How do ligaments heal: Non-surgical repair of ligament injury
In this article we will explore how ligaments heal and how you may be able to accelerate that healing.
In our twenty-eight plus years of helping people with ligament laxity or instability or with partial ligament tears we have seen many people with many ligament injuries in varying degrees of joint and spine instability. Each person, like yourself, is unique in your goals of medical recovery desire. You may be an advanced athlete, a person who does a physically demanding line of work, or someone approaching or have achieved retirement age and you like to play golf, tennis and pickleball or simply be able to take long walks with your life partner. You may also be a pareson in post-surgical recovery and are investigating ways to speed your ligament healing.
In this article we will look at ligaments and how you may be able to heal them faster and stronger. We will look at the simple ligament sprain throughout the joints in the body and we will look at the complex cervical and lumbar spine ligaments that are causing a vast myriad of difficult conditions and symptoms.
Healing the simple ligament sprain
The people who have simple ligament sprains, probably don’t think they are that simple. You may have an ankle that is all swelled up and black and blue. You may have twisted a knee and now that is all swelled up. You may have jammed your wrist and thumb and now your hand is all swelled up. To you, there is nothing simple about this ligament sprain. You can’t play, working is difficult, but if you went to the urgent care center, emergency room or doctor and you have a range of motion or you can put weight on it you were told this will heal by itself.
What are we seeing in this image? An explanation of an ankle sprain
What you probably do not need to know about an ankle sprain is the exact number in the millions of people that seeking medical care for it. What you need to know is what to do about it. Whether it is an ankle sprain, a toe sprain or a knee sprain, hip sprain, back sprain, neck sprain, shoulder, elbow, hand, wrist or thumb sprain ligament injuries all heal in the same way.
In this illustration we see that an ankle sprain and be a problem of one or multi-ligaments depending on the severity. Whether one or multiple ligaments, the body will start a healing process that is all the same to all of them.
A complete rupture or disintegration of a ligament will most likely require surgery.
Quick note: A complete rupture or disintegration of a ligament will most likely require surgery. Some people do explore non-surgical options for these treatments, this may include an array of stem cell therapy or Platelet Rich Plasma therapy. If you are exploring these options please understand that in our years of experience we have found these therapies cannot grow something from nothing. If you have catastrophic ACL injury and there is nothing left of the ligament except stubs at the shin and thigh bone connection points, injection therapy will not grow all the missing ligament back from nothing.
A simple sprain heals on its own – let it
If you have a simple sprain, meaning you do not have a complete rupture and this is something that will likely heal on its own, despite your ankle being all blown up or your wrist is badly swollen or you can’t turn your head to the side or get in or out of a chair because of your back, you have probably already seen all the common do it yourself guides on the internet in how to treat a ligament sprain. You may have also been to the doctors and you have a hand out with post-injury care. Here we will present a condensed down version as to not rehash all the information you have seen already.
Do you have a graded sprain?
In your information search or diagnosis who may have been identified as having:
- Grade I sprain. Your ligament, in a hyperextension type motion has become stretched out and may have torn a little. But you can walk on it or have little range of motion difficulties.
- Grade II sprain is a bit worse version of Grade I. This may be characteristic of a more severe discoloration in the joint. More tear, more bleeding, and more black and blue. There is also a little more restriction of movement and putting weight on it hurts a little more.
Grade I and Grade II will most likely heal on their own IF YOU LET THEM. Meaning you give the body its chance to heal that ligament without you going back on the field or court. We also know that many of you need to continue to work. You may not be able to allow this problem to heal sufficiently because you have to be on the job. We will get to that later.
- Grade III is a completely torn or ruptured ligament. If this has happened to you and you have a walking boot on or your shoulder is now in a sling, this will in many cases require surgical care and you should consult with the orthopedist about a surgical date. We also understand that some of you reading this article have already gone down this route and are trying to avoid a surgery.
The typical treatment guidelines
If you have reached this point in this article it is likely that you have a more complex problem because the simple remedies have not worked for you.
Treatment guidelines still surround the often controversial RICE or sometimes PRICE Guidelines. We have an article on the RICE and PRICE treatments. We will summarize it here below.
Rice and Price
- The RICE Protocol is Rest, Ice, Compression and Elevation
- The PRICE Protocol adds Protection (brace or cast), Rest, Ice, Compression and Elevation
For many athletes a doctor’s recommendation of the RICE protocol for healing their sports related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism from a surprising source, the doctor who created the RICE treatment guidelines, Gabe Mirkin, MD.
In a recent article on his own website, Dr. Mirkin admits that both ice and rest (key components of RICE) may delay healing. This insight comes nearly 40 years after Dr. Mirkin authored the The Sportsmedicine Book (1978), where he coined the acronym RICE for the four elements which became the standard of care in treating soft tissue injuries- Rest, Ice, Compression and Elevation. Coaches, physicians, physical therapists and the lay public have recommended and followed the “RICE” guidelines for decades, but as Mirkin states on his website:
- “it now appears that both ice and complete rest may delay healing, instead of helping.”(Updated June 22, 2020)
Ligaments do not like to be immobilized. They either do not heal well or they become stiff and inflexible
RICE generally involves resting or immobilizing an injured joint. The detrimental effect on ligament healing by taping or bracing a joint so it is immobilized is well documented. A physical examination of “rested” ligaments after immobilization shows them to be less glistening and more “woody” on palpation. They are stiff and less flexible. Many of you reading this article may find a degree of comfort in seeing that maybe rest is not the best thing for your type of injury. That resting may in fact not only delay ligament healing, it may also prevent a good, solid ligament heal. You must clear your desire to get mobile again with your doctor’s advice if you have an injury that you cannot put weight on or have a limited range of motion. You must also clear with your doctor any type of post-surgical guideline before resuming your desire to get resume mobility.
