September 2018 No. 52
Treating Linear Scars over Joints
This blog is a dialogue between our clinical experts Jerry Ditz, DPT, Dip. Osteopractic, Cert. SMT, Cert. DN and Karol Young, OTD, OTR/L, CHT.
Question: Linear scars over a joint, such as those created by extensor tendon repairs over finger joints or in a total knee arthroplasty, can limit range of motion and function. What is your treatment approach when working with a scar over a joint?
Karol: Treatment of a linear scar over a joint depends on the phase of healing. Proper care of healing wounds impacts scar formation, so initially I educate the patient about wound care and the phases of soft tissue healing (1). Joint movement plays a key role in increasing soft tissue extensibility over the joint and thus active and/or passive range of motion is initiated as soon as healing allows.
Treatment for newly healed incisions (immature scar) begins 48 hours after suture removal and includes circular massage and rolling of the soft tissue surrounding the scar. Immature scars will blister or become painful if direct mechanical stress is applied too early.
No specific topical treatment (lotion) is recommended as research shows scars improve better with compression than topical treatments (2). If maturing scars are hypersensitive, graded textures (attached to a tongue depressor) are applied to the scar until tolerable.
Jerry: As Karol stated, treatment is based on the healing phase of the scar. Following a total knee arthroplasty, staples or sutures must be removed and drainage absent to begin working on the scar. At this time the patient begins simultaneous massage and active range of motion. In the short sitting position with feet off the ground, the patient starts at the top of the incision with pressure from the thumbs providing circular massage along the edges of the scar while actively moving the knee slowly through flexion and extension, repeating ten times. After ten repetitions, the patient moves the pressure one inch distally, repeating the exercise until massage has been applied the full length of the incision.
Question: What is your treatment for unusually tight or thick scars?
Karol: When a scar does not respond adequately to massage, I recommend longer periods of scar compression using paper tape or sports tape (3). Silicone gel sheeting can be used in combination with compression as it appears to provide hydration to the scar (4). For patients who form excessively thick or adherent scars, a custom fitted compression sleeve or glove should be worn 23 hours a day.
Jerry: My treatment for maturing scars which are tight or thick is the use of cupping. I do not perform this on patients who have incomplete wound closure, a history of vascular disease, or uncontrolled diabetes (5). In general, cupping should not be attempted until at least 8 weeks after surgery (with no complications). As the patient is squatting or walking, low-level static cupping is applied over the scar, ideally with a cup that covers the entire scar. Because of the length of a total knee arthroplasty incision, a sink plunger is large enough to distract both the scar and the patella.
During the first cupping treatment, I leave the cup in place for approximately one minute. The patient then repeats the functional movement to assess for changes in pain or range of motion. If the patient notes a positive change, the treatment is repeated twice more, with the functional movement repeated between each cupping treatment.
Regardless of scar treatment, the healing wound requires time to reach scar maturity. A linear scar is what is seen on the skin, but it represents surgical exploration of multiple tissue layers underneath. Thus, it is not just about the linear scar, but it is about mobilizing multiple tissue planes. It is important for therapists to understand we cannot create rapid change in a scar; we can only encourage the tissue change over time.
1. Pitzer GB, Patel KG. Proper care of early wounds to optimize healing and prevent complications. Facial Plast Surg Clin N Am. 2011; 19: 491–504.
2. Foo CW, Tristani-Firouzi. Topical modalities for treatment and prevention of postsurgical hypertrophic scars. Facial Plast Surg Clin N Am. 2011;19: 551–557.
3. Alkhalil A, Tejiram S, Travis, TE, et al. Translational animal model for scar compression therapy using an automated pressure delivery system. Eplasty. 2015 Jul 2;15:e29.
4. Bleasdale B, Finnegan S, Murray K, Kelly S, Percival S. The use of silicone adhesives for scar reduction. Adv Wound Care. 2015; 4(7): 422–430.
5. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One. 2012;7(2):e31793
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Disclaimer: HandLab Clinical Pearls are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.