Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

1. fibroblastic repair (Early sub-acute) phase 
2. maturation-remodeling (Late sub-acute) phase
   

Late Sub-acute injuries feel even less red, hot, swollen and painful than in the Early Sub-acute phase.
During this phase, the scar begins to modify into its mature form with steady increases in tensile strength and a decrease in capillaries. Additional collagen fibers are laid down and realigned according to tensions placed on the tissues by normal pressure and movement  At this stage, massage and joint mobilization can align scars to allow for optimal range of motion and functionality. Although scar tissue gradually approximates normal appearance and function, typically the tensile strength of a scar is less than 80% of a functional tissue. Besides vascularity, it lacks elastin, and appears stiff compared to normal, noninjured tissue.  After approximately 3, weeks a firm, strong, nonvascular scar exists but the entire maturation phase can take several years to complete.

The goals of Late Sub -acute inflammation are:

• to fill the area and make the scar more durable
  
• more collagen - to anchor scars to stable tissue and to remodel the scar according to stresses and pulls
  

 
Physiology - In order to reinforce the damaged area with collagen, the following physiological processes happen:

• Scar remodelling -  collagen cross links are being laid down to further fill in the scaffolding established in the Early subacute phase
• Wound contraction - scars try to anchor to the most stable tissue (usually bone) Myofibroblasts make contractile fibers that attach to bone or other fascial planes and pull the healing tissue down and together.  Thus, less tissue is needed to fill the space, but the result is less mobility

  Therefore, Pain treatment in the Late Sub -Acute SOI  focuses on continuing to decrease any remaining edema and spasm, and working with the scar as it forms to decrease fascial adhesions, and to decrease its magnitude, so as to maintain optimal range of motion and strength of the muscles.

The Symptom Picture is :

• even more decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• There is some possible remaining edema
• If bruising occurred, it is now turning yellow or brownish.
• Pain is more pinpoint and only felt with over pressure
• There may be muscle weakness

Treatment Plan  works to decrease the symptoms. Therefore

• Continue to Decrease remaining edema and spasm
  
• Maintain available ROM (range of motion) and strength
  
• Decrease fascial adhesions and scar tissue
  

Treatment follows directly from the Plan, So in addition to treatments for Acute and Early Subacute SOI, add in:

• MFR (myofascial release) and XFF (cross fiber friction) are best to reorient scar fibers in the direction of muscles, for optimal function and strength
  
• Continue to Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting excessive stress on developing scar tissue
  
• Continue to Address trigger points that refer into the area
  
• Continue to massaging the opposite side to decrease the stress on compensatory structures, and proximal to the injury to push circulation back to the heart, speeding the removal of toxins from the injury
  

Self Care Recommendations follow the Plan too, so good recommendations include

• Continue to Educate the client on the importance of not overdoing/ re-injuring the area, as they are feeling
  
• Do encourage Pain-free movement of the area
  
• PIR/RI exercises that you have identified on the table and practiced with client to strengthen the area, progressing to gentle active stretches that do not cause pain
  
• Tell clients to warm up the area with Heat prior to exercise and to ward away any areas of acute inflammation that have been flared by exercise with cool (or ice) applications after
  

Hydrotherapy : Mild contrast, beginning and ending with Heat

Contraindications include:

• Do not overwork the area with massage or stretch (if it is painful, it is too much)
  
• If client experiences Pain or Spasm with massage or stretches or exercise, reduce or eliminate the process causing the Pain
  
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session

Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

1. fibroblastic repair (Early sub-acute) phase 
2. maturation-remodeling (Late sub-acute) phase

Early sub-acute injuries feel less red, hot, swollen and painful than in the Acute phase. This easing of symptoms continues into late Sub-Acute stage; with even less pain and signs of being less red, hot, and swollen  The hallmark of Sub-acute phases is  about forming and reforming the protective scar.

The goal of Early Sub -acute inflammation is:

• to fill the damaged area with new tissue

 
Physiology - In order to fill in the damaged area with new tissue, the following physiological processes happen:

• new capillary buds begin to form into the wound, allowing for an increase in blood flow that brings oxygen and essential nutrients for tissue regeneration
• fibroblasts synthesize collagen in a loose connective tissue matrix which replaces the clot formed in the acute stage
• the result of increased blood flow and building the connective tissue web is a very fragile granulation tissue, a scaffolding that lays down the basic framework for future collagen fibers to attach to.
• lactic acid levels rise in the area - as a result of microphage activity and the hypoxia that ensues from the cell and toxin debris.  This also gives rise to increased collagen production.

  Therefore, Pain treatment in the Early Sub -Acute SOI  focuses on continuing to decrease inflammation response, without damaging the fragile granulation tissue that has formed to fill in the area.

The Symptom Picture is :

• decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• decreased Muscle spasms (muscles contract to protect against trauma) that can now be addressed if treatment doesn't cause more pain
• Bruises are starting to heal and often turning yellow in color
• Pain is more localized and felt when tissue is stretched to resistence

Treatment Plan (works to decrease the symptoms. Therefore

• Continue to Decrease SHARP signs
  • remaining edema with diminished heat and redness
  • pain
  • can begin to address a loss of function
• Maintain available ROM (range of motion) and strength
• Begin to decrease spasms

Treatment follows directly from the Plan, So in addition to successful treatments from the Acute SOI, add in:

• Reducing Spasms - using spasm relief techniques of

                  GTO (golgi tendon organ technique) for long tendons
                  OI (origin/ insertion technique) for short tendons
                  MA (muscle approximation technique) for the muscle bellies

• Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting the stress of a stretch on fragile granulation tissue
• Address trigger points that refer into the area of trauma, avoiding pressure directly on the injured area
• Continuing to massaging the opposite side will decrease the stress on compensatory structures, and massaging proximal to the injury will also continue to push circulation back to the heart, speeding the removal of toxins from the injury

Self Care Recommendations follow the Plan too, so good recommendations include

• Educate the client on the importance of not overdoing/ re-injuring the area
• Do encourage Pain-free movement of the area
• PIR/RI exercises that you have identified on the table and practiced with client

Hydrotherapy : Mild contrast, beginning and ending with Cool

Contraindications include:

• Do not massage with pressure or stretch that puts drag on the granulation tissue(so as not to redamage the compromised area)
• Use only gentle squeezing and light strokes distal to the injury
• If client experiences Pain or Spasm with massage or exercises, reduce or eliminate the process causing the Pain
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session