The Management of Sprain, Strains and Trauma - Part One
Sprain, strains, and other traumatic injuries should be treated as early as possible to prevent the development of complications. When treating sprains/strains and many other musculoskeletal disorders, attention to Blood and circulation is of utmost importance. This is true especially for extracellular bleeding and Blood-stasis. In chronic disorders, disturbed Blood/blood circulation, and inadequate nourishment from Blood are often underlying causes of tissue degeneration. Obstacles to circulation may arise from any of the Pathogenic Factors and dysfunction in any of the systems that affect the Blood (Lungs, Spleen, Liver, vessels, etc.). Table 10-1 through Table 10-6 summarize contemporary TCM classifications and treatment of sprains and strains.
Sprains are injuries to ligaments. Sprains characteristically are due to some sort of extrinsic force placed on the joint that moves the joint beyond the limits of the physiologic barrier. They can also be due to fatigue failure and hysteresis. When a sprain occurs, some degree of “subluxation” can result. Overall failure of ligaments (and tendons) is usually sudden and is preceded by the micro failure of the attachments between collagen fibres within the tissue and loss of the ability of the ligament (and tendon) to recover its length. It is important to distinguish between an eventual failure due to a sustained load (creep failure, hysteresis) and sustained cyclic loading and unloading (fatigue failure), from acute overload in excess of physiological tolerances. Treatment of subluxations and ligamentous congruity and strength is necessary if the joint is to regain full function.
Grading of Sprains
Sprains, like strains, are graded from mild to severe.
• Mild or Grade I Sprains result in no detectable lengthening of the ligament and therefore no obvious abnormal laxity of the joint. However, the joint is dysfunctional and joint play is often abnormal.
• Moderate or Grade II Sprains are distinguished by lengthening or partial tearing of the ligaments, and almost always are associated with some degree of subluxation. The joint may be hypermobile, but joint stability is retained mostly.
• Severe or Grade III Sprains result in a complete loss of joint stability. The distinguishing factor on examination is the end-feel, which lacks the normal capsular or leathery end-feel and increased range (unless limited by oedema). Usually there is no or only a little pain, and the patient has fears of “giving way.”
It is also helpful to grade strains/sprains as: acute (first 48 hours), subacute (48 hours to 6 weeks) and chronic (more than six weeks), each of which grades is related to a different stage of the inflammatory cascade.
This classification is rather arbitrary, and the difference between grades I and II is always subjective. Evaluation of a patient should be done as soon as possible after the injury (especially in mild and moderate sprains), since swelling and pain may make accurate examination more difficult. Tenderness and localized oedema indicate the anatomical site of the tear in most instances (Ombregt et al ibid).
With sprains the patient is often aware of the injury as soon as it occurs. However, since symptoms are delayed often, the patient may continue with his activities and miss the opportunity to minimize bleeding and swelling. Pain (Garrick and Ebb ibid) from severe (grade III) sprains may disappear within minutes and be disproportionately mild. Mild sprains often remain painful for a long time, especially when left untreated.
The term muscle strain is used to describe injuries to the musculotendinous unit, also called the “contractile unit.” Strains can occur anywhere within the contractile unit: In the tendon body, the tenoperiosteal junction, at the musculotendinous junction, or at the muscle belly. Strains can also initiate reflex contraction of the extrafusal fibres (spindles) with resulting viscous cycle of spasm, inhibition, and pain.
Causes of Muscle Strain
Strains usually occur due to intrinsic tension within the musculotendinous unit, most commonly when tension is suddenly and actively increased. This can occur with excessive muscle effort, such as in weight lifting. Strains may be due to overstretching, as well. Increase in tension can result from abrupt contraction of antagonistic (during eccentric contraction) muscles and tendons, causing muscle fibres to fail before the muscle lengthens. Tension in the contractile unit is greatest during deceleration (eccentric action), requiring the muscle to have some ability to lengthen at the same time as it maintains the contraction. Muscle stiffness, with decreased ability to lengthen during deceleration, is a common cause of strain. Another cause, which in part may also depend on muscle flexibility, is a sudden interruption of motion during activity. This occurs frequently during sport activities (Garric and Ebb ibid). Muscles that cross two joints, such as the hamstrings, biceps, and gastrocnemii are particularly at risk at their musculotendinous junction (Ombregt et al ibid).
