Nothing is worse than spraining your ankle when you just wanted to have a great time doing the activities you love. Yet everyone has experienced a sprained joint at one time or another. In fact, ligament injuries are the most common injuries we suffer from and can take a very long time to heal.
Ligament injuries are quite damaging to the joint as they affect its stability and mobility and, if they do not heal well, will lead to degeneration of the joint and osteoarthritis.
So you just sprained your ankle dancing in front of a friend in your perfect leprechaun imitation and now you are wondering what you need to do in order to heal your ligaments (as well as your ego).
This article will explore the types of treatment options one has available to them. For those who want to know right now, the answer is walk it off and apply ice and/or compression to your ankle if you can. Unless you fractured a bone or sustained a serious injury, this is the best strategy to recover from an ankle sprain. At the end of this article we will describe what we at Three Peaks Teaching and Research Clinic can do for your sprains.
For those wanting a little more substance, we will explore further into how ligaments heal.
Ligament injuries, or sprains, can occur on any joint on the body, from the mighty ligaments of the pelvis and spine to the tiniest ligaments of the fingers and toes. All ligaments are made of connective tissue called collagen (type I fibers) and are strong and durable. These fibers are strong enough to allow force to flow from bone to bone and resist other forces that can send the bones into opposite directions. When ligaments are injured they are repaired with a weaker collagen (type III fibers) which is created quickly but lacks the strength and durability of the original collagen. This creates weakness in tissue strength and stiffness. The new collagen is not packed in as densely as the original structure as the remodeled tissue contains other material like fat, blood vessels, pockets of inflammation, etc. which further weakens the structure.
Remodeled ligaments are weaker, less stiff and absorb less energy than before they were injured. Remodeled ligaments regain only 40-80% of their original stiffness and functionality. Remodeled ligaments are also unable to resist increasing force and become sprained, or technically having inferior creep properties, as well as being unable to hold its shape and being sprained under a static force, or technically exhibiting greater stress relaxation. Once ligaments sustain injury, they remain less capable at resisting loads than uninjured ligaments and are at risk for being permanently stretched.
The remodeling phase of ligament repair can continue for many months to years (!!!!), during which time the collagen, which makes up the ligament, are continually torn and regrown as it adapts to the forces that it experiences during joint movements. Movement provides ongoing opportunities for the ligament to adapt, either by becoming more functionally improved or degrading and lengthening with applied loads.
Ligaments, not old age, play a crucial role in the development of osteoarthritis. Osteoarthritis begins when one or more ligaments become more unstable or lax. The inability of the ligaments to heal causes an increase in the degeneration of joints and disks.
Several strategies have been used in an attempt to heal ligaments such as rest, immobilization, NSAIDS, corticosteroids, and prolotherapy. While they can alleviate the subjective symptoms, they may not contribute to actual cellular repair.
Immobilization and Rest or R.I.C.E.
Healing ligaments are dramatically affected by the presence or absence of joint motion.
Immobilization of a joint with a ligament injury will cause serious harmful effects to that joint such as synovial adhesion, an increase in collagen deterioration, a decrease in collagen creation, and a greater percentage of disorganized collagen fibrils.
Immobilization also causes the healing to change from repair and building (anabolic) to recycling and degeneration (catabolic) of the ligament.
Decreased stress on ligament tissue alters tissue turnover, so that with time, tissue degeneration exceeds formation and the new ligament structure is less organized. Prolonged immobilization of a limb decreases the water content and the glycosaminoglycans in the ligament and alters the orientation of the collagen fibers. This causes the ligament to have less mass and strength.
Decreased ligament stress also decreases the tensile strength at the bone ligament connection.
No studies favor immobilization and rest for ligament healing.
Mobilization and Exercising
Patients who treated their ligament injuries with motion were able to return to work faster and resume sports activity sooner than those who were immobilized. Early mobilization was found to decrease pain, swelling and stiffness and preserves the ligament’s range of motion.
Controlled resumption of activity, including repetitive loading on ligament increases strength and mass and the collagen content of the ligament is near normal. Strength of repaired ligaments were greater when subjects were allowed to continue exercising rather than being forced to rest.
