Inflammation in Acute Sprain Injuries
Tim McKnight, MD
The role of inflammation in acute injuries is to enhance the flow of blood cells and
chemical mediators to the site of injury. Upon arrival of these cells and mediators to the
site of injury they destroy, dilute or wall off all injurious agents and allow repairing
cascades to begin.
There are several distinct phases of the inflammatory process, each serving a unique
purpose towards repair and healing. The initial stage results in reduced blood flow
through the small arteries (arterioles) by means of vasoconstriction. This typically lasts
3-5 seconds. If you have ever cut yourself, you know that initially there is little bleeding
at the site of injury. Arteriolar vasoconstriction is the reason why this happens.
This is quickly followed by vasodilation of these same arterioles as well as opening of the
small vessels in the neighboring capillary bed. Heat and redness are the cardinal signs of
this phase. As these vessels engorge with blood the hydrostatic pressure raises leading to
leakage of plasma and plasma proteins out of blood vessels and into surrounding tissues.
The result_is local swelling. Removal of these fluids and the swelling they cause happens
via thin draining channels called the lymphatic vessels. This is a passive process that
occurs slowly and is aided by both muscle contraction and elevation.
With the leakage of plasma proteins and fluids out of the vascular bed the blood becomes
more viscous due to relative increasing concentrations of both red and white blood cells
remaining inside the blood vessels. This increases viscosity which serves to slow blood
flow enough to allow white blood cells responsible for tissue repair to move more slowly
towards the vessel wall where they attach temporarily. After they adhere to the inner
walls of the blood vessels in a process called margination they are able to migrate
through the vessel wall and into surrounding injured tissues.
The arrival of white blood cell lines in the surrounding tissues results in release of
digestive enzymes and an entire cast of chemical mediators from "activated" white blood
cells that aid in tissue "clean-up" and repair. Unfortunately, sometimes these chemical
mediators can cause additional destruction of healthy tissue or excessive scar formation
by cells called fibroblasts, particularly when inflammation persists.
With this background on the purpose and process of inflammation in injured muscles,
tendons, and ligaments, let's consider modes of intervention which could prevent further
tissue damage and accelerate repair. The standard RICE approach contains aspects of
merit, but also significant flaws which may be counter-productive.
Rest ("R") is the standard approach for sprains. The principle being that pain serves the
purpose of warning us against continued activity which could further extend the injury .
While no one would consider immediately sprinting all-out on a bad ankle sprain,
prolonged rest is likewise harmful. Rest results in muscle, tendon and ligament atrophy
(shrinkage) which then leads to further weakness and re-injury. Rest also results in
dampening of signals from nearby sensory nerve fibers which normally serve to assist
with balance and proper body positioning. Therefore, the absolute worst intervention is
complete rest! Generally, the sooner one can get the joint moving through its normal
range of motion, the less likely surrounding connective tissues and nerves will be to lose
their intended function.
Observations in the medical world also bear out this point. It is standard protocol now
following open heart surgery to encourage walking within 24 hours of surgery by
adequately treating post-operative pain. Many open heart patients have been known to go
home only four to five days after surgery, primarily due to the speed of recovery that
early activity promotes! On the contrary, individuals who are made comatose by
artificial or chemical means for any extended period of time experience a tremendous
loss of lean body mass and have a very prolonged recovery once they are allowed to
"wake-up". Often, severe infections and a multiplicity of other organ system
complications develop while a person is at complete "rest". In short, rest leads to atrophy
and weakness, while movement enhances healing and vitality because it stimulates blood
Ice ("I") is the long-standing treatment for any sprain, bruise or soft tissue injury .Most
circles endorse ice for the first 48 hours following -soft tissue injuries such as sprains.
This practice should be seriously challenged. The theory has been that ice restricts blood
flow and reduces swelling, thereby minimizing pain. As outlined above, the
inflammatory process is well orchestrated, each step serving both a purpose and as a
precursor for the next. Leakage of blood plasma into surrounding tissue with subsequent
swelling allows for the healing and repairing blood cells to find their way to the site of
injury. If ice is truly able to restrict blood flow, how would these repairing white blood
cells find their way to the site of injury?
The application of ice penetrates only a few millimeters of tissue and therefore may not
be operative in deeper tissues. Furthermore, the highly complex clotting system is a
quick acting system that stops most active bleeding by the time ice can be applied.
Finally, ice usually results in inactivity, at least during the standard 15-20 minutes of
application. Valuable time may be sacrificed during icing that could be put to better use
to enhance joint re-alignment and mobility.
Compression ("C") is the third principle and like ice is directed towards reducing
swelling. This step makes some sense because it attempts to interrupt the inflammatory
process by preventing the elevation of arteriolar hydrostatic pressure. While compression
may limit some tissue edema, it may also assist in lymphatic drainage by preventing thin
lymphatic walls from being compressed by excess tissue edema.
Elevation ("E"), like ice and compression, is the third mechanism of limiting tissue
swelling. While elevation may limit tissue swelling to a degree, its value may be
primarily in enhancing lymphatic drainage from the site of injury and edema.
In short, the inflammatory process has been designed, not as a means of extending injury
and prolonging recovery, but as a means of orchestrating tissue repair. Personal
experience as a physician has shown me that the RICE approach often delays recovery.
A more logical approach involves restoration of joint alignment with the associative
muscles, tendons, ligaments, nerves and blood vessels as quickly as possible after injury .
Minimizing swelling can also be an objective to reduce pain without interfering with the
inflammatory process. By quickly elevating the injured limb and applying gentle, but
progressive traction on the joint normal alignment can be restored before pain sets in and
muscle contraction and loss of mobility occurs in response to pain. With the limb
elevated compression wraps or preferably gentle massage can be performed to "milk" the
edema out of the injured tissue into the draining lymphatic vessels.
The overall goal of early sprain intervention is two-fold. First, excessive and prolonged
swelling should be minimized by appropriate means in order to reduce pain and assist in
the return of natural range of motion. Early, gradual and progressive movement of the
injured joint in ranges of motion that do not exacerbate pain enhances recovery -Traction
is an especially effective way to encourage movement. It can be accomplished by means
of a stretch band (Flexband @). With the joint placed in gentle traction, movement in all
directions can be initiated which helps to re-align injured ligaments, tendons, muscles,
The second goal of sprain recovery is enhancing tissue blood flow. Blood heals.
Surgeons know this. Patients who have impaired blood flow from advanced heart disease ;
or diabetes take longer to heal. A one inch cut on the face requiring stitches normally
requires three to five days of healing before the stitches can be removed. The same cut
and repair on the leg requires seven to ten days to heal. Why? The face heals faster
because the blood supply is greater.
The recovery process of any sprain is accelerated by blood flow. Movement is the
mechanism of enhancing blood flow. The key to movement is gradual, progressive and
relatively pain free in all directions the joint is intended to move. Rest is for the
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