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At Caring Medical, we treat athletes of all levels, every day. We recommend that to treat acute sports injuries, not with RICE, but with MEAT. The
R.I.C.E. treatment is the conventional method of pain management and sports injuries
today. Just go to any emergency room or sports
trainer with an acute
ankle sprain or other ligament
injury, and the injured person will be given these instructions: Rest, Ice,
Compression, and Elevation.
Most people would also receive instructions to take anti-inflammatory
medications. This treatment is recommended because ligament
sprains are sometimes accompanied by quite a bit of swelling,
called edema. The premise with the RICE treatment is that the swelling
and edema is harmful to the tissue.
Where did such a preposterous idea originate?
Unfortunately, sports
medicine specialists and athletic trainers fell into the trap that muscles
were like tendons
and that tendons
were like ligaments.
Muscles,
unlike ligaments
and tendons,
are encapsulated within a tight, compartmental, special tissue
called fascia.
These fascial sheaths only have a limited amount of space and in high-energy
trauma, as can occur in sports,
this limited space can be encroached upon by a hematoma
(blood
clot in the muscle) or be externally compressed by a hematoma in another
compartment (or broken bone,
etc.).
This increased tissue
pressure within the fascial sheath that contains the muscle causes a decrease
in the blood
circulation (malperfusion), causing further tissue
damage. This further tissue
damage causes an increase in the edema, which increases the pressure in the
space even more, causing even less oxygen to
get to the injured
tissues (hypoxia),
which causes the pH
in the tissue
to be decreased (acidosis)
and a vicious cycle is set up. This continued increase in a specific muscle
facial sheath is called compartment syndrome.
Compartment syndrome, if not immediately taken care of, quickly progresses to
permanent muscle, nerve,
or circulation
damage. RICE treatment is very effective at eliminating edema, so it could,
theoretically, prevent a compartment syndrome situation from occurring. What
occurred in the early 1970s, unfortunately for the athletes of the world, is
that sports
medicine doctors and trainers started treating every injury as if it was
going to turn into compartment syndrome.
A muscle, tendon,
or ligament
injury is very easy to identify on physical examination. The first thing to
do is ask the athlete to point to the injured or painful area. The very astute
clinicians would also inquire if the big black and blue area on the skin
was the area of the injury.
Since muscles are completely different than ligaments
and tendons,
the treatment regime for muscles does not apply in any way to ligament
and tendon injuries.
The main difference between muscles and ligaments is that muscles are massively
strong structures with a tremendous blood
supply, both outside and inside the muscle (this is why steak is red). Ligaments,
on the other hand, are small tissues
that have a poor blood supply both inside and outside of the ligament (why they
appear white). Muscles, because of their good circulation,
heal quickly and rarely cause a long-term problem, whereas ligaments,
due to their poor blood supply, often heal incompletely and are the cause of
most chronic
sports injuries and pain. It is our opinion that nonhealing
ligaments are the number one cause of early retirement in athletes.
Understanding the difference between ligaments
and muscles
is crucial to understanding why the RICE treatment is totally inappropriate for
healing
ligaments. One of the main protective mechanisms of the body is the
fight-or-flight response. During the fight-or-flight response, the blood
flow to the muscles may increase a dramatic 25-fold during strenuous exercise.
Exercise also has specific, direct effects on muscles themselves. Muscles may hypertrophy
(get bigger) by up to 60 percent. This hypertrophy occurs because of an
increased diameter of the muscle fibers.
The energy
storing and releasing capability of the muscles then becomes much greater. The
person manifests this by becoming stronger and faster. More weight
can be lifted and longer distances run before exhaustion.
Contrast this to the effect of exercise on ligaments.
Exercise does not notably increase the blood
supply to ligaments. (Akeson, W. et al. The Chemical Basis of Tissue Repair.
Chapter 6 in Rehabilitation of the Injured Knee. Hunter, L., editor, 1984, St. Louis, MO: Mosby, pp 93-148.)
