The word “adhesion” is familiar to many people, but its exact meaning and possible implication are often not as clear. An adhesion is simply tissue that is stuck together that shouldn’t be.
During normal healing after trauma, infection or surgery, the body repairs damaged tissue. A scar forms as tissue is mended. In many cases, however, the body goes overboard and more tissue, which should slide and glide on each other, becomes adhered. For example, an adhesion around a knee surgical scar may restrict skin moving on the muscle beneath it. Abdominal surgery may restrict the slide and glide of organs on each other as you breathe in and out or run.
Adhesions can be thin sheets of tissue, like plastic wrap, or they can look like thick fibrous bands. Whether adhesions cause problems depends largely on where they are located. According to Eugene Hardin, M.D., Chair of the Department of Emergency Medicine at Martin Luther King Jr. Medical Center, 93% of people who undergo abdominal or pelvic surgery develop abdominal adhesions.
Most adhesions are painless; however, they cause 60%-70% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain. According to Dr. Hardin, “Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years,” if at all.
In physical therapy, we clinically see adhesions restrict motion in a number of areas. Abdominal adhesions such as those from old gall bladder surgery done before laparoscopy were often associated with loss of shoulder motion. To understand how this could happen, think of the body as being covered by a skin-tight body suit, and then picture the suit as being 3-dimensional, encompassing the inside of the body itself.
If you have a surgical scar, and adhesions develop around the scar superficially as well as internally, it is like sewing a dart in the body suit. In some cases, especially if the patient isn’t active enough to maintain good mobility in that area (and sometimes even if so), the steady pull from the dart starts to pull tissue above it toward it. In the case of a shoulder, it is often pulled forward and down.
Adhesions from appendectomy scars can create orthopedic problems associated with tightness in the right hip flexors such as the iliacus and psoas (muscles that run across the front of your thigh and attach above the crease where your leg joins your body). The job of these muscles is to lift your leg up, such as when you walk up stairs. Often, these adhesions tighten the hip flexors by reducing their mobility.
A frozen shoulder, medically known as adhesive capsulitis, is…you guessed it, adhesions of the capsule of the shoulder joint. In some cases, it can occur after an inflammation, such as bursitis or tendonitis. This usually happens when it involves the non-dominant arm. Pain from the inflammation causes the patient to limit the use of that arm and soon the patient starts to compensate in subtle ways. Since it may be uncomfortable to reach back to put the arm in a coat, the person leads with that arm to avoid the motion. Soon, the lack of mobility causes adhesions to form in the capsule, and instead of becoming less painful, the arm becomes more and more restricted.
With inflammation, it is a fine line to determine how much to push the arm through motion and how much to rest it. A good rule is to help the arm stretch through full motion at least a couple times a day. In the case of trauma such as fractures, dislocations or tears in the muscle, a period of immobility is usually necessary. This is often a ripe opportunity for adhesions to grow and is why physicians order physical therapy as soon as possible.
Physical therapy, specifically manual therapy, which is a gentle hands-on approach, can be very effective in treating adhesions. People commonly think of a therapist’s painfully stretching stuck shoulders, but a therapist skilled in manual therapy can achieve good results, with very little pain, in increasing mobility of mild to moderate adhesions. This is done by gently mobilizing the tissue and gaining movement in the structures, which are adhered. The same is true for some adhesions caused by surgery.
By following the pull on the tissue created by the adhesion, tissue can be mobilized gently to regain mobility, even if the adhesions have been there for years. Certainly, deep adhesions that become problematic may need to be surgically released, but this is usually the last resort since the surgery itself often causes more adhesions.
So if you notice pulls or tugs on areas that start to affect your posture or restrict your motion, see your doctor. If an adhesion is suspected, ask for a referral for manual physical therapy.