The position of a muscle at a point of strain can change the way in which the afferent (sensory) nerves are changed. If the muscle is in a lengthened (eccentric) position, the afferent stimuli generated immediately after will be decreased, whereas if the muscle is in a shortened (concentric) position, the subsequent afferent will be increased (Donaldson et al 2001).
TENDON AVULSION is a strain-type fracture that results from a tendon and its bony attachment tearing loose from the surrounding bone. Such fractures vary in size from a small flake that is barely visible (as is occasionally seen with “tennis elbow”) to the large avulsions (many centimetres in length) seen when the hamstring origin avulses a portion of the ischial tuberosity (Garric and Ebb ibid).
GRADING OF STRAINS. Strains are graded in severity as mild, moderate, or severe.
• Mild / grade I strains are generally viewed as microscopic disruptions resulting in no defect in the unit on examination.
• Moderate / grade II strains involve significant but not complete disruptions of the musculotendinous unit.
• Severe / grade III strains are complete ruptures of the contractile unit.
It is also helpful to grade strains as: acute (first forty-eight hours), subacute (forty-eight hours to six weeks) and chronic (more than six weeks), each of which is related to a different phase in the inflammatory cascade.
MUSCLE CONTUSIONS. Muscle contusions result from a direct impact to the muscle belly. This results in bleeding and swelling. Intramuscular bleeding (as opposed to intermuscular) can result in severe pain that may last for a long time, as it may be difficult for the body to disperse the blood. If possible, the blood should be aspirated within three days to minimize the chance of myositis ossificans development (Brown ibid).1 After the blood is aspirated, a pressure wrap should be applied. The next day, active contractions with the muscle in a fully shortened position are helpful to prevent the formation of adhesions (Ombregt et al ibid). Trauma may be followed by deformation of the sarcomeres in the longitudinal and, more rarely, transverse direction. This may impact the ability of the actine and myosin filaments to slide by each other and cause the muscle to shorten. This can lead to abnormal stimuli and abnormal muscle tension. Such deformations may slightly change the axis of muscular contraction and distort the mobility and motility of a part of the body. Regions of hyperdensity may be formed at the beginning of trauma, oedema, and fluid stasis. Some scarring processes may begin, as well (Barral and Croibier 1999). For more information on treatment see chapter 6.
MYOSITIS OSSIFICANS. Myositis ossificans is a benign condition that often results from trauma to muscle tissue. It can also be inherited. The condition is characterized by heterotopic bone formation, which occurs after injury to muscle fibres, connective tissue, blood vessels, and underlying periosteum (Gilmer and Anderson 1959). It occurs most often in males fifteen to thirty years old and the muscles at most risk are the brachialis and quadriceps. This condition is some-times found in the hip adductors and pectoralis major and the bony deposit (in the muscle) is often connected to the underlying bone. The patient usually suffers from pain at the affected muscle: The muscle is shortened and resists stretch¬ing and often a firm mass is palpable. Often the range of movement in the neighbouring joint becomes restricted. Radiographic changes are only evident two to four weeks following trauma. This condition does not respond to conservative treatment, although the administration of diphosphonates may prevent the deposits of bone. Traumatic myositis ossificans may resolve on its own in the course of one to two years (Ombregt et al ibid).
Treatment of Acute Sprain/Strain
Treatments of acute injuries follow four steps that address bodily responses to trauma (Kunnus ibid). Treating the area with PRICE: protection, rest, ice, compression, elevation, and support is recommended early on.
1.Immediately after injury ice and compression are used to minimize bleeding and swelling (mostly during first seventy-two hours).
2.During the first one to three weeks after injury (depending on severity), protection by immobilization or just rest of the injured tissue/area usually allows healing without extensive scarring. Elevation helps drain oedema and clear injured cells.
3.When soft-tissue regeneration begins, controlled mobilization and stretching of muscles and tendons stimulate healing.
4.Later at six to eight weeks post-injury, the rehabilitative goal is full return to pre-injury level of activity.
