Fat Camp: Translating the language of strains and sprains

Denver had a pair of high-profile injuries two weeks ago, and confusion reigns as to what all these terms mean. I wanted to try and sort it all out for you. You might want to keep this one around - you’re likely to glance at it frequently in the coming months. I also want to sincerely thank Denny Clifford, MD (known around these parts as Ponderosa) for his help on the Western side of this piece - it’s always a pleasure for us to work and share information together, and Denny is without question one of medicine’s good eggs.

The American Academy of Orthopedic Surgeons gives these guidelines on their public site: Sprains and Strains: What's the Difference?

Strains

Marcus Thomas, for starters, has a ‘strain’ of the pectoral muscle. What’s the difference? A strain is the simplest and lowest danger of all the soft tissue injuries - it just means that some fibers are torn in a muscle or tendon (tendons connect muscles to bones). It’s a very partial tear - a worse version of the common post-workout soreness that any athlete experiences. There are two main types: Chronic strains, which result from overuse of the muscles and tendons - prolonged and/or repetitive overuse. An acute strain, on the other hand, is caused by a direct blow to the body, overstretching or excessive muscle contractions. Even a violent muscle spasm caused by dehydration can cause an acute strain.

Denny put it this way:

A strain is an injury to a musculotendinous unit which is the entire muscle and the tendon by which it attaches to the bone. (Ligaments attach bone directly to other bone without intervening muscle.) A strain is an injury to any part of this unit: in the tendon, at the juncture of the tendon and muscle, or within the belly of the muscle itself. There are also avulsion fractures where a tendon and its bony attachment are pulled from the surrounding bony structure. Such fractures can be as small as a flake (such as seen sometimes in tennis elbow) to as large as several centimeters (which occurs with some hamstring injuries in the pelvis and hip pointers).

Strains are sometimes the result of overstretching a muscle. More frequently the injury occurs because the tension within the muscle is suddenly and abruptly increased. This can occur because the muscle group antagonizing the injured muscle suddenly contracts and there is insufficient time for the muscle to lengthen and thus it tears. The increase in tension can also occur within the muscle itself, that is, pulling itself apart because motion at the involved joint is resisted or abruptly interrupted; an example would be lifting a weight that is too heavy.

Strains should definitely not be viewed as being caused by overstretching since most injuries occur within the normal range of motion. Muscles have two active functions - to produce motion and to stop motion by acceleration or deceleration. Tension developed in the musculotendinous unit is greatest during deceleration or what is sometimes called eccentric motion and this is when most injuries occur. The ability to lengthen rapidly in a controlled manner is the highest order of muscle function. Certain training techniques which are emphasized by trainers like Broncos strength and conditioning coach Rich Tuten create the likelihood that these injuries will be less frequent although obviously not avoidable completely.

A weak muscle is a tight muscle. It makes no difference if that weakness is primary, that is, not strong enough to perform the task, or secondary as a result of fatigue. In either case, when the muscle is faced with a task beyond its capabilities, whether involving strength or endurance, it will tighten and fail producing a higher likelihood of injury. Injuries are cumulative over a season and injuries more likely because of this fact. Fatigued muscles and injured muscles are tighter and more prone to injury. 18-game season anyone? Not if you want healthy players in the game (I can’t say strongly enough how much I agree with Denny on this).

A common mistake is to assume muscle injuries are due to tightness and rehab the injury with stretching as the primary goal. This is classically seen with hamstring injuries where the tear is thought to be from tightness. This approach leads to chronic strains and tears because the muscle is in fact NOT STRONG ENOUGH. Even though it seems to have normal flexibility as soon as it becomes fatigued it tightens and becomes reinjured. Strengthening along with flexibility is the essential rehabilitation process to build endurance and strength so the muscle won’t tighten during performance.  Overuse injuries are strains that result in significant losses in strength, but are perceived by the athlete as a loss of flexibility. It is essential to balance flexibility training with strength reacquisition or the gains will be short lived.

There’s only one thing I'd like to add - the muscles that exist in opposition to those which are most commonly overdeveloped - such as when young players like to get into squat contests (which most strongly develop the quadriceps), but don’t spend equal or more time on the antagonistic muscles of the posterior leg tend to develop injuries. One smart thing that Knowshon Moreno did in the offseason was to get the muscles of the leg balanced and stronger, even though he’s lighter. The weight may or may not help his career, although I’d expect it to. It will help his health and reduce the number of injuries - at his position, you can’t expect to stop them.