This is probably because the ligament
is not important in the fight-or-flight response. It is not involved in the
defense of the body if attacked. The ligaments are always strong and on alert
(unless injured). The strength of the ligament is dependent on stress
to the joints
to maintain ligament
strength. Exercise does not have the profound stimulatory effect on
ligaments that it has on muscles.
Why Say No to Rest,
Immobilization, and Ice?
Ligaments
are made up primarily of type I collagen. This particular type of collagen is
very resistant to stretching (has a high tensile strength). Collagen is a type
of protein,
therefore the collagen is made up of amino
acids, building blocks of protein.
What most people do not know is that the collagen in ligaments is thought to
remain relatively metabolically inert, with a half-life on the order of 300 to
500 days. This means that the metabolism
of collagen is very, very slow. It is a good thing this is true, because blood
supply to ligaments is so poor. This is another reason ligaments heal so slowly
and are so prone to injury. Muscles, on the other hand, have a tremendous blood
supply that can increase 25-fold during strenuous exercise. Anything that
decreases the metabolic rate or blood supply to
the ligaments will further promote the decline of the ligaments, and profoundly
delay their healing.
The Detrimental
Effects of Ice on Sports Injuries
The cells that make up ligaments, tendons, and organs
are extremely temperature-sensitive. The metabolic rate at which these cells
function is directly proportional to the temperature
in their environment. For each 10 degree Celsius change in the temperature,
there is a more than two-fold increase in the cell metabolism.
(Guyton, A. et al. Textbook of Medical Physiology. Philadelphia, PA: W. B. Saunders, 1996, p. 620.) In other words, in order to increase cell metabolic rate
by more than 100 percent, the temperature of the tissue must increase by 10
degrees. Conversely, cooling
tissue will decrease that cell's metabolism.
It is obvious that ligaments
require improved circulation
to the area in order to heal after an injury, since the blood
supply to ligaments is normally so poor. Yet ice is arguably
the most widely used therapeutic
agent in medicine today, which most definitely decreases circulation. Ice
has been shown to be one of the most efficient forms of cryotherapy, and
is often the first line of treatment for traumatic
injuries. As with many common and time-honored remedies, the use of ice has
developed over time. The effect of ice on the tissues and their healing has not
been studied in depth until recently.
The Research on Ice
In one landmark study done at the University of Hawaii, Dr. Sherwin Ho and
associates, put a commercially-available ice wrap on one knee for 20
minutes, and on the opposite knee a
wrap was placed at room
temperature. The knees
were then injected with dye and scanned for blood
flow. The study showed that all iced
knees demonstrated a decrease in arterial
and soft
tissue blood flow, as well as decreased bone
uptake of the dye, which is a reflection of changes in both the bone
blood flow and metabolic rate. The average decrease in arterial
blood flow was 38 percent, 26 percent in soft
tissue blood flow (ligaments),
and 19 percent in bone
uptake. In the 21 people studied, the "ice effect" was not related to
age, sex,
knee
circumference, or skin
temperature after cooling. The authors go on to conclude that these findings
provide a scientific rationale for the use of ice in limiting further hemorrhage
and cell injury after traumatic musculoskeletal injuries and surgical
procedures.
See the thinking in modern medicine? The last statement would only apply if swelling
were occurring in a closed space, leading to the development of a compartment
syndrome. This only occurs in muscles (and only those with a lot of damage) and
never occurs in ligaments.
The last statement would, therefore, not apply around the knee
which is full of ligaments. The last statement in the article should read,
"The findings provide a scientific rationale as to why ice should not be
used in acute
ligament injuries because ice has a dramatically negative effect on circulation
and cell metabolism." The net effect would be impaired or at best,
delayed, soft
tissue healing.
The decrease in bone was
measured a full two hours after the ice wrap was removed. Imagine what the
decrease in blood flow to the bone
was during the ice wrap? The weak link in the musculoskeletal system that is
responsible for most nonhealing
sports injuries is at the point where the ligaments
attach to the bone.