A structured program of rehabilitation and exercise can delay or possibly avoid ACL reconstruction.
Motion itself increases blood flow to the injured joint, providing the damaged tissue of the ligament all the nutrients required for healing under loading conditions, cells within the ligament sense tissue strains and respond by modifying the tissue.
NSAID’s have been a treatment option for sprains for many years but evidence has emerged that they are only mildly effective in relieving the symptoms of most muscle, tendon, and ligament injuries and are harmful to soft tissue healing.
Prostaglandin based healing responses results in the recruitment of cells into the injured area to initiate the healing process. NSAID’s are known to block the production of prostaglandins which play a significant role in ligament healing. Due to the pain killing effects of NSAID’s, patients ignore the symptoms of ligament injury which can cause further injury to the ligament.
NSAID’s are no longer recommended for chronic soft tissue injuries. In the case of bad sprains, NSAID’s should be used for the shortest period of time possible, if used at all.
Cortisone injections have been used as a treatment option for soft tissue injuries, including ligament sprains. Cortisone injections are effective at decreasing inflammation and pain in ligament sprains for up to 6 to 8 weeks after treatment. The anti inflammatory properties of cortisone act like NSAID’s by preventing cells to be recruited to the area of injury to begin healing.
Cortisone injection studies have shown that the treatment of injection of cortisone into the injured ligaments are harmful to ligament healing. Injection of cortisone into ligaments or tendons have been shown to actually inhibit collagen formation, even to the point of breaking it down. Steroid injected ligaments have a thinner/smaller size and is weaker at resisting loads and many experts caution against their use for treating ligament injuries.
The goal for surgery for ligament injury is to have minimal complications and retain range of motion in the joint while restoring its stability and function. The use of surgery to repair ligaments has become an increasingly controversial treatment option. Repaired ligaments remain weaker than the original ligament and are unable to hold the same tensile load.
Given this, surgical repair has had a high degree of success where patients can return to sport in a year or two depending on the ligament repaired. After 6 years after having the surgery, they were able to continue their sports related activity at the same levels as right after their surgery but their physical activity decreased over time.
Prolotherapy has become a favorite and successful treatment option for musculoskeletal and arthritic pain. It involves the injection of small amounts of sugar (dextrose hypertonic), a mixture of saturated and unsaturated fatty acids (sodium morrhuate) or platelet rich plasma into ligaments and tendons at their attachment sites to the bone, trigger points and joint spaces.
Ligament and tendons have shown an enhanced healing response through inflammation that benefits soft tissue repair in muscles, tendons and ligaments after injury. Prolotherapy injected ligament show an increase in ligament mass, extra cellular matrix, thickness, and in junction strength with the bone.
Prolotherapy injections are given to the ligaments of the entire spine, pelvis, and peripheral joints. Case studies have shown the success of prolotherapy for treating any ligament injuries such as the SI joint, lower back, neck, shoulder, elbow, knee, tmj and other articulations.
What can your Therapist do?
The therapists at Three Peaks Teaching and Research Clinic are highly trained in the application of manual therapies in order for anyone with a ligament sprain to recover quickly. The frequency of treatment is dependent on what stage of healing you are in and what your overall goal you have set for yourself to return to activity. The outcome of your treatment is dependent on the severity of injury, the treatment approached that was used, age, general health, and the willingness to follow the prescribed treatment plan and self care recommendations.
Your therapist will first assess the degree with which you have sustained a sprain to your joint and determine if massage therapy is right for you. If it is in your best interest to proceed with massage therapy, your therapist will work to resolve your condition in the following way.
Cryotherapy will be used to manage pain and swelling of the injured structure.
They will address muscle guarding to allow better range of motion of the joint while not leaving it vulnerable for injury.
Since a sprain is a result (symptom) of musculoskeletal dysfunction, your therapist will work with you to discover the cause of the dysfunction that led to your sprain.
You will be encouraged to resume physical activities, especially those that will stress the injured ligament, at moderate levels to maintain strength and balance. For a more specialized focus on ligament healing, your therapist will refer you to one of our many allied trainers and health care professionals that will return you to your pre-injury state quickly.
For more information see one of our therapists today. Click here to book an appointment today.