It must be stated, however, that, though the first step involves immobilization, most experimental and clinical studies demonstrate that early controlled mobilization is superior to immobilization for the primary treatment of acute soft-tissue injuries. Care should be taken not to bring the fibres under longitudinal stress in order not to disrupt the healing breach. Therapeutic movements are of short duration and amplitude, but repeated frequently (Ombregt et al ibid). PRICE is therefore used with flexibility.
The following treatment principles are the most important aspects in the treatment of sprains, strains, and contusions.
The treatment of acute injury should be directed toward minimizing bleeding, oedema, and protection from further injury.
MINIMIZE BLEEDING. Most injuries involve the rupture of small blood vessels. Microscopic capillary bleeding in deep neck muscles, for instance, has been shown to persist for up to five days after motor vehicle collision injuries (Aidman 1987). At the beginning of treatment, preventing or arresting hemorrhaging is the primary concern. The extraversion of blood will produce far more disability than, say, the loss of a few fibres of muscle, tendon, or ligament (Garrick and Ebb ibid).
Most sprains and strains are mild or moderate (1st or 2ed degree). Therefore, by definition, the injured structure retains anatomic continuity and ability to function. The accompanying bleeding, however, may distort normal anatomical relationships, resulting in pain and loss of motion/function. Bleeding and inflammation are in fact essential for proper healing. However, it is best to prevent the blood from seeping into unaffected tissues that then suffer unnecessary inflammation and stasis which will further inhibit circulation and drainage of the affected tissues. Also, inflammatory responses are often excessive and may be out of proportion to the severity of the injury and may lead to excessive scarring.
COMPRESSION. Compression is the most effective means of stopping bleeding, but to be effective, compression must be selective. Compression must be directed toward, and be in contact with, the bleeding site. For example, tissues injured around the ankle joint are deep to the bony surfaces. They lie in a depression under the malleoluses, where a pressure wrap or tape may be applied. Therefore, to effectively transfer compression to the tissues, a U-shaped pad should be used, or else compressive force will probably only redistribute the swelling to areas where it will do more harm (Figure 10-2).Manual pressure should be applied as soon as possible: within minutes of the injury.
CRYOTHERAPY, LOCAL ANAESTHESIA, AND ANTI-INFLAMMATORY MEDICATIONS. Cold application is helpful, but not as important as immediate compression. The efficacy of cold therapy has been studied on ankle sprains, showing an average of fifteen days reduction in the time of recovery (Knight et al 1980). Cryotherapy has several effects, including reduction of cell metabolism and oxygen consumption. These reductions can prevent secondary hypoxic injuries in uninjured tissues (Knight 1978). Cold also has an analgesic effect by acting as a counter irritant and decreasing inflammatory responses (Cailliet 1991). At the same time, cold/cryotherapy has been criticized, as it can cause oedema, especially in the acute phase of an injury and, therefore, may lead to the inhibition of the healing process (Leduc et al 1979). Many TCM physicians are biased against cold therapy and state that it leads to the development of arthritis and scarring. Others use cold therapy during the first twenty-four hours.
Cold packs or ice should be combined with compression early on. Crushed ice or frozen gel capable of contouring around the anatomy should be applied for a minimum of twenty minutes, repeating every two to four hours. Icing of the spine, however, to treat deep-seated lesions is ineffective, and in fact may be detrimental by causing muscle cooling and spasm. In sprains of the sacroiliac (SI) joint, ice is often helpful but should be applied over the SI only, avoiding the lumbar muscles. Icing is helpful for interspinous liga-mentous injuries, costotransverse and costosternal sprains, hyperextension/flexion injuries (whiplash) in the neck, tendinitis (acute and chronic), and in the early stage of muscular strain. Cryotherapy is especially helpful in peripheral joint sprains and musculotendinous injuries.
The application of heat in acute injuries has been shown to be detrimental in the early stages (Hohl 1975). Heat is helpful in the chronic stage. In TCM, however, heat is recommended by some physicians in the acute phase (also see page 369).
