won't find real relief from the mechanical issue until you start addressing the underlying chemical issue (inflammation).