Grading of Strains

Grade I - Tenderness and swelling that is minor and only associated with microscopic disruptions in muscle fibers.

Grade II - Significant tears, but not complete disruption of the musculotendinous unit (such as suffered by Ty Warren, who may make it back this season or have to wait until next - it’s too early to tell. The injury was to the tendon, but seemed from the coverage to include both Grade II and III issues).

Grade III - Complete disruptions of the musculotendinous unit with loss of ability to move the joint or bone attachment. Requires surgical repair, such as with Elvis Dumervil last year.

Treatment principles are the same as for sprains:  RICE (explained below)

Long term rehabilitation requires attention to strength and flexibility training in concert with endurance. Emphasis of one over another will result in muscle imbalance and more injury.

Sprains

Definition: A sprain occurs when there is a stretching or tearing in the ligaments, the fibrous tissues that connect bones to bones, and which stabilize and support the joints (with the help of other tissues, including the muscles. Muscles aren’t directly involved in sprains but they are essential to stabilizing many of the joints). Ligaments directly attach bone to bone without intervening muscle. There are two basic principles to understanding sprains: 1) That in most joints ligaments share with muscles the responsibility of stabilizing that joint and 2) That ligaments prevent only abnormal joint motion.

It should be evident that ligaments are not the exclusive stabilizers of joints. Consider the  extraordinary variation in joint stability or laxity on normal individuals. At one end of the spectrum are “loose jointed” individuals who can place their limbs in seemingly pathological positions yet have never had an injury and report no discomfort. At the other end are those whose joints are “tight” and yield little if any to abnormal forces.

By definition, ligaments do not limit physiologic motion and further, they are not injured when placed through a normal range of motion even when injured. Thus, you can’t further injure a ligament, unless you put the joint through an abnormal range of motion. Interestingly, the secondary effects of ligament injury are typically more challenging to treat than the ligament injury itself. The swelling, pain and muscle spasm lead to disuse of the very muscles that will be required to bear more responsibility for joint stabilization.

Sprains are caused by direct or indirect trauma - including falls, blows to the body, over-torquing of a joint, and so forth - that does one of three things: the incident knocks a joint out of position, overstretches the ligaments (which causes tearing of the fibers), or even ruptures the ligaments. Obviously, these can vary greatly in severity. Treatment may require any of the modalities listed below, and it may require surgery.

Denny put it this way:

Mechanism of injury

Sprains occur as a consequence of a joint’s being forced beyond its normal range of motion (a hyperextended knee) or forced in a plane through which little or no motion normally existed (a lateral ankle sprain). Almost by definition, a sprain requires some subluxation (dislocation) of the joint from minor to frank (total) dislocation. In this light, major dislocations are the treatment of the ligaments injured in this process.

The abnormal forces producing the sprain can occur quickly or more slowly, but the extent of injury is related to the joints inherent stability and how far the abnormal motion went.

Symptoms

Pain is almost uniformly present to varying degrees. It is usually sharp and localized to the area of injury. Paradoxically, in the most severe injury (Grade III sprains) the pain may disappear in a minute or so and complete tears of ligaments often result in less pain than lesser injuries. It makes diagnosis simply by sight impossible.

Swelling is almost always present and seems to correlate with the degree of injury. The worst injuries have the most swelling and also the initial management will affect the amount of swelling. For instance if heat is applied or the injured joint is allowed to remain dependent (functioning) rather than elevated the amount of swelling will be worse.

Limitation of motion is a consequence of the swelling and pain and becomes worse with the passage of time. Most people will test their range of motion after the injury when the initial shock has subsided and a physician or trainer will be seen frequently testing the range of motion possible without inducing further pain.

Sense of instability often accompanies more severe sprains. It will be described as “looseness” or a wobbly feeling. Any feeling of such laxity should be strongly heeded and the joint immobilized. Hearing a ‘pop’ as the injury occurs is usually a sign of a higher Grade II or a Grade III.

Grades of Sprains

The grading of ligament injuries is based upon the extent to which the ligament has been torn. A ligament is comprised of thousands of collagen fibers arranged in parallel fashion. When a ligament is stretched beyond its elastic limit, individual fibers fail and break, but at different locations within the ligament. The ligament may lengthen because the torn fibers slide over one another, yet allow the ligament as a whole to appear intact.

The determiners of which category or ‘Grades’ an injury falls into as as follows:

Grade I - Mild

In a mild sprain, the ligament is stretched and some fibers will tear, resulting in some pain and some swelling, but there is no loosening of the joint. In other words, there’s no abnormal laxity and no abnormal motion.

