Treating Orthopedic Injuries
Patrick O’Neil, PA
At one point or another, most of us have had a sprained or strained joint. This sort of injury is extremely common in athletics, military training, hiking, and even just crossing the street. These injuries can run the gamut from a simple sprained ankle with some slight swelling to a ruptured ligament with soft tissue bruising, swelling, and severe pain.
On more than one occasion, I have been on a night patrol with a group of men all carrying huge rucksacks, when I heard someone fall and then a muffled groan as they tried to stifle themselves from the intense pain they were feeling from a really bad sprain. It has happened to all of us, but you don’t need to be in the woods to get a bad sprain. The worst sprain I ever had was going down a flight of stairs and my boot caught on the step and I completely rolled my ankle and hobbled around like an invalid for a week.
It has long been an accepted approach to treat orthopedic injuries with the Rest, Ice, Compression, and Elevation methodology (RICE). Today, there are those practitioners, like myself, that will add in a “P” for Protection to that acronym (PRICE). Some may believe I am splitting hairs with adding Protection, but I believe it is absolutely critical to protect the joint from further injury.
Soft Tissue Injuries
When soft tissue is damaged you can expect certain physiological reactions to occur. You will most likely have inflammation in the area surrounding the damaged ligaments, tendons or muscles. There can also be bruising and bleeding within the injured internal compartment. Some of this bruising can be quite dramatic. A slight amount of inflammation is actually good for the tissue as it releases something called IGF-1, which promotes healing. Too much inflammation can cause decreased circulation, stiffness, and delayed healing. Unfortunately, there is no real consensus as to what is “too much inflammation.” I know….pretty lame, right? Welcome to the grey area of medicine where I live and work! As the tissue starts healing, the inflammation reduces and collagen starts to replace the damaged tissue. Collagen is also known as scar tissue. You can have a partially torn ligament that collagen will try to strengthen, but scar tissue is never as strong as the original tissue it replaces.
PRICE for Acute Orthopedic Soft Tissue Injuries (First 48 hours)
PROTECT: A sprained joint has been weakened due to some form of injury. We absolutely have to protect that joint from further injury or we can turn a partially torn ligament into a complete rupture. Before we do anything else in the way of treatment, we MUST ensure that the injured joint is protected. In most cases, we protect a joint by immobilizing it.
REST: The joint must be allowed to heal with as little movement as possible. We don’t want to aggravate the injury. In my practice, this usually involves some form of activity limitations. For example, if I have a young man that sprained his ankle at school, I will give him a school note that says: “No lower body exercises, running, jumping, stairs, standing greater than 10 minutes, walking greater than 100 yards for two weeks.” This decreases the amount of normal activity and the joint can rest and recuperate.
ICE: Ice, or anything cold, is great for reducing inflammation by reducing the blood flow to the injury. It also helps reduce the pain level. There are a ton of products out there from cold packs, special gel packs that can be frozen and thawed multiple times, frozen peas, to bags of ice. Our family had boys that participated in sports. We kept several of the gel packs in the freezer so they could ice a joint down after practice. Once they were finished, they just threw it back in the freezer until the next injury occurred. When using anything frozen, remember to wrap it in a thin cloth and apply it for no more than 20 minutes. You don’t want to accidentally freeze the tissue or cause a cold injury. 20 minutes on, let the skin return to normal temperature, and then you can reapply for another 20 minutes.
COMPRESSION: Compression helps to limit the swelling and also provide a little pain control to the area. The only product I use for this is an ACE bandage. I can control the amount of compression I am applying to the joint. If I happen to wrap the joint a little too tightly, I can very easily loosen the bandage. I am not a real fan of the commercially produced compression sleeves. Every patient has a different body thickness, swelling, etc. The ACE wrap accommodates everybody regardless of body type. Keep it simple: Get ACE bandages in 3” (ankles and wrists), 4” (elbows and maybe shoulders), and 6” widths for knees.
ELEVATION: Keeping the affected limb above the level of the heart will do two things for you: It will decrease swelling and decrease the throbbing sensation you feel when the limb is below the level of the heart. I first experienced this when my loving Grandmother accidentally shut the car door on the four fingers of my left hand. That was a special kind of pain, I assure you. I learned very quickly that every time I lowered my hand below the level of my heart, it throbbed pretty badly. When my hand was elevated above my heart, it only throbbed a little bit. Propping the injured extremity on a pillow works wonders for reducing the pain level when trying to sleep.
After 48 hours, the acute phase has ended and we should start seeing some improvement in the appearance of the injury. The swelling should be reducing, the pain level should be decreasing, and any bruising should show the normal signs of absorption by turning a lighter color. If you are still in a lot of pain and the swelling is still pretty bad, you may want to see your primary care provider or go to the Emergency Room and have an X-ray taken of the injury.
After the acute phase has ended, I recommend gentle massage and moist heat to the affected limb. The massage will help break up any excess scar tissue that is forming and also help improve circulation to the affected area. Moist heat will also help increase circulation to the tissues by dilating the capillaries allowing increased blood flow.
Gentle stretching and a gradual return to full activity occur slowly. Don’t push it too quickly. You can easily set yourself back a couple of weeks by trying to return to normal activity too soon after the injury. Gentle stretching to achieve full normal range of motion, followed by a progressive strengthening program will bring about a full recovery in most instances.
I cannot stress just how important a good athletic trainer or physical therapist is during this period. It can make a big difference in the outcome of the injury. They are the experts when it comes to knowing just how quickly the injury can be pushed into normal activity.
As I have discussed numerous times in my articles, when in doubt seek medical attention. I would rather a patient come in and we get an x-ray showing everything is OK, than to have them come in two weeks later with an injury that was actually a fracture and is now healing improperly. Always play it safe.