Different theory on treatmt of sprains & fractures

[Tortoise]

Just passing on thoughts here – no responsibility taken for anybody who decides to try this for themselves!

Having recently re-sprained my ankle , I was following the conventional managemt of RICE, immobilisation, non-weight-bearing etc. BUT, I’m thrilled I went to my physio, who has a very different approach. He was recommended by my GP (who has a special interest in sports medicine) in the past for another issue.

Apparently there’s a growing body of research on bunnies etc (sorry, bunnies ) that has included trials of immobilisation vs anti-inflammatories vs early exercise, and various combinations, for the same injury. Apparently, those whose treatment was exercise (NO immobilisation), with NO anti-inflammatories, healed very much quicker and with better functional outcomes.

The upshot of the theory, if i’ve got it right:

1. No further damage will be done by movement and weight bearing unless it’s a very unstable fracture. Healing happens without immobilisation. That is really just for pain management.

2. It’s ok to push into the pain (within reason). Take pain killers eg panadeine +/- forte to allow earlier movement and weight-bearing. This is apparently (I’m a bit shakier on this bit) because the pain is caused by pressure on the nerves by the inflammation etc, not related to further trauma of muscles/ligaments/bones etc. Further injury would only happen if pushed to the point/force of the original injury, so to speak.

3. Don’t take anti-inflammatories – they will actually slow down the healing process. The inflammation is part of the body’s mechanism of healing.

4. Use ice initially if very swollen. Otherwise use heat to increase blood flow and speed up healing.
It’s apparently also possible to get stability in a joint even without major ligaments, by strengthening the right muscles. The physio knows a guy with no functional ACL in his knee, but he no longer needs one! Apparently it can be done with the ankle as well. This gives me much hope for long term bushwalking, and getting back to it much quicker.

I’ve had to go with lower height boots because of an on-going achilles tendon problem. (Better to walk with less ankle support than not to be able to bushwalk at all, i figured.) On the day of the injury, I was also missing my poles – they had accidently ended up 150kms away.

Years ago I had plaster, for 4 or 6 wks, for an injury to the same ankle. I have had a considerably reduced range of movement ever since. But my physio has even given me hope for that, showing how one of the ankle bones has moved forward relative to the one underneath, that is restricting movement. He reckons I can improve that too, by strengthening the right muscles that I haven’t been specifically working on, to get it back closer to where it should be. That’s in addition to the exercises I have been doing to improve proprioception.

I'm pretty excited. No doubt others will have different, equally strong views, but I think it's worth putting it out there. Maybe somebody else knows the research first hand. Having come from conventional medical circles, I know how strongly views were held on some things 30 years ago, for which a 180 degree turn has since been made, with views being held just as strongly as they used to be, but are now in the opposite direction.

[Ellobuddha]

I think there must be something to it. Although I think a combo of treatment is best.

I used to play a lot of union and have done the ligaments in right ankle three times, left ankle twice and both knees once each. The right ankle was by far the worst, especially the last time. I actually vomited it hurt that much.

I was told by an army PTI to go the 20/20 for 20. 20 mins in bucket of ice water, 20 mins out for 20hrs ( basically 24 hrs but easier to remember) once the initial swelling went down I got back onto it as much as I could bear. Some meds were helpful but only for pain relief, no anti inflams.

I found this healed quicker for a more substantial injury than having it up for a week, where everything seems to lock up.

No scientific basis or understanding. It just worked. Think its the combination of drawing out the swelling/ or reducing it with ice and then movement.

Maybe someone a little more learned than I could explain why it works.

[GPSGuided]

It's not completely without truth. It's long known that various Eastern traditional medicine treatment of fractures, sprains and bruises can lead to better outcomes. Specifically the use of non-rigid splints can be better than our traditional use of hard plaster casts which often led to severe atrophy and rigidity after 4-6 weeks. Eastern medicine often also have various topical ointments and gummy like paste that are used for these injuries. No ideas what's in them but seemed to have worked decently through the centuries.

Last edited by GPSGuided on Thu 17 Apr, 2014 2:11 pm, edited 1 time in total.

