Chronic Pain

Strains and Sprains

Today lets talk about common injuries-strains and sprains- along with how to prevent and treat them.

Sprains and Strains are defined as pain from the partial tearing, or total rupture, of tendons or ligaments as they connect to joints. They usually occur after a fall or sudden movement that violently pulls or twists a part of your body such as your knee, ankle and back. Chronic repetitive and overuse of muscles or joints can also cause injury as seen with golf and tennis players.

Common symptoms of strains and sprains that may necessitate medical attention include:

•Warmth, redness, swelling, stiffness and bruising lasting longer then 2-3 days

• If the joint gives away while attempting to bear weight, this could mean instability

• Hearing a pop in the joint after an injury, with a continued popping sensation when the joint is moved may indicate a serious injury

• If movement or weight bearing causes pain

• If the joint appears misaligned, it may mean a complete rupture or fracture

• If an injured muscle doesn’t move at all; the muscle may be completely torn

• You have repeated sprains or strains in the same joint it may indicate a chronic issue

• If you have difficulty moving or walking after straining your back muscles

• You have a fever, and the injured area is red and hot; you may have an infection

Although the degree of pain and swelling are usually the best indicators of how severe a sprain or strain is, that is not always the case. Some injuries, like Achilles tendon tears, may cause only mild pain at first, but are actually more severe.

A sprain is an injury to a ligament, the strong fibrous bands that connects bone to bone. The most common areas of injury are the ankles, elbows, wrists and knees. A strain is the overstretching or tearing of muscles or tendons. Tendons are the dense fibrous cords of tissue that connect bones to muscles. The most common locations for a muscle strain are the hamstring muscle and the lower back.

Bursitis is different in that inflammation is in one or more of the over 150 bursa (small sacs) that secrete synovial fluid to lubricate a joint, allowing muscles and tendons to slide across bones painlessly and without friction. When bursitis occurs, movement becomes difficult and painful. The more the joint is moved, the more it aggravates the underlying bursitis. This aggravates inflammation in a never ending cycle. Bursitis is usually caused by repetitive motion and trauma, but, underlying arthritis, gout and chronic diseases can be the culprit as well.

Bursitis occurs more frequently in the  shoulders, elbows, knees, hips and ankles.  Symptoms include swelling, redness, and worsening pain with activity.  Seek out medical help for treatment options.

With a sprain, you may have bruising around the affected joint, whereas with a strain, you may have spasms in the affected muscle. There  are different degrees of strains and sprains. These range from first and second degree-  where the tendons and ligaments are still intact, to a third degree where a total rupture and instability at the joint have occurred. If serious enough, immobilization, or even surgery, may be required. An x-ray or MRI, (magnetic resonance imaging) can define the degree of damage or if a fracture has also occurred.

Being out of shape or not able to do an activity often leads to injury. Too often, we have the best of intentions but lack the ability to perform as we should. A classic example is the middle-aged man trying to keep up with the twenty year olds in a game of football or basketball. A notorious injury is the jump shot in basketball that ruptures the Achilles tendon when the foot hits the floor at an angle. Or when dad is trying to out-run his son down the court and twists wrong. As tendons age, they are able to tolerate less stress, are less elastic, and easier to tear. By the 40-50’s the Achilles tendon is more brittle and less accustomed to strenuous activity. To prevent or limit injuries, warm up before the game, wrap the predisposed joint for added support and circulation, and play with similarly skilled players. Also, allow your body time to recover between exercises and activities. A stressed, inflamed joint is more likely to get injured then a rested one.

Improper equipment or being unfamiliar with how to safety utilize equipment are other major causes for injuries. This is especially true for those who jump in without training. I once had a patient who used to work out on machines at her gym. She attempted too much weight while using an upper body one, and when she couldn’t control it, the machine dragged her arms up and over her head at such a rapid torque, both rotator cuffs were damaged. I strongly recommend you don’t start an exercise regimen without proper training.

For decades, providers have recommended following the RICE (rest, ice, compression and elevation), or PRICE (where P stands for protection) for the immediate treatment of sprains and strains within the first 24-48 hours.

Recent evidence in a 2012 editorial in the British Journal of Sports Medicine suggested replacing RICE and PRICE with POLICE — protection, optimal loading, ice, compression and elevation. But the “ICE” part of the treatment also remains poorly tested. In some trials, patients who received cold treatments did better than those who did not. In other studies, there was no difference. “We do know it’s a good pain reliever,” says Thomas Kaminski, who helped devise the National Athletic Trainers’ Association’s official guidelines on ankle sprains, published last year. Most experts continue to recommend some kind of cold treatment, with the reasoning that people can start moving their sprained joints more quickly if they hurt less. Don’t apply ice directly to the joint-buffer it in a towel. Apply for 10 minutes on, then 10 minutes off, as often as possible.

Wrapping and compressing helps decrease the swelling, gives the joint support and keeps it warm, thereby increasing circulation. But don’t excessively compress. If it gets blue, tingly, or numb loosen it. Elevating the injured area above the level of the heart helps to decrease bruising, throbbing and swelling. But, it reoccurs once standing so, if it’s your arm or leg, prop it up on a pillow for the first 24-48 hours. Medicines can temper the pain, but all have potential side effects. Some of them-non-steroidal anti-inflammatory drugs (NSAIDS) like ibuprofen, could theoretically interfere with the healing. Kaminski recommends using acetaminophen if you need a pain killer for the first 48 hours, with use of NSAIDs safe after that time, if cleared by your provider.

Barbara Bergin, a fellow with the American Academy of Orthopedic Surgeons agrees. “You just can’t beat rest, ice, compression and elevation,” she says. But she adds that you should only follow this prescription until you are able to consult with the appropriate healthcare provider. For example, when “you sprain your ankle and it’s a Sunday afternoon and you don’t want to go to the emergency room [because] you’ll have to wait in line for hours, pay a lot, and your doctor will be in on Monday.”

Studies have since confirmed the value of early exercise for all but the most severe sprains. They have also shown benefits for balance training- for example, standing on the injured foot with your eyes closed- which improves the function of nerves in the joint and can increase stability. Initial immobilization may be necessary in severe injuries, but for most, getting the area of concern moving is integral to a quicker recovery. That’s why bed rest is no longer recommended with back pain; taking it easier, yes, total inactivity, no. In fact, returning people to simple tasks and lighter activities within a few days is actually beneficial. Physical therapy can aid in a faster improvement by decreasing the acute inflammation with ultrasound and safe, supervised mobilization.

As far back as 1994, doctors at Oregon Health and Science University randomly divided 82 patients with sprained ankles into two groups. One group wore an elastic wrap for two days, and then switched to braces that allowed for movement. They exercised their ankles under the supervision of the physicians, gradually putting more weight on the injured joint. The other group wore plaster splints for 10 days, preventing motion in their ankles. Then they started the same exercise and weight-bearing program.Ten days after their injuries, 57 percent of the early mobilization group had fully returned to work, compared with only 13 percent of the plaster splint group. Three weeks after their injuries, 57 percent of the early mobilization group still experienced pain, compared with 87 percent of the plaster splint group

So progress slowly and safely. For example, if you’ve sprained your ankle, you might start by walking slowly on a flat treadmill, then move to an incline at faster rates. Someone with a sprained wrist may begin with range-of-motion exercises, and then move on to lifting very light objects. You can expect some discomfort during rehabilitation. But, a sudden flare-up of severe pain is a signal to take a step back, move more cautiously, and seek medical advice. Most mild to moderate sprains and strains will regain full mobility within 3 to 8 weeks. More severe injuries can take months to fully recover.

    -Dr. Courtney

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