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Aug 18

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Ankle Sprain: Revisiting a Common Injury (Part II)

 


Ankle Sprain: Revisiting a Common Injury (Part II)

By Bryan Dorrel, Associate Professor

Tarleton State University

The Healing Process:

Following an ankle sprain, the human body takes extraordinary steps to heal itself. The healing process can be viewed as occurring in three distinct phases, each unique and important. This inflammatory process is characterized by the distinct signs and symptoms of pain, redness, heat, swelling and loss of function. How long it takes an athlete to transition through each phase of healing is related to how severe the injury is but it can be prolonged with improper care of the injury. The three phases of the healing process include:

· Phase I: Acute inflammatory response – Usually lasting 24-72 hours. This is characterized by the release of the chemical histamine which promotes swelling & protein accumulation. Phagocytosis begins to occur in an attempt to return balance to the injured area by removing damaged cells. Formation of new granulation tissue made up of fibroblasts and collagen occurs transitioning the injury into phase II and the more permanent formation of scar tissue.

· Phase II: Proliferation – Can last a few hours or upwards of 10 days depending on the extent of the injury. Phase II is characterized by the removal of damaged cells and the tissue used to temporarily repair the injured area. Permanent scar tissue is formed and revascularized so that oxygenated blood flow and nutrients maybe transported to healing tissues. Toward the end of phase II, sensory and proprioceptor nerves form. Although scar tissue is formed, the injury is still in a weakened state as the scar tissue is not as strong as the original tissues. It is often during this phase that an athlete “feels” much better and is eager to return to play. For an injury to be fully healed, the scar tissue needs time to mature and to be “remodeled”.

· Phase III: Maturation & Remodeling – Maturing of an injury and remodeling of scar tissue can take a long time. This process can take upwards of two years and involves scar tissue maturing into the appropriate new fibers of those tissues which were injured. If we injure connective tissues or muscle tissues, the healing process is relatively the same; however, connective tissues and muscle tissues are not. While scar tissue formation may temporarily patch a injured muscle, it cannot possibly be the ideal replacement for healthy muscle fibers. But it works until new muscle fibers are formed. Another aspect of phase III is remodeling. Remodeling means to realigning scar tissue into an optimal pattern through rehabilitation and reconditioning. When scar tissues form, they are randomly deposited in the injured area. By remodeling the scar we are taking a weak patch and realigning those fibers into an optimal alignment with the other fibers of the surrounding injured tissues.12 Even after the remodeling phase, research suggests that a healed and remodeled ligament is not as strong as it was pre-injury. Research on healing ligaments suggests that a ligaments internal structure never fully returns to its original state or that it regains its full biomechanical function as a tissue which may predispose an athlete to reinjury.

Factors which affect the healing process:

The process of tissue healing can be negatively influenced by many factors. These include: blood oxygen levels, stress, impaired blood flow, infection, age, obesity, sex hormones, some medications and nutrition.

As a ligament injury is transitioning through the three stages of healing, without a doubt, return to play before an injury is fully healed can negatively impact the healing process and potentially result in re-injury. Monitoring the athlete as they work through the healing process is one of the most effective strategies for healing, as it helps to stimulate repair and improve lost range of motion and strength.3 Research is supportive of controlled mobilization and exercise following ankle sprain.

Currently serious questions are being raised regarding the role of non-steroidal anti-inflammatory drugs (NSAIDs) during the healing process. Often prescribed following musculoskeletal injury, there is evidence that NSAIDs reduce pain and assist to improve short term function following new ankle sprain.2 But questions persist regarding the long term effect of taking an anti-inflammatory drug, when the human body actually heals it-self through an inflammatory response to injury.2,3,14 There is concern that NSAID use may impair ligament, muscle and bone healing and affect long term repair of injury.14-17 NSAID use should be managed very closely by a medical doctor and long-term joint health should always be a priority for athletes under our care.

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2. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes. Journal of Athletic Training (Allen Press). 2013;48(4).

3. Hauser R, Dolan E, Phillips H, Newlin A, Moore R, Woldin B. Ligament injury and healing: a review of current clinical diagnostics and therapeutics. The Open Rehabilitation Journal. 2013;6(1).

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8. Henriksen M, Aaboe J, Graven-Nielsen T, Bliddal H, Langberg H. Motor responses to experimental Achilles tendon pain. Br. J. Sports Med. 2011;45(5):393-398.

9. Henriksen M, Rosager S, Aaboe J, Graven-Nielsen T, Bliddal H. Experimental knee pain reduces muscle strength. The Journal of Pain. 2011;12(4):460-467.

10. Hodges PW, Tucker K. Moving differently in pain: a new theory to explain the adaptation to pain. Pain. 2011;152(3 Suppl):S90-S98.

11. Hall S. Basic biomechanics: McGraw-Hill Higher Education; 2014.

12. Starkey C. Therapeutic modalities: FA Davis; 2013.

13. GUO S, DIPIETRO L. Factors Affecting Wound Healing. J. Dent. Res. 2010;89(3):219-229.

14. Paoloni JA, Milne C, Orchard J, Hamilton B. Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use. Br. J. Sports Med. 2009;43(11):863-865.

15. Elder CL, Dahners LE, Weinhold PS. A cyclooxygenase-2 inhibitor impairs ligament healing in the rat. The American Journal of Sports Medicine. 2001;29(6):801-805.

16. Pountos I, Georgouli T, Calori GM, Giannoudis PV. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. The Scientific World Journal. 2012;2012.

17. Baoge L, Van Den Steen E, Rimbaut S, et al. Treatment of skeletal muscle injury: a review. ISRN orthopedics. 2012;2012.

Bryan Dorrel can be reached at bdorrel@gmail.com.

About the author

Professor Bryan Dorrel Associate Professor Tarleton State University

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