Surgery worked as promised to alleviate your pain. But then months (or years) later, matters regress. The location now seems tight, impairing mobility and function. Some types of exertion cause discomfort.

The issue is internal scar tissue, part of the body's natural healing response after an injury. The problem is that scar tissue lacks the flexibility and elasticity of normal healthy tissue.

"Scar tissue is very common after surgery," says Dr. Corbin Hedt, a physical therapist at Houston Methodist. "It's part of the body's initial triage to an area of injury, but it then has to undergo a process of remodeling to reform into the native tissue that was damaged."

Sometimes that remodeling process occurs on its own. Other times it requires therapeutic interventions to coax the process.

There are many types of therapies for scar tissue, but the standard treatment commonly involves exercise and massage — specifically, stretching and pulling the scar tissue to soften, align and elongate it.

What is scar tissue?

Scar tissue is essentially collagen, a protein that serves as a building block to support many tissues and structures throughout the body — bones, cartilage, tendons, ligaments and skin, as well as an array of other tissues and organs.

After surgery, it proliferates at the site of the trauma, helping to generate tissue repair and provide structural reinforcement.

"The body is always generating collagen for different reasons," says Dr. Hedt. "But after an injury, after surgery, the body lays down collagen in overdrive — a quick and disorganized means of stabilizing the area."

The new foundation is different from the original, healthy tissue. Healthy tendons, for instance, are made of fibers that run parallel, providing strength and mobility and allowing for proper blood flow. Scar tissue's random layering — typically in crisscross patterns — results in a tough, fibrous tissue that doesn't move as freely, have as much blood flow and is structurally weaker. The resulting stiffness creates a physical barrier to natural movement and can cause discomfort.

Scar tissue typically begins to form the first day after surgery, but it may not produce symptoms for months, years — or ever.

Most common areas for scar tissue issues

Scar tissue can develop anywhere in the body and cause issues, but the most commonly affected areas involve the big joints because they feature lots of moving parts.

"Following surgery in those areas, just one little thing that's off — be it strength, range of motion, etc. — can create a different mechanic in how those joints work," says Dr. Hedt. "Restoring the complete normalcy that we were born with is going to be difficult. "

The most common areas where Dr. Hedt reports encountering problems with scar tissue and healing are:

• Knees
• Hips
• Shoulders
• Large muscle groups such as hamstrings, quads and calves

Dr. Hedt notes that scar tissue frequently causes reduced range of motion, stiffness and discomfort after hip replacements, anterior cruciate ligament (ACL) repairs and rotator cuff surgeries.

"A lot of times it's just excess scar formation around the joint capsules that prevent that full unencumbered motion," says Dr. Hedt.

Therapy to remodel scar tissue

In severe cases, or those involving injuries that affect livelihood — such as those suffered by athletes — doctors can perform follow-up surgery to remove scar tissue. But Dr. Hedt emphasizes that surgery isn't recommended in the vast majority of cases, only if it's absolutely necessary.

"Breaking up" scar tissue isn't the answer either. Dr. Hedt calls that a "misnomer."

The real solution, he says, is supporting the remodeling process of scar tissue, stressing it in a way that ensures it regains normal range of motion, strength and mobility. First-line therapy typically includes:

• Manual stretch therapy
• Joint mobility exercises
• Soft tissue massage
• Myofascial release

It's best to begin such therapy soon after the surgery, though long enough after for the area to heal. However, the therapy can still be beneficial years later.

"By then, scar tissue tends to be really stiff and not easy to move," says Dr. Hedt. "But there are different tricks and tools that we use — stretching for long-durations, working on strength deficits that may be causing poor mechanics and employing different ranges of motion that help the scar tissue work better."

There are also instrument-assisted techniques, such as dry needling, a technique similar to acupuncture where needles are inserted into tight and fatigued muscles. Another is the Graston technique, which employs stainless-steel instruments in massages. Warning: Graston can be very uncomfortable.

Dry needling and Graston are widely available, but Dr. Hedt emphasizes that the best therapy is very "individual dependent" — what the patient is truly deficient in, how tight the tissue is and where the needs are the greatest. There's very rarely "a cookie-cutter approach and every patient is evaluated independently," he says.

"But for the vast majority of scar tissue I see on a daily basis, the combination of therapeutic exercise and manual therapy goes a long way," says Dr. Hedt. "Patients usually benefit from that."

Dr. Hedt says it's time to seek therapy for post-surgical scar tissue issues when you're experiencing pain or mobility problems that interfere with everyday activities. Texas law requires a referral from either a primary care doctor or the surgeon for such therapy.