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Introduction
We have all faced injury at some point in our lives. Some of us seem more predisposed to injury than others. And let’s just air out what we already know: injuries suck. But what if I told you there’s a way to make injuries happen less, and that you can bounce back quicker from them?
In this article, I explain the acute tissue-injury cycle (why we get pain, stiffness, and inflammation) and how to allow those injuries to heal optimally while preventing future injury.
Imagine you’re out for a jog. You’re running in some crowded streets, so you find yourself weaving through the people - up on the sidewalk, down on the road, back up on the side—- *POP* – you hear it before you feel it. You start to feel a warmth and searing pain on the outside of your ankle. You go to put pressure on it but you can’t - it feels too weak and every step is reminding you of what just happened - you sprained your ankle. Thankfully, there was no bone involvement and nothing was broken. The next day, you are left with a not-so subtle reminder of a black-and-blue mark and swelling around the joint that makes a pregnant lady’s ankle in the mid-August heat look skinny. You have no choice but to rest it and walk with a slight limp for the rest of the week.
After about a week, your ankle is starting to feel “normal” again. The bruise is starting to diminish, and you can actually point out the bony landmarks of your ankle again. The soft tissue is tender, but at least you are seeing progress. And you have to get back into training right? But what if this happens again? How do you know it’s time to start pushing it? Should you ever run again?
Let’s peel back the mystery of what happens to your body during an acute soft-tissue injury. Soft-tissue refers to any part of the musculoskeletal system involving skin, muscle, tendon (what attaches muscle to bone), or ligament (what attaches bone to bone). Please note this excludes bone pain and nerve pain. Acute phase of injury is an injury that occurs within 4 weeks of an incident - like our sprained ankle from running on uneven surfaces in this scenario. Now that we understand the medical jargon, let’s move on.
Our body will go through phases of healing at the first onset of injury. Again, we are specifically talking about acute soft-tissue injury here, so understand that healing is different for bone and nerve pain, and chronic pain is for a different conversation as well. There are three main stages to tissue healing. They are: Inflammation, Proliferation, and Remodeling.
Phase I: Inflammation
The inflammatory phase of the tissue-injury cycle occurs at ‘Ground Zero’ and kicks off the body’s amazing journey to get back to normal (or, whatever baseline is for you). This phase is about 4-6 days long, so to make it easy, the first week status-post injury. So that swelling you experienced around the injured area? Yeah, that is part one of this journey. What that swelling is doing for you is bringing a rush of blood to the area. Blood has healing properties like platelets, leukocytes, and monocytes. These little cells act like a well-run construction crew coming in after demolition has happened. You’ve got your platelets which have growth factor and both pro- and anti-inflammatory cytokines which act like the foreman of the job. They signal when to start cleaning up the damaged tissue, and once the job looks clean, these cytokines and growth factors will signal when the next crew needs to come in to start rebuilding the job-site (phase 2 of the tissue-injury cycle). The leukocytes and monocytes are the workhorses of phase 1. They work in tandem to do the actual grunt work of cleaning up the damaged tissue.
The importance of phase 1: inflammation, is to make sure that the site is clean and ready to start a rebuild of the injured tissue. If you have ever tried painting your house, you don’t putty holes after you apply the final coat of paint. You have to make sure your canvas is ready for the final product to produce a better outcome.
There is some conflicting evidence in the medical field regarding the RICE protocol. This, for those who have never heard the term, stands for Rest, Ice, Compression, and Elevation. In addition, most medical professionals will recommend utilizing an NSAID or anti-inflammatory to help with swelling. However, if the inflammatory phase is so important to set up the rest of the tissue-injury healing cycle, is stunting that inflammation really best? Would it be better to not use this protocol at all? Or, is it worth refraining from utilizing at least ice and NSAIDs until after the 4-6 day window of phase 1? Let’s explore this more later.
Phase II: Proliferation
Now that we have laid the ground-work for rebuilding, the next phase is focused on creating the scaffolding to allow the injured tissue to rebuild, or remodel. Phase two is called the Proliferation Phase. This phase is about 1-3 weeks from the initial injury, or about 4-24 days. The key player in this phase is known as collagen, or in more layman's terms, scar tissue. As collagen starts to form, it is creating the framework, or scaffolding, for the injured tissue to rebuild or remodel. Interestingly enough, scar tissue appears to have a better vascular system (ie blood flow to the cells) when compared to “normal” tissue. This may be because of the need for that blood to repair the tissue in the first place (think back to phase 1).