[Gadgetgeek]

I think there is something to this, Lots of athletes don't do 4-6 weeks of rest on light injuries. Once the initial swelling has gone down, I agree, light exercise is the best way to get back into the game, even just unloaded movement. I've met lots of people who baby an injury for 4 weeks, then go to full power and re-injure. Better to ease back into activity, and keep the strength up. I also agree that over-use of OTC drugs can probably slow things down. I've had quite a few nasty twisted ankles from falls, and I've generally tried to force things back into action as quick as I can, and they've healed up nicely. That said, when I broke my arm, I didn't get any treatment (dumb idea, very very very dumb idea) and it delayed the healing for a long time. after 6 weeks the bones were still not fully healed. So, I guess its not perfect.
The body is very adapatable, .

[Empty]

I think think this is very interesting particularly the bit about anti inflamitories counteracting the bodies natural response. I think the same is true for the build up of mucus etc when we colds and the like and then we take drugs to reverse that effect. I have often wondered about this.

[Walk_fat boy_walk]

Apparently, those whose treatment was exercise (NO immobilisation), with NO anti-inflammatories, healed very much quicker and with better functional outcomes.

This (sort of) equates to the old "walk it out" method for sprains. As someone who's sprained one ankle more times than I can remember (like Ellobuddha, can blame army for a lot of that) I can sort of vouch for it... Continued movement straight after the injury does seem to help a sprained ankle (and there is really no choice on a multi-day walk, unless you want to pop the PLB which would be inappropriate for a sprain IMO), but I've often wondered if this causes longer term damage? I also get the impression that it depends how badly/many times its been sprained... The first time can be a major snapping of the ligaments that I can't imagine could be "walked out" and requires crutches for a lot of people, but the more times you do it a) the weaker it is/easier to sprain, and b) the more rapidly it recovers and becomes more conducive to walking out. In my experience anyway - I pretty much have permanent swelling around that ankle now.

It’s apparently also possible to get stability in a joint even without major ligaments, by strengthening the right muscles. The physio knows a guy with no functional ACL in his knee, but he no longer needs one! Apparently it can be done with the ankle as well. This gives me much hope for long term bushwalking, and getting back to it much quicker.

I can see how this might work - as I described above more and more damage to the ligaments seems to mean that it can now heal very quickly after a sprain and be walked on immediately. Nowadays I regularly sprain it by just walking normally. The remedy seems to be to stand up and keep walking (with a grimace). I find if I immobilise and ice it just makes it sorer and doesn't heal any quicker anyway. I have often wondered if this is due to the ligament having been worn away? I'm no doctor though.

[GPSGuided]

I think one still needs to understand there are different levels of sprain. Some are more suited to active recovery while others need proper rest and possible other treatment. Must know the extent and level of injury before considering the various treatment options.

[Gadgetgeek]

If you've torn something, what often happens to the achillies, then its probably going to not help to use it. But small amounts of damage, like the normal sort of ankle roll, are probably going to be in that use it to heal camp. Its also a lot of pain tolerance and the like. The way I see it, if you can use it, and it feels stable, use it. If you can't or it won't hold weight, or moves funny, better stay off it. At least in the short term.

[Tortoise]

I think one still needs to understand there are different levels of sprain. Some are more suited to active recovery while others need proper rest and possible other treatment. Must know the extent and level of injury before considering the various treatment options.

I'm sure this is true. The first time I did this ankle, I passed out from the pain when I tried to put any weight on it. But who knows, maybe I'd have had a much quicker return to better function if it hadn't been in plaster.

I found it fascinating that the physio maintains that the same approach can actually be used for non-displaced, stable fractures as well.

[Gadgetgeek]

I would disagree with your physio. I had, what turned out to be, a stable fracture of both radius and ulna. had I gotten it plastered, in six weeks I would have been back in action, but as it turned out my arm was only half healed after that time. it sucked. now I'm just as sample size of one, and its very likely that I did not take as much care as maybe I should have while healing. but I'm convinced that the healing was delayed by my actions with my arm. (in my defense I had no idea it was broken, and had no reason to suspect so. But next time I'll get xrays)

[Bluegum Mic]