The immediate induction of local anaesthesia at the site of the lesion effectively blocks the nociceptive impulses which are responsible for muscle spasm. This may prevent changes within the nervous system that lead to sensitization. Cryotherapy may work in the same way, since it has local anaesthetic effects. The use of topical Toad venom (Can Su) is effective in some superficial lesions. Hua Tuo’s Powder Containing Venenum Bufonis (Doing Su San) may be used as an anaesthetic (taken with a little wine) or used topically. Iontophoresis, ultrasound, or DMSO may be used to increase penetration. 2 Here is the formula for Hua Tuo’s Powder:
Venenum Bufonis (Can Su) 3g
Rhizoma Pinelliae (Ban Xia) 2g
Radix Aconitii (Chuan Wu) 6g
Radix Rhododendri Mollis (Yang Zhi Zhu) 2g
Fructus Piperis Nigri (Hu Jiao) 6g
Fructus Piperis Longi (Bi Ba) 6g
Pericarpium Zanthoxyli (Chuan Jiao) 6g
In general, effective analgesia is said to be capable of preventing the onset of complex regional pain (or RSD), or other pathogenic changes in the nervous system. Thus the use of narcotic medications should always be considered if the patient is in severe pain.
Steroids injected within the first forty-eight hours of ligamentous sprains can reduce traumatic inflammation and prevent most structural and reflex changes. Pain also disappears, enabling the patient to move the joint in a normal way. Steroids injected during the granulation and repair stage, however, lead to fewer fibroblasts, diminished collagen fibre formation, and result in a weaker repair. Thus, in acute/early stages of ligamentous sprain, steroids have a beneficial influence, while they may have a harmful one in the later stage. Steroids seem to have larger negative effects on tendons. They are safe intra-articularly in most stages of traumatic arthritis (Ombregt et al ibid).
ELEVATION. Elevation, or at least avoidance of weight bearing, is another element in the initial treatment of an acute injury. Painful movements should be avoided, but other movements should be encouraged in order to prevent the development of weakness and adhesions from disuse. If the injury is severe, however, a period of rest and immobilization may be needed.
THERAPEUTIC MOVEMENTS AND EXERCISE. Immediately after the injury, one may need to protect and rest the injured area. Strapping the joint to protect it from unwanted movements may be needed. Premature and intensive mobilization leads to enhanced type-3 collagen production and weaker tissues than those produced during an optimal immobilization/rest period (Kanus ibid). Some acute inflammatory processes may last up to three weeks. Depending on severity, the patient may need to remain immobile or rest for that length of time. This is true especially if sprains are of the 2nd and 3nd degree (i.e., involve clearly torn tissues). However, some movement of tissues by cross-fibre massage and passive motions may be indicated to prevent adhesions and encourage collagen deposition to align in the direction of stress. Movement also stimulates proteoglycan synthesis and tissue repair (ibid).
Passive movements in the direct or indirect direction (limited/painful or non-limited/non-painful) should be within the allowable joint play and/or soft tissue range, and should be painless. They should start as soon as possible, especially in mild to moderate sprains/strains. After three weeks or so, a controlled mobilization in increasing magnitude should be started, even in severe sprains.
For muscle tears, mobilization should start after three to five days of immobility. This limits the size of the connective tissue area formed within the injury site, reducing scarring and inflammation (Kanus ibid). Stretching and resisted movements should be avoided. Ombregt et al (ibid), however, advocate light cross-fiber massage and active or electrically induced contractions, with the muscle in a fully shortened position to be started on the second day post- injury. They warn against using strong passive stretching or resisted movements. Return to sport activity can be allowed when the strength of the injured limb has been restored to within 10% of that of the unaffected limb (three to six weeks).
For tendinous lesions, a gentle passive tissue mobilization by cross-fibre massage together with passive movements are used to orient the randomly distributed collagen. They are performed for no more than a minute or two, starting on the day after injury (Ombregt et al ibid).
For ligamentous lesions, a gentle passive mobilization in the non-painful range together with cross-fibre massage are used, as well. Active movements can be used as long as no pain is elicited. There should be no attempt to increase this range in the acute or subacute stage (Ombregt et al ibid).
