WHAT HAPPENS IN AN ACUTE LIGAMENT SPRAIN AND HOW CAN I MANAGE IT?

In our Physiotherapy practice (www.physionoosa.com.au) we get asked many questions, but this is one that has been at the top of the list this week; perhaps because training and competing for many sports is well under way and the inevitable injuries result.  So, one our Physiotherapists, Ross Drummond has penned some thoughts on ligament sprains.


When we expose our joints to extreme force beyond which our muscular and neurological systems can handle, increased tension and stretch to a ligament can cause it to tear or rupture.  The following grades of ligament sprains are:

Image from Brukner and Khan, Clinical Sports Medicine
2007

Grade 1 - mild:  stretched fibres, some micro tears, normal joint integrity and movement
Grade 2 - stretching and resultant tears to many fibres of the ligament with joint and ligament laxity present but a defined end-point noted on testing
Grade 3 - complete tear of the ligament with excessive joint laxity with no defined end -point noted on testing  (Brukner and Khan 2007)

Once the injury occurs the area will go through the following phases of inflammation called the 'inflammatory cascade'.  This ensures the ligament heals in the best was possible and will typically display the following 5 cardinal signs of inflammation:
1. Rubor (redness)
2. Calor (heat)
3. Tumor (swelling)
4. Dolor (pain)
5. Functiolaesa (Loss of function)

Inflammatory Phase:
This phase commences following the acute trauma to the ligament and can typically last anywhere between 3-5 days.  When the tissue cells become damaged they stimulate the release of  various chemicals and inflammatory mediators that initiate the inflammatory response.  These chemicals include prostaglandin, bradykinins and histamine.  They work together to increase blood flow to the site of injury through vasodilation and increased permeability of the tissues.  These chemicals elicit a pain response and pressure from the swelling onto local nerves increases the pain we feel.  The main objective of inflammation is to target and eradicate the irritant and repair the damaged tissues.   Rehabilitation in the early phases (initial 24hrs) of injury can greatly improve recovery. This consists of protecting the injured area to be protected from further damage by immobilisation and minimal weight bearing of the injured joint, rest from activities that will involve the injured body part and by using ice, compression and elevation (RICE).

Brukner and Khan flow chart 

Repair Phase:
The second phase of inflammation is mediated by blood clotting over the damaged tissue cells.  At this time, blood platelets form a mesh to initiate healing.  Within the blood clotting mechanism, fibroblast cells commence the lay down of immature collagen tissue which typically occurs between 3 and 21 days post injury or trauma.  During this stage of healing, electrotherapy such as ultrasound has been shown to encourage fibroblast activity which encourages a structurally stronger ligament.  Physio guided rehabilitation assists in facilitating better alignment of collagen and elastin fibres thereby reducing adhesions and scarring.

Remodelling Phase:
This phase follows the repair phase and can last for up to a year depending on the severity of the damage.  This phase involves the maturation land realignment of collagen tissue fibres.  When first laid down, collagen tissue is disorganised and therefore doesn't possess a great amount of tensile strength.  Through the gradual introduction of controlled strain in the ligament's plane of motion, the ligament gradually strengthens and realigns fibres in a longitudinal manner.  This controlled strain can be facilitated through controlled exercises that progress to functional activity,  Physiotherapist directed exercise programs will safely assist the final process of remodelling and aid recovery.  The risk for re-injury during this phase can be reduced by providing additional support to the joint and ligament with strapping, strength training of muscles in surrounding areas and performing proprioceptive exercises to improve joint positioning sense.

Remember, Physiotherapy guidance is important to facilitate healing and obtain full movement capacity and there is only a very short window of recovery.  If you delay treatment for your injury now then you may prolong time off training, reduce competition ability and performance and increase your chance of re-injury.


   "An ounce of prevention is worth a pound of cure" 
Quote by some wise old person named Benjamin Franklin.


References:

Brukner, P and Khan K (2007)  Clinical Sports Medicine. 3rd Edn.  McGraw Hill Medical. Sydney

Martini, FH & nath, J (2008) Fundamentals of Anatomy and Physiology. 8th Edn.  Benjamin-Cummings, CA

Wolf et al (2013) Treatment of acute ankle ligament injuries: a systematic review. Archives of Orthopaedic and Trauma Surgery. Vol 133, No 8, pp: 1129-1141