These studies show that ice decreases both the soft
tissue (ligament) and the bone
blood flow. Realize that the blood flow decreased significantly with only a
20-minute wrap. Many athletes ice their injuries for much longer than 20
minutes. The next time the trainer comes toward you with an ice pack, tell him,
"Thanks, but no thanks. I want my injury to heal."
Dr. Ho had already published articles in 1990 on the negative effects of ice,
where he showed that as little as five minutes of icing a knee can decrease
both blood flow to the soft tissues and skeletal
metabolism. He found that icing a knee for 25 minutes decreases blood flow
and skeletal metabolism another 400 percent! (Ho, S. Comparison of various
icing times in decreasing bone
metabolism blood flow in the knee. American Journal of Sports Medicine.
1990; 18:376-378.)
Healing is hindered by a decrease in blood flow and metabolism to the area.
Icing increases the chance of incomplete healing by decreasing blood flow to
the injured
ligaments and tendons. This increases the chance of re-injury or the
development of chronic
pain.
Did you ever wonder why almost all athletic trainers and therapists
ice a limb for 20 minutes? Why not 15 or 30, but always 20? It does not matter
if you are in France, Idaho, or Germany, they all ice for 20 minutes. In 1980,
at the American Orthopedic Society meeting for Sports Medicine in Big Sky,
Montana, and then again in American Journal of Sports Medicine, physicians from
the Louisiana State University School of Medicine reported on five athletes who
obtained nerve
palsies (nerve
injuries usually to the peroneal nerve
that moves the foot
up) from too much ice around the knee.
The conclusion of the article was, "Applying ice for more than 30 minutes,
and preferably for not more than 20 minutes, should be strictly avoided."
(Drez, D. et al. Cryotherapy and nerve palsy. American Journal of Sports
Medicine. 1981; 9:256-257.) They reported that one of the athletes still had a
nerve palsy at nine months. Here is our answer. You are iced for 20 minutes
because the athletic
trainer or therapist
does not want to give you nerve palsy!
Immobilization and
Rest Are the Worst!
Immobilization,
also known as stress
deprivation, is extremely detrimental to the joints
and ligaments.
Immobilization causes the following changes to occur inside joints:
1.
Proliferation of fatty tissue within the joint
2. Cartilage
damage and necrosis
3. Scar
tissue formation and articular cartilage
tears
4. Increased randomness of the collagen
fibers within the ligaments
and connective
tissues
5. Ligament
weakening with a decreased resistance to stretch
(Laros, G. Influence of physical activity on ligaments insertions in the knees
of dogs. Journal of Bone and Joint Surgery. 1971; 53:275; Arnoczky, S. Meniscal degeneration due to knee instability: an experimental study in the dog. Trans.
Orthop. Res. Soc. 1979; 4:79.)
Both intra-articular
and extra-articular (inside and outside, respectively) ligaments
and periarticular
(joint
soft
tissue) connective
tissue are brutalized by immobility.
Gross inspection of the ligaments after stress
deprivation shows them to be less glistening and more "woody" on palpation.
Under a microscope the collagen
of the ligament
is very random. Chemically, the ligaments lose water
and glycosaminoglycans
(which help maintain structure) so there is a net loss of mass in the
ligaments. There is also more degradation of the collagen with stress
deprivation. These changes translate to a much weaker structure.
In one study, knee
ligaments immobilized for even a few weeks showed that the ultimate load,
linear stiffness, and energy-absorbing capacity of a bone-medial
collateral ligament-bone
preparation is reduced to about one third of normal. (Ford, H. Physiology of
Soft Tissue Healing. Chapter 4 in Rehabilitation of the Knee: A Problem Solving
Approach by Bruce H. Greenfield, 1993, Philadelphia, PA, F.A: Davis Company,
pp. 85-109.)
In addition to weakening of the ligaments
themselves, immobilization
decreases the strength of the fibro-osseous
junction where the ligament attaches to the bone.
If rest and immobilization
hinders ligament
and tendon
healing, then studies should show that early mobilization and exercise
helps soft tissue healing. This is exactly what has been shown. For this reason
a much better approach to healing sports injuries
is the MEAT regime.