Grade II - Moderate

Moderate sprains produce some degree of joint instability. There is substantial tearing of the fibers of the ligament, but the ligament remains essentially intact and fully attached to the bones. There is usually some noticeable degree of joint instability along with some swelling and pain. Again - there’s some abnormal laxity present and minimal abnormal motion is possible.

Grade III - Severe

A severe injury to the ligament is usually instantly (not always, as we’ve discussed) and intensely painful - the ligament(s) immediately tear either all the way through or completely away from the bone. The patient commonly hears a ‘pop’ and it’s frequently audible to those around him. I was once in a high school gym when a Grade III of a right shoulder took place during a wrestling match and the whole place heard it clearly and gasped - it was like a gun going off.  The pain is usually excruciating as well as immediate. The loosening of the joint that occurs as a result makes the joint non-functional. Substantial swelling is normal to such injuries. As you’d expect, there’s abnormal laxity present and full abnormal motion is possible (a complete rupture). Grade III injuries almost always require surgical repair, as do some Grade II injuries, depending on the joint and physical activity expected upon repair.

If the news doesn’t give you the indicators of severity, you can’t really tell which category the injury fits into from reading those sources. Occasionally, an old friend who’s consulted on the case will drop a bit of information or two, but that’s not common. There are confidentiality issues involved, after all.

Prevention:

The AAOS had these recommendations to prevent strains and sprains. They’re aimed at the average person, but they even help pro athletes to stay healthier.

  • Participate in a conditioning program to build muscle strength
  • Do stretching exercises daily
  • Always wear properly fitting shoes
  • Nourish your muscles by eating a well-balanced diet
  • Warm up before any sports activity, including practice
  • Use or wear protective equipment appropriate for that sport

Treatments

You’ve all heard of it - it’s the acronym RICE, and it works. Here’s how:

  • Rest (don’t use it while it’s in the early stages of recovery)
  • Ice (or cold packs)
  • Compression (such as an elastic wrap)
  • Elevation (keeping it elevated decreases swelling)

Other options:

There are a wide variety of options for treatment - electrostimulation, microcurrent, massage (some forms work very well for sports injuries particularly), acupuncture, TENS units and a variety of topical ointments from Western and Eastern pharmacies are also helpful. Ice brings down swelling, while heat and infrared lamps have also been effective in many cases. For serious or multiple injuries, there’s a lot of new research on hyperbaric chambers that’s quite promising, although still new.

There’s a whole arena of Dit Da Jow preparations from Oriental medicine, which, much like Western Medicine, was in great part (though not exclusively) developed through times of war, and the need to develop treatment of the training and battlefield injuries that are a part of the war arts. Dit Da Jow literally means ‘Punch Kick Medicine’. These are often topical, although there are a wide range of herb formulas that will reduce the severity and duration of injuries if taken immediately after the injury occurs. The herb formulas were easy to transport, prepare and take:  I kept some of them in my bag and rarely went anywhere without them. I was doing a lot of sports myself back then, and they came in handy for my patients, myself and my training partners. I found them to be surprisingly effective, and I’d recommend them - any acupuncturist or herbalist either carries them or knows where to get them. And no, I don’t sell them wink

The National Institute of Health offers these guidelines for the care of soft tissue injuries. See your doctor if:

  • You have severe pain and cannot put any weight on the injured joint.
  • The area over the injured joint or next to it is very tender when you touch it.
  • The injured area looks crooked or has lumps and bumps (other than swelling) that you do not see on the uninjured joint.
  • You cannot move the injured joint.
  • You cannot walk more than four steps without significant pain.
  • Your limb buckles or gives way when you try to use the joint.
  • You have numbness in any part of the injured area.
  • You see redness or red streaks spreading out from the injury.
  • You injure an area that has been injured several times before.
  • You have pain, swelling, or redness over a bony part of your foot.
  • You are in doubt about the seriousness of the injury or how to care for it.

I hope that this has helped to clear up some of the mists of this subject, one that often must seem arcane to the non-practitioner. Whether it’s for you or for your favorite player, you might want to keep access to the sources listed here. Knowing the difference and keeping in mind the AAOS and NIH recommendations can help you to manage injuries in your own life. Knowing about the players? That’s just a bonus.

Go Broncos!

Learn to laugh at yourself. You will be ceaselessly amused. - Sri Gary Olsen

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