Tag Archives: fracture

Why Ice and Anti-inflammatory Medication is NOT the Answer

This is a reprint from Stone Athletic Medicine:

In July I posted a blog discussing The Overuse of Cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!

The Stigma of Inflammation:

Editor in Chief of The Physician and Sports Medicine Journal (Dr. Nick DiNubile) once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders; inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair, and remodel. You cannot have tissue repair or remodeling without inflammation. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1). Researchers headed by Lan Zhou, MD, PhD, at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated “overwhelmingly, NSAIDs inhibit or delay fracture healing” (2). And you want to stop this critical process of healing by applying ice, because inflammation is “bad”?

The Anecdotal Rationale for Ice:

Somewhere along the line the concept that ice facilitates healing became conventional wisdom. Sorry, that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.” Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps work so well at removing swelling.

Inflammation is a necessary component in the first phase of phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of “Iced! The Illusionary Treatment option gave me a good analogy. Take two tubes of toothpaste, one is under ice for 20 minutes, the other is warmed to 99 degrees. In which tube will the toothpaste flow fastest? It does not take an advanced physics degree to know that answer.

What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A study published in 1986 (yes, 1986, is old, but this is a foundational study) found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). Ice can increase swelling and retard debris removal!

The Acronym RICE is Bogus:

The acronym RICE is bogus in my opinion. First, Rest is not the answer. Rest does not stimulate tissue repair. In fact rest causes tissue to waste and can cause abnormal gene transcription of collagen tissue. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscle.

The other reason RICE is bogus is obvious; Ice. Ice does nothing to facilitate collagen formation. Ice will not influence progenitor cell development. Ice does not regenerate tissue. Ice does not facilitate healing – it inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.

Closing thoughts:

Bottom line, ice and NSAIDs are over utilized. I am not saying never, but I am saying ice is not a magical cure all that fixes everything and is required for healing. It is not the gold standard that it has come to be. My goal with this blog is to get individuals to stop and think before immediately turning to ice and NSAIDs. Is it really the best option? Is it necessary for this injury at this stage? I understand it is not the only form of treatment clinicians use, but ice certainly is the most heavily used. Go ahead, I will wait while you look at your treatment logs.

My goal is to get this trend reversed one clinician and one patient at a time. Have you seen the video discussion between Kelly Starrett, DPT and Gary Reinl? If not I recommend you watch it. It’s fascinating. I am glad to have expert minds like Kelly and Gary in this fight with me.

I ask health care professionals to do one thing, just try it. Pick one client with chronic musculoskeletal pain, skip the ice, skip the NSAIDs and try to use light exercise as a repair stimulus. Then, try skipping the ice on a client with an acute mild injury. The outcomes might surprise you.

Cold Laser for All Animals and People

Leave a reply

Cold laser therapy offers a wide range of options for tissue therapy, wound healing, pain management, and improved circulation. Cold laser therapy is a game changer for many pets suffering from painful injuries. This technology allows us to successfully treat many injuries including tissue damage, inflammation, wounds, and even scars with minimal invasion.

The technology has been used in Europe since 1970 to promote healing, but has only been approved by the FDA for use in the U.S. since 2002. It is only recently, though, that U.S. veterinarians have begun using it to treat many different conditions that affect pets today, such as fractures, ligament and tendon injuries, post-surgical incisions, arthritis, nerve injuries, sprains, muscle strains, abrasions, lesions, and more.

Cold laser therapy is non-invasive and makes use of light in order to stimulate activity or regeneration in cells in addition to increasing blood circulation. Unlike hot laser treatments that target tissue deep beneath the skin’s surface, cold laser therapy treats injuries or damage on or near the surface – without the risk of cutting or burning from the lasers. Most conditions require between three and eight treatments, though I have seen great improvement after the first laser session. Most animals enjoy their seession: many fall asleep or thoroughly relax.

How to Reduce the Risk of Injury

Leave a reply

What if I told you there was a simple way to reduce the risk of injury, increase mobility and flexibility, and increase blood flow to muscles? Before a workout or a horse show event, myofascial release can optimize your performance, and that of your horse, and greatly reduce the risk of strains, sprains, fractures, or tears.

Restrictions and tensions of the soft tissue (muscle, fascia) do not show up on standard hospital imaging and many patients (both human and animal) suffer pain and injury because their pain cannot be diagnosed.