Why We Don't
Recommend NSAIDs
Non-steroidal
anti-inflammatory medications.
NSAIDs Hamper Ligament
and Tendon Healing
The following statement comes from a well-known sports medicine book that has
gone through five printings. "In spite of the widespread use of NSAIDs there
is no convincing evidence as to
their effectiveness in the treatment of acute soft tissue injuries."
(Bruckner, P. Clinical Sports Medicine. New York City, NY: McGraw-Hill Book
Company, 1995, pp. 105-109.)
This is a true statement, but definitely not strong enough. More appropriate
would be something like, --In spite of the widespread use of NSAIDs there is
substantial evidence that they hamper soft tissue healing.--
NSAIDs have been shown to delay and hamper the healing in all the soft tissues,
including muscles, ligaments, tendons, and cartilage.
Anti-inflammatories
can delay healing and delay it significantly, even in muscles with their
tremendous blood supply. In one study on muscle strains,
Piroxicam essentially wiped out the entire inflammatory proliferative phase of
healing (days 0-4). At day two there were essentially no macrophages
(cells that clean up the area) in the area and by day four after the muscle
strain, there was very little muscle regeneration compared to the normal healing
process. The muscle strength at this time was only about 40 percent of
normal.(Greene, J. Cost-conscious prescribing of nonsteroidal anti-inflammatory
drugs for adults with arthritis.
Archives of Internal Medicine. 1992; 152:1995-2002.)
The authors concluded that NSAIDs might delay muscle
regeneration, when their study did in fact show delayed muscle healing. But
you know politics...
Another study confirmed the above by showing that at day 28 after injury the
muscle regenerative process was still delayed. The muscles of the group treated
with Flurbiprofen
(NSAID) were significantly weaker. The muscle fibers were shown under the
microscope to have incomplete healing
because of the medication. (Almekinders, L. An in vitro investigation into the
effects of repetitive motion and nonsteroidal anti-inflammatory medication on
human tendon fibroblasts. American Journal of Sports Medicine. 1995;
23:119-123.)
The key question regarding the healing of sports injury is, "What exactly
does any therapy do to the fibroblastic cells
that actually grow the ligament and tendon tissue?" Treatments that
stimulate fibroblast proliferation will cause ligament
and tendon repair and will help the athlete heal. Therapies that kill or
hamper fibroblastic growth will be detrimental to the athlete.
In 1993 at the University
of North Carolina School of Medicine, Division of Orthopaedic Surgery, Sports
Medicine section, Dr. Louis Almekinders and associates studied human tendon
fibroblasts to determine the effect of exercise and the NSAID Indomethacin on
fibroblasts. Group I was the control in which no treatment was done; Group
II-the tendons were exercised; Group III-the tendons were exercised and
anti-inflamed with Indomethacin; and Group IV the tendons were just
anti-inflamed with the Indomethacin. All the tendons underwent injury through
repetitive motion, similar to what would happen to an athlete in training.
Seventy-two hours after the injury, it was noted that compared to controls the
only group that showed increased levels of prostaglandins was the exercised
group. The group that was exercised and received the NSAID, as well as the
NSAID group, had statistically significant lower levels of prostaglandins
(specifically Prostaglandin E2) in the tendons.
This showed that the NSAID blocked the inflammatory
healing of even the tendon
injuries that were exercised or rehabilitated. The tendonitis
that was treated with just the NSAID
had almost no prostaglandins
in the sample, signaling a complete inhibition of the inflammatory healing process. The
effect was even more pronounced at 108 hours.
The researchers also measured DNA
synthesis in the fibroblasts. This showed which fibroblasts were
proliferating. Again, the exercised group was the only group that exhibited
elevated levels of DNA synthesis
in the fibroblasts. Compared to the control group there was 100 percent more
growth of fibroblasts in the exercise group. The tendons treated with
Indomethacin had no DNA synthesis noted.