For traumatic arthritis, it is essential to restore full range of movement as soon as possible. This is true especially in middle-aged and elderly people, as post-traumatic adhesions are apt to form. Movements should be performed to the point of discomfort, but not pain. All possible movements should be attempted, one by one, and a small but definite increase in range should be achieved each day. If this fails, intra-articu-lar steroid injections may be needed (Ombregt et al ibid). Other treatments such as functional techniques, muscle energy (MET), joint distraction, acupuncture, and herbs are useful as well, for both the acute and chronic stages.
MASSAGE. Starting on the second day post injury, cross-fibre massage can be used, gently, for a minute or two, and may help prevent adhesions. Effleurage can diminish swelling and pain and encourage restoration of normal movement. Effleurage strokes should always be directed towards the heart.
BLOOD LETTING AND ACUPUNCTURE. Bloodletting of visibly congested blood vessels (a TCM technique) in the area and Well/Jing/Ting points is helpful to reduce local pressure and encourage circulation, often leading to immediate reduction of pain and throbbing sensations (Figure 10-3). The Sinew channel(s) is activated by needling or bleeding one fen proximal to the Well/Jing/Ting point on the affected channel’s side. The Well/Jing/Ting point on the other side is moxaed; then superficial local needles are inserted to surround the area that shows stasis and swelling. No strong or deep stimulation should be attempted at local areas, as this often only increases inflammation and pain. The appropriate Connecting channel is used often. This also helps in dispersing congestion and stasis.
LASER THERAPY: Laser therapy has been reported to both prevent and treat oedema and to be generally useful when used early in the treatment of sprains and strains.
MEDICINAL HERBS. Medicinal herbs are prescribed according to the stage of the injury (see part two).
SURGERY. Although surgery may be necessary at times, several studies have shown that, for example, non-operative management and early mobilization of medial collateral ligament ruptures of the knee have as good an outcome as surgery. However, if the knee is very unstable and both the medial collateral and ACL are torn, exercise may have an adverse effect. Comparable outcomes have been shown for surgical and non-operative management of acromioclavicular (AC) joint separation, partial Achilles tendon tears, patellar dislocations and complete ruptures of ankle ligaments (Kunnus ibid).
Sub acute Stage
Treatment is again predicated on severity. The sub acute stage starts about thirty-six to seventy-two hours post-injury, approximately when oedema has stabilized. The practitioner is advised to treat swelling as quickly after the injury as possible, because, once established, oedema becomes harder to manage. When patients present at the office a day or two post-injury, the treatment principles remain the same, first arresting all swelling, then eliminating oedema, and then restoring function.
1. Electrogalvanic Stimulation. Once swelling is stabilized, the addition of high-intensity electrogalvanic or interferential stimulation with the muscle in the shortened position can help eliminate swelling and prevent adhesions from forming. This, however, should not be started too early. Active muscle contraction with the muscle in the shortened position may prevent adhesions as well.
2.Blood Letting and Acupuncture. Techniques as described for the acute stage are still used.
3.Topical Herbal Soaks. Topical herbal soaks and plasters with or without massage are helpful.
4.Contrast Therapy. Contrast therapy (alternating hot and cold baths) should start at this time, first soaking the affected area in warm water, or herbal decoction (at 100o F) for about four minutes, followed by one minute of cold icy water bath.
Heat can increase blood flow, reduce pain and muscle spasm, and relax joints. Encouraging active movement during the heat treatment is very important, as this will facilitate lymphatic and other fluid movements and drainage.
