From mechanics to mobilization: a biomechanically-informed rehabilitation framework for cesarean-related scars.

BACKGROUND

Cesarean delivery often results in both abdominal wall scars and uterine scars. However, current rehabilitation strategies for cesarean-related scars lack standardization and a biomechanically informed framework that integrates superficial (abdominal wall) and deep (uterine niche) scar management.

OBJECTIVE

To synthesize the pathomechanical basis of cesarean-related scarring and to propose a stage-specific, biomechanically informed rehabilitation framework, while explicitly acknowledging the evidence gap between superficial and deep scar management.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Scopus from inception to August 2025, supplemented by hand-searching of reference lists. A total of 2,138 records were identified; after duplicate removal and screening, 345 full-text reports were assessed, of which 101 studies met the inclusion criteria. Studies on cesarean scar healing, adhesion biomechanics, mechanotransduction, assessment tools, and physiotherapeutic interventions were synthesized. Evidence was classified by level (I-IV) based on study design, adapted from the Oxford Centre for Evidence-Based Medicine hierarchy. A clear distinction was maintained between interventions applicable to superficial (abdominal wall) scars and those hypothetically extended to deep (uterine niche) defects.

RESULTS

Aberrant mechanical tension is identified as a biologically plausible contributor to pathological scar and adhesion formation following cesarean delivery. Subjective (e.g., POSAS, VSS) and objective (e.g., ultrasound elastography, transvaginal ultrasound) assessment tools are evaluated. Effective mechanotherapy interventions are unified into a proposed three-tier biomechanical framework: (1) reducing mechanical load transfer, (2) passive mechanical stabilization, and (3) mitigating external mechanical forces. However, a substantial evidence gap exists-most mechanotherapy studies focus on dermal scars, and direct validation for uterine niche rehabilitation is absent. Interventions such as silicone therapy, taping, and manual therapy are strongly applicable to superficial and adhesion-related components but remain hypothetical for myometrial defects.

CONCLUSION

A biomechanical perspective is clinically relevant for post-cesarean scar care, particularly for abdominal wall scars and adhesion-related symptoms. The proposed three-tier framework offers a structured, phenotype-based approach to clinical reasoning. However, direct mechanotherapy for uterine niches remains unproven. This framework should be viewed as hypothesis-generating and a guide for superficial and adhesion-related management, not as a validated protocol for uterine isthmocele rehabilitation. Future prospective trials with ultrasound-based outcomes are urgently needed.