If a muscle is tight or stiff, moving it too fast can result in an injury. Fascia wraps around the entire muscle and every soft tissue in the body. When properly softened and stretched through massage, the entire structure of the body can function smoothly and safely. The investment of pre-activity body work can save months of costly rehab.

High-Speed Exercise and Bone Response

Leave a reply

This important article, by veterinarian Nancy Loving, is a must read! Originally posted in the Horse magazine.

Bone was once considered an inert material with its structure defined by genetics. But it turns out there’s a lot more at work, explained Larry Bramlage, DVM, MS, Dipl. ACVS: “Selective breeding dictates the initial skeleton, but adaptive training in response to exercise modifies it further.” He and other racehorse surgeons are striving to better understand the balance between tolerable and excessive damage—the adaptive kind that occurs naturally and the type that sidelines animals or ends their careers.

During his presentation at the 2013 American Association of Equine Practitioners’ Convention, held Dec. 7-11 in Nashville, Tenn., Bramlage, of Rood & Riddle Equine Hospital, in Lexington, Ky., explained that bone is the only tissue capable of entirely reconstituting itself. With this capacity to change, he noted, there are several ways long bones strengthen themselves in response to training, including modeling and remodeling. Modeling is the process in which bone adds to itself, both inside and out, while remodeling is how existing bone tissue alters itself.

Bramlage started by describing the dynamic nature of bone activity on a cellular level. Two types of bone cells are involved in bone modeling and remodeling: osteoblasts and osteoclasts. Osteoblasts become trapped in the bone and become osteocytes, which are key to sensing biomechanical loads on the skeleton during exercise and directing bone tissue response accordingly. As they detect mechanical loads, they prompt additions to (formation) or reductions in (dissolution) bone mass, to achieve correct bone density for current athletic demands. Osteoclasts then tunnel through and cut canals into the bone, with osteoblasts following to make new bone. Continue reading →

Splints

Leave a reply

On each side of the cannon bone is a long narrow bone known as the splint bone. There are two main conditions which affect the splint bones: The term “splints” commonly refers to an inflammatory condition and a calcium lump on the bone, while the term “broken splint bone” refers to a fracture of the splint bone and a calcium lump where it is trying to heal. When lameness in this area occurs, the above conditions may be confused.

An injury to the horse causing a splint may be the result of direct trauma, such as a kick, or a concussion resulting from jumping, running or working.

Veterinarians use many different methods to treat “splints”, but most would agree that the horse should be rested and placed on soft ground for at least 30 days.

The outlook is good for most horses except those in which the bony growth is large and interferes with the knee joint or the suspensory ligament. Sometimes surgery may be helpful in these difficult condition.

Fractures of the splint bones must be differentiated from the inflammatory condition known as “splints”. Fractures of the splint bones can occur anywhere along their length, but are most commonly located at the lower third. Heat, pain and swelling will occur over the fracture site. The more acute the fracture, the more severe the swelling.

When a horse is recovering from an injury, massage will help keep surrounding muscles from taking on an excessive load. Keep muscles supple and loose will help the recovery process and keep the tightening in the injured area from being passed to the next group of muscles.

How Can I Prevent Injuries?

Leave a reply

The junction where skeletal muscles attach to bone is an area of high stress. These are common sites of muscle injury, since when the muscle contracts to create movement, tension quickly forms. When muscles, particularly at these stress points, are kept at maximum efficiency, many injuries can be prevented. No sprain, strain, or fracture is simply a local incident. Anatomy tells us that ligaments, tendons, fascia, and muscles are woven together to form one system that acts and reacts together in the body. Regular massage keeps motion effective and reduces the risk of injury.

What is “Protective Splinting”?

2 Replies

When an injury occurs, whether a sprain, fracture, or dislocation, the muscles will splint the injured area by tightening the muscles. It is nature’s way of preventing further injury. Then, the horse, human, dog, etc. will compensate by using other muscles and a change of posture to cope with the change.In the short term, this muscle splinting is a helpful action. Once the original injury is healed, the body may not return to the original, balanced posture. So the protecting area starts the pain cycle anew, and the irritated inflamed and injured area continues to grow. This is called a positive feedback loop, where the process continues to grow. The cycle can be interrupted, and health restored by encouraging the tight muscles and tissue to let go of the now healed area. Proper posture and function can be restored through deep tissue massage, cold laser therapy, myofascial release, trigger point therapy, stress point therapy, etc.