Thermotherapy. At one time, thermotherapy was seen mainly as a component of the post-cryotherapy rehabilitative process (contrast therapy). However, recently new information has emerged demonstrating that thermotherapy (heat) allows the patient to attain pain relief through the effects understood in the well-known gate-control theory, a concept now known as “thermal analgesia.” When muscles and tissues are tight, circulation to the area is restricted, resulting in progressive ischemia and increasing pain. Properly applied heat allows muscular tissue to relax, facilitating increased circulation and relieving pain by allowing metabolic toxins to be removed from the area and increasing tissue oxygenation. While hot water bottles conform well to various body surfaces, they cannot be easily secured to the body. Further, the water in them cools quickly, requiring the patient to continually refill them. Heating pads are usually a safe source of heat. However, the FDA and Consumer Product Safety Commission have logged many cases of injury and death with their use, estimating a total of 1,600 new burns and eight fatalities each year. A patient who wishes to work or carry out sports activities while receiving heat cannot use a heating pad, since it is dependent on an electrical source. Prism technologies manufacture a small plastic bag containing a solution of sodium acetate and a small metal disc. This “Heat Solution” (also known as Zap PacR) is activated by grasping the metal disc inside the bag and clicking it once (Figure 10-4). This action forms a nucleate crystal, which initiates a cascade of exothermic crystalline precipitation. The heat produced may last as long as one hour. The bag can be indefinitely recharged by placing it in boiling water or a microwave oven. Another alternative for heat therapy is the ThermaCareR which only begins to heat after the package is opened, and reaches its target temperature of 104°F in about thirty minutes. It provides a consistent heat over an eight-hour period. Two versions are available for musculoskeletal use: a back wrap for low back pain, and a neck-to-arm wrap that treats the neck, shoulders, arms, and wrists. These heat wraps conform to body contours and are fully portable, allowing the patient to carry out normal activities while wearing them.
Heat therapy is mostly suitable for late-stages and chronic disorders. A recent study has shown that heat is superior to icing (or other modalities) in the treatment of chronic low back pain (Mooney 2004).
5.Exercise and Mobilization Therapy. Mobilization therapy within the no painful range is for the most part passively started. Passive motion should be applied first in the indirect direction (toward the no restricted barrier) and initiated within the allowable and comfortable joint-play and soft-tissue range. These measures may prevent the formation of troublesome adhesions, establish appropriate proprioception, and reduce noxious nervous stimulation. Direct movement into the restricted barriers is carried out as tolerated and with care (i.e., without causing any pain or discomfort). Stretching and resisted movement should be avoided at this stage. It may be necessary to immobilize the affected tissues for up to three weeks in some severely injured patients.
Patients usually respond to pain with guarding and avoidance of painful movements. The resulting prolonged disuse leads to muscle weakness. Furthermore, because movements become uncomfortable, the muscles responsible for such movements become less active, and the joint loses the stability normally afforded by these muscles. This increases the likelihood of a recurrent injury. Strengthening exercises at the sub acute phase should not be started too soon (especially if a tendon/ligament is involved) before the tissue has had a chance to form a breaching scar. Active exercises are started about two to three weeks after the injury. Light isometric muscle contractions are usually safe. They will not aggravate the condition unless a tendon or fracture is involved, and they should be gauged appropriately. Recently, even fracture care has been changing, and early mobilization, which has been the practice in TCM for a long time, is increasingly being applied. The patient is taught particular exercises and instructed to perform about five repetitions hourly while awake. Vigorous activity should only be resumed after normal function has been restored. Otherwise, immature fibrous healing may rupture and maintain the disability. Also, the body will try to compensate for the dysfunction and establish abnormal patterns that may place unfamiliar stresses on numerous muscles and joints. This will cause a cascading increase in symptoms that may be much more difficult to deal with than those directly resulting from the original injury (Brown ibid).
Late and Chronic Stages
The same treatment approach can be used in the chronic stage, with more aggressive techniques. However, in tendinitis or muscular strains, excessive strain from exercise can be detrimental. Often muscle length must be restored first. With instability, strength and length are addressed at the same time. A Rupturing of the adhesion may be needed. For trau-matic arthritis in the late stage (Ombregt et al ibid), stretching out the capsule requires many repetitions of long steady pushes maintained for a minute or so, as long as the patient can bear it. No increase in range can be expected for several visits, and persistence is required. Heating the joint prior to treatment is helpful.
A recent multi-site, randomized, actively-controlled, investigator-blinded study compared heat wrap to oral ibuprofen (400 mg TID) and acetaminophen (1,000 mg QID) for lower back pain. Topical heat-wrap therapy was superior to acetaminophen and/or ibuprofen in pain relief, lateral trunk flexibility, decreased muscle stiffness, and disability reduction. Further, investigators discovered that the improvements persisted for over forty-eight hours after removal of the heat wrap, far longer than the duration experienced with non-prescription oral analgesics (Pray 2003).
Many Osteopathic (or TCM) manual therapy techniques can be used in the management of sprain and strains. See “Osteopathic Treatment Methods” on page 484.