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

HOW BEST TO OPTIMISE YOUR TRAINING

Well, it has been a long time between posts and something I plan on rectifying.  Someone once said to me that we all make time for the things we want to do!

A question I get asked a lot in clinical practice is “How do I get the best out of my training in order to achieve my goals?” or words to that effect.  So I thought I would attempt to shed some light on the topic of “training optimisation” especially given the endurance trail running season is upon us.  So I have penned some thoughts with long distance trail running in mind, however the principles can be applied to other distance and other sports.  Here are some variables to take into consideration.

DISTANCE

www.nutrs.com.au  best running group around!

How long is the event and how should I go about preparing for it?  A general rule of thumb is to aim to cover the distance of the event in one week’s worth of training.  Ie:  100km race; reach 100km of training the week approximately 3-4weeks out from race day.  Periodisation of training needs to implemented in order to gradually build to these levels without succumbing to injury or illness.  For example:  use 4 week cycles to build up distance and time on your feet progressively over 3 weeks, followed by a recovery week similar in distance/time to the initial 1^st or 2^nd week of that macro cycle.  Start conservatively, build gradually and hasten slowly. 

TIME ON FEET

How long will the event take me to complete?  Aim to spend up to 50% of this time on your feet in training in one session at a pace slower than what you will be competing at.  This allows for hydration and nutrition plans to be tried and tested, develops mental toughness and preparedness and allows for the musculoskeletal system to harden and adapt to training.  This needs to be at sub-threshold levels….long, slow and steady conversational pace.  This pace is important so that the system isn’t stressed or over-reached.  Allow time for recovery before the next session and ensure that the next training session isn't hard or fast.  

PACE

Take the time to enjoy and breathe!

Ensure that your training program adequately trains the aerobic system.  This can’t be stressed enough.  This is the foundation upon which the all physiological systems of the body depend upon for long distance events.  Long, slow, sub-threshold training should be the cornerstone of your training.  Once a solid grounded base has been achieved over at least 8 weeks (at least 2 macro-cycles) only then should specific higher heart-rate sessions be included and only then for sessions strategically positioned into the training program.  This allows for adequate time to recover from harder sessions and prevent any injuries.

TERRAIN

Local Noosa Trails

What type of surface/terrain will I be running on? Technical single track, wide fire trail, mountain goat ascents/descents, road, stairs.   Attempt to mimic this in training as much as possible in order to prepare the legs for what will be required.  If a large portion of the course is technical, then this requires a specific skill set that needs to be trained prior to event day.

TOTAL ASCENT/DESCENT

Mt Solitary in the Blue Mountains is a popular training ground 

If your event has 4000m of ascent gain over 100km, then training needs to simulate this; e.g: broken down into 400m+ of ascent over 10km.  Practice different methods of ascent to mimic your climbing of these ascents during your race.  How you ascend and desend early on will vary later on in an event when you are tired and fatigued.  This is particularly important for ultra-events where power-hiking steep uphills will be required and often this is something we often don’t practice enough in training.

ENVIRONMENTAL CONDITIONS

Aim to train in environmental conditions similar to race day.  Often this is not possible when travelling interstate/internationally, so aim for training in the coolest/warmest parts of the day to simulate your race environment.  Be prepared with your hydration, nutrition and electrolyte needs ahead of time.  Also plan to arrive in your race destination with plenty of time to acclimatise.  A general rule of thumb for events at elevation is to allow at least 1 day for every 1000ft of elevation above sea level.  Expose yourself to the elements on arrival in your race destination and allow the body to adjust.  You need to get out and move in the new environmental conditions and not just sit at the nearest café!  This assists with acclimatization physiologically but also allows you to test the adequacy of any gear specifically required for an event in a unique environment.

RECOVERY

“One can not underestimate the power of rest”. This probably deserves blog of its own.  Recovery should be the cornerstone of every training program.  Physiological changes and adaptations to training can only occur when the body is allowed to rest.  Recovery and rest can take different forms and there is a large body of evidence to support active recovery such as: light aerobic activity different to that usually trained.  Recovery also is largely influenced by nutrition and hydration strategies, musculoskeletal strategies (physiotherapy, massage, acupuncture etc) and sleep! Finding the right combination for you is as much and art as it is science.

So, there are some areas to consider when planning your training program for your upcoming event.  

Enjoy those trails, enjoy your training and remember "Mistakes are proof you are trying" Anon