The first thing to realize is that ligaments heal in phases. Let’s quickly review these phases.
You had a ligament sprain, you twisted your ankle or knee or low back in a bad way.
Phase 1: The swelling is the acute inflammatory phase.
You will all recognize the acute inflammatory phase. Your knee or ankle has swelled up and possibly become discolored. What is happening?
- The discoloration may represent an internal bleeding, a tear in the ligament and surrounding tissue.
- Your body is sending healing factors and fluid to the site of the injury. The fluid is there in part to create a “water cast,” to help immobilize the injured area. This is why you may be recommended to resting the injured joint. Not to move it while the immune system figures out how to fix the injury.
Phase 2: The Repair: The proliferative, regenerative, and tissue remodeling phase.
- This is your body’s healing phase. You will know when this phase is over because the injured area does not hurt and you no longer have restricted range of motion in the area.
- You will know when this phase is not complete because you may still pain pain, swelling, and some restricted movement.
The process can take months to resolve itself, and despite advances in therapeutics, many ligaments do not regain their normal tensile strength. This can now turn into a “nagging,” injury and may turn to itself into something that will require:
- More rest
- More ice
- Tapes and joint braces and anything else that you may find online to wrap up the joint.
At some point you may have to go further in your search for this nagging injury and you may consult with your doctor who will then refer you onto a specialist.
At this point you may get:
- An x-ray
- An ultrasound
- An MRI
For many people, including yourself, there is not enough damage on these images to justify a surgery unless you have a complete tear or rupture or you have a partial tear and a lot of other wear and tear damage. For most, conservative care options will be accelerated which may include:
- Longer periods of rest.
- Changing activities, bilking instead of running, or doing your job in a different way, (sitting when you can instead of standing all day, etc.)
- Stronger Anti-inflammatories
- Physical therapy
- A better boot or brace
- Cortisone injections
Eventually you either learn to live with this or you get a surgery. Years can go by between the two.
How do ligaments heal then? One way, movement instead of rest.
Numerous strategies have been employed over the years attempting to improve ligament healing after injury or surgery. One of the most important of these is based on the understanding that monitoring early resumption of activity can stimulate repair and restoration of function and that prolonging rest may actually delay recovery and adversely affect the tissue’s response to repair.
How do ligaments heal then? Another way, stop using anti-inflammatory medications.
Likewise, there is a shift away from the use of steroid injections and nonsteroidal anti-inflammatory medications. Although these compounds have been shown effective in decreasing the inflammation and pain of ligament injuries for up to six to eight weeks, their use has been shown to inhibit ligament healing. For this reason their use is cautioned against in athletes who have ligament injuries. Such products are no longer recommended for chronic soft tissue injuries or for acute ligament injuries, except for the shortest possible time, if at all.
Your ligament problem
The joints most often affected by ligament injuries are the knees, hips, shoulders, ankles, elbows, and wrists.
For knee injuries – we have these articles:
- Lateral Collateral Ligament Injury of the Knee
- Posterior Cruciate Ligament (PCL) Injury and Treatments
- Medial Collateral Ligament Knee Injury
- ACL reconstruction surgery alternatives and regenerative treatment options
How do ligaments respond to injury
When ligaments are exposed to loading over an extended period of time, they increase in mass, stiffness, and load to failure. However, when ligaments are overloaded, or exposed to tensions greater than the structures can sustain, the tissue fails resulting in partial or complete ligament discontinuities. When these discontinuities, also known as disruptions or tears, occur, the body responds by attempting to heal the injury through a specialized sequence of overlapping, but distinct cellular events. These events are the same that occur as part of the body’s response to any soft tissue injury and can be categorized by three consecutive phases that occur over time: the acute inflammatory phase, the proliferative or regenerative/repair phase, and the tissue remodeling phase. The acute inflammatory phase begins within in minutes of injury and continues over the next 48-72 hours. During this phase, blood collects at the site of injury and platelet cells interact with certain matrix components to change their shape and initiate clot formation. The platelet-rich fibrin clot releases growth factors that are necessary for healing and provides a platform on which many cellular events occur.
Platelets such as those in Platelet rich Plasma Therapy
Several growth factors have been identified, each playing a specific role in the inflammatory process. Some of the numerous growth factors which have been identified include Platelet-Derived Growth Factor, Transforming Growth Factor-β, Vascular Endothelial Growth Factor, and Fibroblast Growth Factor.
- Platelet-Derived Growth Factor and Transforming Growth Factor-β attract immune system cells to the area and stimulate them to proliferate.
- Vascular Endothelial Growth Factor aids in new blood vessel formation, which increases vascularity in injured areas.
- Fibroblast Growth Factor promotes the growth of the cells involved in collagen and cartilage formation. When stimulated by growth factors, neutrophils, monocytes, and other immune cells migrate to the injured tissue to initiate matrix turnover by ingesting and removing debris and damaged cells during the inflammatory phase.
The proliferative/repair phase begins when immune cells release various growth factors and cytokines, which initiate fibroblast proliferation to rebuild the ligament tissue matrix. The tissue formed initially appears as disorganized scar tissue with more blood vessels, fat cells, fibroblastic and inflammatory cells than normal ligament tissue.
This article is currently being updated. For more information see our research article