I agree with your physio for certain injuries but not all (gadgetgeek your a good example of the difference). When we injure joints/fracture (especially ligaments) they heal by laying their fibres in the direction needed and forces applied ie if a weight bearing joint you need to weight bear as soon as plausable to allow the fibres to heal in their correct orientation with respect to the forces exerted whilst weight bearing. Same would apply to the knee, hip etc. As for your arm this does not apply so much as its not so much your bodies force acting upon it vs gravity in these instances (with an injured arm you more likely to not use it as you have another vs to walk we need both legs so we tend to suck it up and deal with the pain). Therefore if sore you may hold it in a position across your body say (and use it less) so the forces acting on the joint/fracture wont be functional or healing in nature. Using the ankle as the example I whole heartedly agree that no further damage will be done by movement and weight bearing. However the risk is instability ie rolling it again so whilst I wouldn't immobilise the joint, I find a flexible tape like kinesio tape fantastic as it allows range of movement but support to prevent that inversion or roll of the ankle.
As for the ice heat debate on a peripheral joint they both have their benifit I feel. If there's excessive swelling then ice is great, however if not so bad heat will encourage blood cells to the area to help. I agree with above also you can use both as a flush ie ice, heat, ice, heat etc. It will cause vasoconstriction then vasodilation causing blood/fluid to drain the area, then come back in. There are certainly some joints in the body I wouldn't recommend heat for especially if a nerves entrapped but thats just my thoughts.
And as for me personally I did this 3 weeks ago and I did nothing other than full weight bear from the moment of injury and kinesio tape for 48 hours and then only when exercising beyond that. No ice no heat (mind you that was only due to running around after kids but normally I would only do it in the first few hours post injury anyway). Its now 100% but I have done this injury many times so my bodies got this down pat now =D



Anywho just my understanding of it all but at the end of the day if you filled a room full of medics of the various modalities you likely won't get two of them to wholeheartedly agree on the best way to treat them lol

[Mechanic-AL]

Being an average garden variety type of male I generally by-pass doctors surgeries all together and only seek medical attention when I've been wheeled through the front door of the Emergency Department on a stretcher. True to this method of operation I have been suffering from Achilles Tendonitis ( self diagnosed of course ) for quite a while now. I assume this would fall into the sprains category. The first, second and third opinions I gave myself where that if I just take it easy it will sort itself out. I have spent well over 2 months being conscious of this injury and attempting to take it easy without putting my feet up and resting completely.
If I was a quack or a bone cruncher I would probably be broke by now because my own treatment has failed to provide any results at all. If anything it is getting worse. I am 51 years old and on my feet all day at work. Both of these factors are probably against the ' no cure is the best cure' remedy. If I was 20 years old and not spending long hours on my feet maybe things would be different. As with most things in life I don't think we can all be lumped in the same bag together and any sort of medical treatment is very much a horses for courses scenario.

AL

[corvus]

My torn ankle ligament after many weeks and physio still lets me know it is not really healed regardless of all the drugs I take including anti-inflammatory and pain relief plus others and as I am 66 I suspect age does slow down healing
corvus

Last edited by corvus on Thu 17 Apr, 2014 11:24 pm, edited 1 time in total.

[GPSGuided]

... I have been suffering from Achilles Tendonitis ( self diagnosed of course ) for quite a while now. I assume this would fall into the sprains category.

Quite different actually. Sprain actually involves an acute tear in the ligaments that holds the ankle joint. Tendonitis is the inflammation of the tendon and associated structures.

[Mechanic-AL]

... I have been suffering from Achilles Tendonitis ( self diagnosed of course ) for quite a while now. I assume this would fall into the sprains category.

Quite different actually. Sprain actually involves an acute tear in the ligaments that holds the ankle joint. Tendonitis is the inflammation of the tendon and associated structures.

Thanks for clearing that up GPS. No guessing why I became a mechanic then. Now if only I could find somewhere to screw a grease nipple into this freaking ankle I'd be laughing!

[madmacca]

However the risk is instability ie rolling it again so whilst I wouldn't immobilise the joint, I find a flexible tape like kinesio tape fantastic as it allows range of movement but support to prevent that inversion or roll of the ankle.

One of the things like kinesio tape is not just the support, but that the movement of the skin with the tape provides you with additional feedback as you move the ankle towards the limit of its range of motion. Basically, rather than phyiscally preventing reinjury, it helps you stop yourself from moving the ankle too far.

[GPSGuided]

Thanks for clearing that up GPS. No guessing why I became a mechanic then. Now if only I could find somewhere to screw a grease nipple into this freaking ankle I'd be laughing!

