Cesarean Scar Pain: How Physical Therapy Can Help

What is a Caesarean or C-section?

A C-section, or Caesarean section, is a procedure that involves an incision to the lower abdominal region. It is performed either under general anesthesia or spinal nerve block. It involves cutting through 7 layers (!) of tissue, including:

• Skin

• Adipose (fat)

• Abdominal muscles

• Connective tissues

• Peritoneum

• Uterus

• Amniotic Sac

Each of these layers can form a scar which can adhere to the adjacent layer, preventing the layers from gliding and sliding over each other. This can cause the "layers" to be stuck resulting in:

1) Localized pain over the scar

2) Period pain and cramping: the uterus doubles in size with menstruation and when stuck by scar tissue, moms can experience increased cramping

3) Low back pain: the uterosacral ligaments attach to the sacrum and restrictions at the uterus restrict the normal mobility of the ligaments causing low back or sacral pain

4) Bladder urgency or frequency: the bladder needs to expand when it fills. Scar tissue can restrict the bladder's ability to expand

5) Painful sex (especially with deep thrusting)

6) Digestive issues (SIBO, constipation, diarrhea, gas & bloating)

7) Difficulty healing a diastasis: pulling on the fascia or muscle layers (causing a pulling apart)

8) Pain with bowel movements

9) Increased diastasis recti or abdominal separation

There are 1.3 million Cesarean sections performed annually or about 1 in 3 American births. Chronic Cesarean scar pain is more common that people realize. Of those who had a cesarean birth, 7-18% of women have scar pain after 1 year of their surgery.

How long does it take to heal after cesarean?

You've probably heard of the 6 week mark when it comes to postpartum healing. The scar will continue to heal for up to two years after your delivery date. There are three phases of healing:

1. Inflammatory Phase

2. Proliferative Phase

3. The Remodeling Phase

The inflammatory phase begins immediately and lasts a few days. During this time, the tissue looks red and swollen. After this, the Proliferative Stage starts and continues for 3-4 weeks. This stage is marked by an increase in collagen production to strengthen the wound. The collagen pulls the edges of the wound together and new tiny blood vessels form to aid in healing. The scar will become thicker, darker, redder, and contracts. It makes the scar more obvious and uncomfortable. Eventually, collagen breaks down at the same rate that it is produced. This marks the beginning of the Remodeling Stage. This stage lasts for several weeks to a few years. Scar remodeling is what changes a thick, red/dark, raised scar to a thin, flat, light scar.

Is there anything I can do to help the pain and/or the appearance?

A study by Wasserman showed that soft tissue mobilization (similar to massage) helped chronic discomfort including premenstrual pain, pain upon pressure to the lower abdomen and pain during bowel movements. With 4 treatment sessions lasting 30-minutes over 2 weeks, they had improved pain and 0/10 premenstrual pain (Wasserman). Another study found similar results: 4 sessions lasting 30-minutes-- improved scar pain and abdominal pressure sensitivity (Ryan).

Moms who have had a cesarean scar should start mobilizing their scar once it has fully healed, usually around 6-weeks after surgery. We help not only the skin layer slide and glide, but also the organs (small intestine, bladder, uterus, colon) slide and glide.

How physical therapy can help:

Manual Therapy:

We assess and treat the cesarean scar through the abdominal wall. It is surprisingly gentle and effective

and many moms are shocked that their "old" cesarean scar of 10+ years ago is causing them some of the issues they are having today such as back pain, painful sex, bladder issues or abdominal pain and bloating.

Cupping:

We use pliable silicone cups or suction type cups to restore the mobility of the layers. Cups are placed on the skin create suction, resulting in increased blood flow to the area. Increased blood flow can help ease sore muscles, improve cellular activity, and promote tissue healing.

Visceral Mobility:

The deeper layers of your scar involve your uterus and sometimes bladder. We use gentle techniques to restore the motion and mobility of your uterus and internal organs through your abdominal wall or intravaginally. This helps the internal organs move and communicate better to improve your digestion, pain, breathing and posture.

Class IV Laser:

Laser is an FDA-approved treatment that uses light energy to rebuild healthy tissue, decrease pain, increase blood flow and increases the body's natural healing abilities. It only takes 1-2 minutes!

Dry Needling:

We use a gentle technique that is is very comfortable. Case reports suggest that scar needling generates a quick decrease in pain and improvement of mobility in scarred tissues. The patient photo below had a vertical abdominal scar on top of a cesarean scar and had wonderful results with dry needling her scar with improved sensation, less pain, reduced hypertrophy of the scar and more mobility. Dry needling cesarean scars has quickly become one of our most popular treatments as it decreases pain, improves mobility and often decreases the cesarean scar "shelf" and reduces the hypertrophy (raised appearance) of the scar.

Dolphin MPS or Micropoint Stimulation Therapy:

This device uses concentrated microcurrent to improve cellular healing, lymphatic flow and to decrease pain. Scars can improve in their appearance and mobility in one treatment session-- even "old" scars.

Scars anywhere in the body can contribute to chronic scar pain, or the adhesions themselves can create problems. All of the above techniques can be used to help any scars, but we see cesarean scars on a daily basis to improve healing, the cesearan scar "shelf", pain, digestion and appearance of the scar.

If you are struggling with cesarean scar pain, reach out for an appointment locally in Richmond, Virginia or via telehealth in the state of Virginia-- specially trained pelvic health physical therapists are trained to help with cesarean scar pain, low back pain, pelvic health issues and adhesions. Call us at 804-372-0291

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Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg. 2005 Mar-Apr;62(2):220-5. doi: 10.1016/j.cursur.2004.08.014. PMID: 15796944.

Wasserman JB, Steele-Thornborrow JL, Yuen JS, Halkiotis M, Riggins EM. Chronic caesarian section scar pain treated with fascial scar release techniques: A case series. J Bodyw Mov Ther. 2016 Oct;20(4):906-913. doi: 10.1016/j.jbmt.2016.02.011. Epub 2016 Mar 10. PMID: 27814873.