Understanding the Healing Process: A Look at Connective Tissue

Understanding the Healing Process:

A Look at Connective Tissue

From the Healing Bridge Physical Therapy

Fall 2001 Newsletter


When injured, the body’s response to restore balance and heal is remarkably similar regardless of the tissues involved. Although there are important differences between repair occurring in tendons, ligaments, muscles and bones, an understanding of the basic process by which healing occurs can help you better understand the process of your own rehabilitation.

All connective tissues share similar structural components such as collagen and elastin fiber, tissue fluid and cellular substances. The specific proportions of these components help determine the function of that tissue. For example, cartilage is approximately 80% water combined with several proteins. This attracts a nutrient-rich fluid that flows back into the cartilage after joint compression squeezes it out during such activies as walking. Tendons and ligaments contain about 66% water, and high amounts of collagen fibers to help bones remain strong and to resist strain.

Any tissue can be stretched or strained beyond capacity, such as when a bone fractures, or when the discs in the spine become painful from extended forward bending, poor posture or lifting technique. When strained beyond their capacity, these tissues send a message to the body’s control systems which starts the three stages of the healing process

Phases of Healing

Phase 1: Inflammation (3 to 5 days)

Chemical substances released by injured tissues initiate the complex inflammatory response. Often we try to reduce tissue inflammation, however it’s critical to the healing process. What you may experience during this phase are symptoms of pain, warmth, tenderness and swelling in the injured tissue, with limited motion. Rehabilitation encourages resting the injured tissue while striving to maintain motion in unaffected regions.

Phase 2: Repair and Regeneration (48 hours to eight weeks)

During this phase, specialized cells are actively resorbing and synthesizing new collagen fibers. The new fibers are small, disorganized in orientation and lack the extensive cross-linking found in mature fibers that add immensely to collagen’s strength. Because of these factors, tissue laid down in this phase is very susceptible to damage from aggressive activity. Gentle range-of-motion exercises, and joint/scar mobilization are the preferred treatments to help promote healthy remodeling and maturation. We try to find the “Goldilocks” amount of movement – not too much and not too little.

Phase 3: Remodeling and Maturation (three weeks to months or years…)

During this stage, there is a decrease in the formation of new cells, and an increase in the organization of the randomly-arranged immature fibers. The judicious application of tension is now important, to guide the developing collagen fibers into assuming their orientation along the body’s established lines of stress. This will allow the new collagen to perform the normal healthy function of the structure as it matures. During rehabilitation, stretching and strengthening using therapeutic exercise and electrical stimulation provide the appropriate tension.

During this description of the stages of healing, you may have noticed that pain is mentioned only during the inflammatory phase. Understanding the pain experience is a topic that countless medical and rehabilitation books have been devoted to. Although pain may be experienced during and beyond any of these phases, the tissues behave in remarkably similar and consistent ways, and they move towards wellness and recovery unless prevented from doing so.

Our goal during your physical therapy treatment is to determine where you are on your healing timeline, and how to best facilitate a fast and optimal recovery! This includes finding the most appropriate treatments which allow your body to progress in the healing process, as well as reduce risk of future re-injury. Perhaps by understanding this amazing process better, you may find that you have more confidence in your body’s ability to heal, and you may better understand how to promote recovery by choosing activities wisely while recovering. If you have questions about this information, please ask your physical therapist or physical therapist assistant!


 • Hall CM, Thein Brody L, Therapeutic Exercise Moving Toward Function. Philadelphia: Lippincott, Williams and Wilkens: 1999:pp 165-184

 • Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd Ec. Philadelphia: Lippincott: 1996.

 • Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. Philadelphia: F.A. Davis Co:1990.