No prob. The key problem with our body is that no replacement part is better than the original. And when the original part doesn't heal well, it becomes a problem for the rest of one's life. With every injury being different to someone else's, his or her experience may not translate well. That's the reason for seeking professional help.

[icefest]

Caveat Emptor:
Kinesio tape has little high quality evidence supporting it's use. On the other hand, there decent evidence that it does not cause any harm.

This is from a recent meta-analysis: (Click on image to read the entire article - no paywall)


If you'd prefer a simpler, non-technical explanation read this:
http://www.running-physio.com/kinesio/

[Gadgetgeek]

When I was doing sport tapes, ice hockey and union rules rugby (juniors and div 3) Our company policy was to tape upon request, but never tell the person that the tape would support the injury. I taped a guys broken thumb so he throw for lineouts (thats a thing right?) It obviously didn't work, I told him it wouldn't, but he wants tape, he gets tape. (also he was an adult, had he been an U18 I would have benched him) In general though, we were instructed to not tape fresh injuries. too many risk involved, although some coaches would tape to get people back on the field. If ice was enough, play on, if not you sit. More often than not our job was getting bleeders back in the game. soft tissue was generally bench time.
As has been said, the tape provides feedback, not support. Even a perfect tape job will only support for about 20 min at best. So for support, a soft splint or elastic is going to do a better job, but at the cost of mobility. So tape works if it keeps you from re-injuring. This is different from AC joint tapes, which are holding the shoulder into place, but even then you have to get them right, use lots of the right kind of tape, and spray to hold everything in, or patella band tapes to hold knee caps in place.
I did lots of ankles and knees for rugby (side support on knees) and lots of wrists in hockey. Lots of players even have it as part of the pre-game ritual. It was easy to tell the guys who cross trained in basketball by the patella bands.

I prefer elastic to KT in the wilderness first aid situation since you can re-adjust as needed, and you can loosen it for circulation if needed. I would go through on average half to three quarters of a roll of KT per site. That would be a lot to carry if you weren't sure you were going to need it. Pre-tapeing before a hike would be fine if you thought that would help. just take all the appropriate precautions.

[Tortoise]

Very interesting getting a variety of thoughts and experience on this. Thanks everyone!

[Jag]

The original RICE guy has put up a summary of latest agpplications & revisions on his Facebook . Worth the 10 mins . ( I can get his name if you want ) .

Basically the first option is to wet the compression tape , afix & apply ice on that for 20 minutes only. This fuses the blood vessels from bleeding out into the injury which would then have had required the lymph glands to send in extra liquid to flush out hence over swelling. Some swelling is needed eg the right amount of fluid to flush. They are using acupuncture a lot more to speed up healing . So maybe it should be CIA. - compression ice then acupuncture.

I think beware muscle wasteage but some tears eg groin need surgery or 6 weeks on the sofa. I took that option .

I always carry an elastic ankle & knee brace when hiking. This has allowed me to walk out a sprain where my poles stopped a full face fall but overextended my foot forward . Later the top ligament overstretch caused plantar fascitus along the arch which had to work too hard compensating . Feet are tricky balancing acts.

Bones sometimes don't join up & require pins. I once broke both leg bones completely at 90' , got them pinned up & was sent home on crutches in 2 days . It took 15 months to lose the blue leg from the vein damage .

[tom_brennan]

For low level injuries (minor sprains/strains), RICE is a short term treatment that aims to speed up subsequent recovery by reducing the initial bleeding/swelling in the joint/muscle. It's not a recovery mechanism itself.

After the initial injury, most physios would be trying to get you exercising/weight bearing/mobilising the joint, which may involve some pain. Certainly not resting beyond the first couple of days.

Not sure about broken bones though – I would be interested in seeing the research.

[roysta]

Hell I don't even know where to go with this.
I severely broke my ankle in 1997.
My left foot was directly to the left and I pulled it around to within 2mm of correct alignment.
Yes, I felt *&%$#! ill doing it but the doctor said it was a correct action.
Despite exercises my foot never returned to 100% mobility.
But I have 90% back and I consider myself lucky to do what I'm doing.
I remember having that titanium plate in there for 18 months and it wasn't enjoyable.
To go on to climb mountains I feel so happy.
I would not wish severe ankle injuries on anyone, it's the worst feeling possible.