The importance of phase 2 is to produce the scaffolding or guide of where and how the tissue needs to rebuild. Think of the scaffolding you see around skyscrapers that are being built. They help create the framework for the final product.
Phase III: Remodeling
Our last phase of the tissue-injury cycle is the longest, and for most of us, our most impatient phase. Phase three, or the Remodeling Phase, occurs anywhere from 3 weeks to 2 years status-post injury. The reason for such a big gap is typically the extent or severity of injury and what other structures needed to heal in tandem with the tissue injured. Most all tissue that undergoes acute injury will need not only to rebuild the tissue injured, but the other important structures will need to heal around it. Tissue needs to revascularize (re-establish blood flow), reinnervate (re-establish nerve conduction) and re-cellularize for appropriate gene expression (the ability for cells to signal or communicate with other cells).
Now that we understand this cycle better, what does that mean for you and your sprained ankle you are dealing with? Well, the first thing is understanding timelines. Our body NEEDS time to heal - on its own - without any extra help from medications, or just “ignoring” the injury.
Promoting Better Outcomes
Dubois and Eschulier 2019 wrote a paper providing, in my opinion, a better framework for allowing our body to heal from acute injury. Remember our acronym RICE and our use of NSAIDs for injury? This paper outlines a more targeted protocol based on the stage of healing. The acronym Dubois and Eschulier utilize is PEACE and LOVE.
PEACE is solely to be used in Phase 1: Inflammation. So essentially, the first 4-6 days after injury.
PEACE:
Protect: avoid any unnecessary use of the injured tissue. It is okay to brace or unload the joint within the first few days from injury (ie. using crutches or a scooter for a sprained ankle)
Elevate: elevating the affected limb above heart level will naturally keep swelling under control. Elevation still allows the inflammation process to happen, but provides some comfort to the individual as swollen tissue can be painful in and of itself
Avoid NSAIDs: again, we are trying to not suppress the body’s ability to heal
Compression: another tactic that allows inflammation to occur, but control extra swelling, similar to elevation
Education: Reread the section on Phase I: Inflammation to better understand why inflammation is so important!
After 4-6 days and utilizing the PEACE protocol, then the importance for optimal and speedy recovery is carried out through the LOVE protocol.
LOVE:
Loading: Optimal loading, meaning that you start moving and using the injured area in ways that do not increase pain. This can help promote repair and tissue remodeling in addition to building tissue tolerance
Optimization: Better mental outlook = better outcomes. Diminishing your fear, depression, or catastrophizing of an injury allows you to just focus on getting better. Injuries happen, and they are not convenient. But you can’t take back what happened, you can only move forward. So take your energy and use it for good. It will make this process quicker and easier for you if you focus more on the present and less on the past or a “meek” future status post injury.
Vascularization: Early pain free aerobic exercise is shown to help improve healing times by boosting motivation and promoting blood flow to injured areas. Exercising can also reduce need for pain medication and get you back to regular activities of daily living (ADLs) quicker
Exercise: Focuses on restoring strength, mobility and proprioception of the injured area. Pain should be minimal. Pain helps guide progression of the exercise program. **Early focused exercise also helps reduce recurrent injuries**
Conclusion
So if you have an injury, go see your doctor. They will check to make sure there isn’t anything more serious going on like compression on nerves, broken bones, or anything requiring urgent fixation or surgery. If this is the case, the goal of treatment is to allow the body to start the healing process, using about 4-6 days to take it easy. Once you are in the second week post-injury, the goal is to start working on range of motion and gentle exercises that do not exacerbate symptoms. If you have pain with one activity, just understand you may not be ready for that activity - yet. Change it up, and keep moving within your limits. After that, your focus should be getting back into more regular and controlled exercise. A trained Physical or Occupational Therapist is key. PTs and OTs are trained to help you progress your training from “rehab” to “maintenance and progression”.
Always remember, it is important to understand that each tissue injury can present differently. Injuries are also influenced by outside factors that you cannot control such as age, pre-existing health conditions, overall fitness and the specific tissue injured. The healing process can, and will be, different for everyone. If you take one thing away from this article it should be that our body has the ability to heal itself. Our goal should be to give our body the right environment to do so - both physically and mentally. Stay positive, and know that there are medical professionals willing and wanting to help you on your journey to recover from injury. Not only do we want to help you heal from your current injury, but we also want to help you prevent further injury in the future.
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