This showed there was no fibroblastic growth occurring. The group that
exercised and took the NSAID showed a little bit of growth. The authors
concluded, "Motion and prostaglandin release in Group II were associated
with increased DNA synthesis. Inhibition of prostaglandin by Indomethacin also
coincided with a decrease in DNA synthesis... Inhibition of prostaglandin
synthesis, and thereby DNA synthesis, may not be desirable during the proliferative
stage of a soft tissue injury, when DNA synthesis for cell division of
fibroblasts is needed to heal the injury to the tendon." The paper also
stated a fact that many researchers in this field are wondering, "Despite
the lack of scientific data, NSAIDs are widely used, often as the mainstay of
treatment." (Almekinders, L. An in vitro investigation into the effects of
repetitive motion and nonsteroidal anti-inflammatory medication on human tendon
fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123.)
Another study was done on the use of perhaps the most popular anti-inflammatory
medication used in sports
medicine, ibuprofen,
in the treatment of tendon
injuries. It was found that only thing the ibuprofen doses used in the
study caused the strength of the flexor tendons
to decrease. A decrease in strength of the flexor tendons of 300 percent was
observed at four weeks. The peak force of the flexor tendons of controls was
12.0 newtons, whereas in the Indomethacin group it was an average of 2.5 newtons.
Extensor tendon analysis showed similar results, with controls having a
breaking strength of 12.0 newtons and the tendons treated with the NSAID, 3.5
newtons. The authors noted, "Examination of the data reveals a marked
decrease in the breaking strength of tendons at four and six weeks in the
ibuprofen-treated animals....This difference was statistically
significant." (Kulick, M. Oral ibuprofen: evaluation of its effect on
peritendinous adhesions and the breaking strength of a tenorrhaphy. The Journal
of Hand Surgery. 1986; 11A:100-119.)
>From the above studies, it is clear that NSAIDs inhibit the fibroblastic
growth process and thus diminish an athlete's chance of healing.
NSAIDs are used because they decrease pain, but they do so at the expense of
hurting the healing of the injured soft tissue. A good example of this is a
study on the use of Piroxicam (NSAID) in the treatment of acute ankle sprains
in the Australian military. Compared with the placebo group, the subjects
treated with Piroxicam had less pain, were able to resume training more
rapidly, were treated at lower cost, and were found to have increased exercise
endurance on resumption of activity. The conclusion of the study was that NSAIDs
should form an integral part in the treatment of acute ankle sprains. (Slatyer,
M. A randomized controlled trial of Piroxicam in the management of acute ankle
sprain in Australian regular army recruits. American Journal of Sports
Medicine. 1997; 25:544-553.) At first glance in reviewing this study, NSAIDs
appear to be great, but the real question is did they help the ligament injury
heal?
In reviewing the study, the answer is a resounding NO! To test ligament
healing the ankles
were tested via the anterior drawer test. During this test the ankle was
moved forward to determine the laxity
in the ligaments.
This study was published in 1997, and the author stated that this was the first
time the clinical measurement of the anterior drawer sign had been used in a
clinical trial. It meant that all the studies done prior to this one, in assessing
whether anti-inflammatories helped with ankle
sprains, did not test whether the ligaments healed. In this study at every
date of testing after the initial injury, days three, seven, and fourteen, the
Piroxicam-treated group demonstrated greater ligament
instability. At the time of the initial injury the ligament instability in
the Piroxicam group and the control group were exactly the same. This study
showed that the NSAID stopped ligament healing,
yet the person felt better. The authors noted..."This result is of concern
in that it may reflect a paradoxically adverse effect of the NSAID-derived
analgesia in allowing subjects to resume activity prematurely."
(Slatyer, M. A randomized controlled trial of Piroxicam in the management of
acute ankle sprain in Australian regular army recruits. American Journal of
Sports Medicine. 1997; 25:544-553.)
Do you see the difference between pain
relief and healing? The athlete needs healed tissue.
Up until the present, too many studies were advocating NSAID use when it came
to ligament
injuries, because they were such great pain-relievers,
when in fact they were and are stopping the healing
mechanisms of the body. Any technique or medication that stops the normal inflammatory
process that helps heal the body must have a long-term detrimental effect
on the body.
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