The most common injuries seen in the office are those that are due to straining of muscles, ligaments and tendons. As a group, these structures are known as connective tissue. When an injury occurs, the first stage of healing is called the reaction phase. This stage can last for up to 7 days. The length of time depends on the extent of the injury and what you do to speed the healing process. In this first stage of healing, you will have an increase in circulation near the site of the injury. Along with this there will be swelling or edema, which is caused by the cells that have been broken during the injury. The first goal is to try and limit the amount of swelling that occurs. When there is too much swelling more cells become damaged and more swelling occurs. This sets up a vicious cycle of swelling – damaged cells – more swelling – more damage. To limit the degree of damage, we usually recommend RICE. RICE is not something you eat but stands for Rest Ice Compression and Elevation.
You want to rest the area that is injured. Continued activity will cause more damage to the injured structures and consequently more swelling and tearing of cells. Ice, in the form of cold packs, will cause local contraction of blood vessels and reduce pain. A good starting point is to use ice for 20 minutes every hour immediately after an injury for four to five hours. The effects of the ice will last for 15 – 30 minutes and will be gone within an hour. For three days after the injury, continue using the ice 3 – 4 times a day. If you have Raynauds, hives from contact with ice, diabetes, or any vascular disease do not put ice on your skin. Instead, place a cold cloth over the area of injury and call us for additional help.
The letter C stands for compression. Wrapping the area of injury with an elastic wrap will help to limit the amount of swelling. For example, if you have turned your ankle and it is starting to swell, put an ice pack around the ankle and wrap up the ankle and lower leg with an elastic bandage. This will help to limit the swelling and allow us to do a better job of speeding your recovery when we examine and treat the injury.
Finally, the E stands for elevation. If it is possible, raise the injured part above the level of your body. If you injured your ankle, raise your leg above your pelvis. If you injured your wrist, support your arm above the height of your shoulder. This allows gravity to help remove the swelling.
During the injury, the breaking of blood vessels initiates several chain reactions. A clot is formed from proteolytic enzymes released by cells called platelets. Your body creates creates a clot or mesh where the vessels have become broken. The lymphatics, the sewer of our vascular system, become blocked with these clots. The cells release substances known as bradykinins, which cause pain, and are released due to the injury. These cause vasodilation, expansion of the arteries, and increased permeability and increased swelling . Other factors are released locally to breakdown severely damaged tissue and prevent infection.
During this phase of injury it is important to limit the inflammation. Some inflammation is essential and unavoidable. Too much inflammation causes more swelling and injury.
Controlling this inflammation and speeding recovery depends on more than just taking an anti-inflammatory drug. Your body uses enzymes to help clear up damaged tissue and speed the recovery. A good example is a multi car accident on a large highway. The traffic will get backed up for miles on the side of the accident and on the other side with people looking at the accident. Due to the damage done, your body attempts to block off damaged vessels so that more blood doesn't escape. Getting the wrecked cars off the road is one of the first things that have to be done to get the roadway open. Enzymes accomplish this. Your body makes some, but taking more of them speeds up the removal of the damaged tissue and reestablishes the normal blood flow to and from the injury site. To summarize, the primary goal after an injury is to limit the amount of injured tissue. To do this, remember the acronym RICE.
- Rest - stop moving the injured area
- Ice – apply cold packs of ice
- Compression – wrap up the area if possible
- Elevation – elevate the injured area if you can
Call the office and we will examine the injured structures to see the extent of the injury. Depending on what is found, we may suggest nutritionally supporting your own production of anti-inflammatories, or taking enzymes to speed the healing process. If they are indicated, studies have shown that healing times can be reduced up to 50% with similar reductions in pain and swelling when enzymes are taken after an injury. The only problem is that they must be started as soon as possible. This is not a time to wait and see if you feel better in a few days, as the window for starting the treatment is very short.
After the Reaction stage, there are two other stages that traumatic injures go through. These are called regeneration and remodeling.
In the regeneration stage, your body builds new capillaries to replace the damaged ones. This process is known as angiogenesis. At the same time, your body starts to rebuild the damaged connective tissue. It does this by making collagen strands. Collagen is made up of amino acids. Amino acids are the small subunits of protein. Consequently, your diet must contain enough protein to help you make these collagen strands.
If you look at a forest, all of the trees are parallel with each other. Once in a while you will see a tree that has fallen down and caught in another tree. Collagen fibers are similar to this. Collagen is supposed to be in parallel lines. After an injury, your body makes a mesh with collagen fibers going in all directions. Another example is the kids game Pick up Sticks. All of the collagen fibers should be parallel, but after an injury they look like the sticks when they are dropped. The fibers are running in all directions. In order to make a strong bond at the site of the injury, this crossing of fibers – or cross-links – are necessary. One problem is that these cross-links limit the range of motion of the structures that have been injured. You may not be able to move your arm or ankle as freely as you once did. In the last stage of healing, remodeling, the cross-links are slowly reduced and range of motion is increased.
In the regeneration stage, we want to continue to minimize any swelling and inflammation and stimulate protein production of the collagen bonds. Controlled motion helps to unsure that most of the collagen will be laid down in the lines of the normal joint action. Dietary modification to insure adequate protein intake is very important as is limiting foods and substances that encourage the inflammatory process. This would include an excess of animal fats, alcohol and partially hydrogenated fats. Increasing omega 3 oils like EPA or eating deep-water fish will help to limit any inflammation. To insure adequate protein intake, small servings of protein should be consumed throughout the day. In the office, our goal is to make sure that the muscles that have been damaged are treated and made functional. Ligaments that have been damaged may need support both structurally and nutritionally. Keeping the joints aligned properly will allow the damaged structures to heal back to their normal lengths. This stage of the healing goes from 48 hours after the injury in a mild case to over 8 weeks in a more severe injury.
In the remodeling stage, the cross links that were formed in the regeneration stage are slowly reduced and the range of motion is increased. In this phase, care is taken to reestablish the motion of the joint. This may require massage type work or stretching. Much of this is done in normal daily living, but the problem is that we tend to protect the injured part by not using it and thereby limit the return to full function. The other major goal in this phase of the healing is to reestablish normal proprioception. This involves muscle coordination. Muscles react to each other. The contraction of one muscle causes an opposing muscle to relax. When a muscle contracts it should not cause another muscle to weaken when it should be helping the contracting muscle. When this ballet of muscle coordination is not functioning properly, ache and pain will be caused when you use the injured part or you will have a decreased range of motion. In the office, we need to test the muscles doing various tasks to determine that the coordination is working properly. In simple injuries, this remodeling stage will begin as early as the fourteenth day after the injury. In severe injuries, the stage may last well over 1 year.
Only when full range of motion and coordinated muscle function has been attained have you recovered from an injury. If these goals are not attained, permanent decreased function and compensations by your body will lead to other problems.
An example is someone who has injured his or her ankle and it doesn't fully recover. They will walk with a slight limp that will cause knee and hip problems. Year's later, arthritis in the ankle, knee and hip joints may result due to the changes that have occurred.
Restoration of normal function depends on successfully completing the three stages of healing. Each one has its own goals and requirements.