by Dr. Joseph Debé
The biggest enemy of every athlete, whether recreational or competitive, is not the other opponent; it is injury. Nothing stands in the way of athletic progress or enjoyment of exercise and sports, like injury does. Fortunately, taking a proactive approach, based upon sound scientific information, can both reduce injury occurrence and injury severity. Additionally, injuries that do occur can be stimulated to heal better and more quickly. There are many factors to consider in this regard. This article will cover what are, in my opinion, some of the more important biochemical and physical factors.
It is helpful to understand a little bit about the healing process in order to appreciate proper injury management. There are three semi–distinct phases of injury healing. In chronological order, they are: the inflammatory, the repair, and the remodeling phases. The inflammatory phase can last up to seventy–two hours. During this initial phase, a cascade of chemical events produces a walling off of the injured area and passage of fluid, blood cells, platelets, and other blood constituents from the capillaries into the damaged tissue. Edema and swelling result. White blood cells are called into the area to prevent infection and to begin cleaning up dead cells and damaged connective tissues. Inflamed tissues become red, hot, swollen, painful, and lose function. The second phase of healing, the repair phase, begins about forty–eight hours after injury and normally lasts up to about six weeks. During this time, normal circulation is restored, allowing delivery of oxygen and nutrients and removal of waste products from the injured tissue. New cells, blood vessels, and connective tissues (collagen and proteoglycans) are synthesized at the site of injury. While the mildest of muscle tears heals with new muscle cells, most injuries involve deposition of scar tissue, which is not as flexible or strong as the original tissue. Every effort should be made to assure that the resultant scar is as functional as possible (how to do this will be explained shortly). The final phase of healing, the remodeling phase, begins about two weeks after injury and may last for longer than a year. The newly formed connective tissue fibers are realigned along lines of mechanical stress and are cross–linked to increase tensile strength. Injuries are best managed by using appropriate therapies to optimize each phase of healing. A qualified healthcare professional should be consulted to properly diagnose the injury and to deliver and guide appropriate treatment.
RICE is an acronym for Rest, Ice, Compression, and Elevation. Depending on the severity of injury, the first twenty–four to seventy–two hours afterward should include "plenty of RICE". Rest obviously prevents further injury to the damaged tissue. Application of ice reduces pain, slows metabolism and constricts blood vessels, which reduces excess swelling. Ice therapy is most effectively applied by way of ice massage. This can be accomplished by filling a small paper cup with water and putting it in a freezer until solid. The top half–inch of the cup is peeled away and that end is applied to the skin of the injured site. The cup is continually moved over the area and light pressure can be applied on strokes toward the heart to try to encourage drainage of edema (fluid) from the injured tissues. Whether ice massage is used or an ice pack is left in place, care needs to be taken not to overdo it. Individuals with poor circulation need to be especially careful. Ice treatments should last between five and thirty minutes, depending on which area is being treated, the severity of injury, and the form of ice therapy used. Ice application should commence a few minutes after injury and should be used multiple times the first one to three days. Compression and elevation both help to reduce the amount of swelling that occurs after injury. Compression is easily applied with an Ace bandage. The bandage should be wrapped starting on the area furthest from the heart. The compression should be tight but not uncomfortable. Elevation involves spending a significant amount of time with the injured area supported in a position higher than the heart. Obviously, not all injuries lend themselves to these procedures.
2. PROTEOLYTIC ENZYMES.
Proteolytic enzymes are among the most powerful of natural supplements for improving healing of injuries. Proteolytic means protein splitting. The body naturally produces a variety of proteolytic enzymes but taking them in supplemental form during the inflammatory phase can tremendously improve the healing process. These enzymes work in multiple ways, including: reducing the body’s production of inflammatory chemicals, such as bradykinin and prostaglandin E2; assisting degradation of dead cells and damaged tissue; limiting excess clotting of vessels in the injured tissues and reducing viscosity of extracellular fluid, thereby maintaining more normal circulation. This allows for enhanced nutrient delivery and waste removal. The result is quicker resolution of the inflammatory phase with earlier initiation of repair. This is important because, although necessary for proper healing, when inflammation is excessive or prolonged, it results in tissue adhesions and delays healing time.
There have been hundreds of articles published on proteolytic enzymes, including double–blind, placebo–controlled experiments. Proteolytic enzyme therapy reduces the symptoms and signs of inflammation: pain and tenderness, redness, swelling, heat, and loss of function of the injured tissue. Proteolytic enzyme therapy has been demonstrated to speed recovery from injuries and allow for quicker return to athletic training and competition. One study compared the effects of Wobenzym® (a mixture of proteolytic enzymes, amylase, lipase and rutin) to placebo in forty-four athletes with ankle sprains and found Wobenzym® to reduce pain and swelling and improve mobility. The Wobenzym® group was able to return to work and to training in 1.7 and 9.4 days, respectively. By contrast, the placebo group took 4.4 and 15.9 days. Prophylactic use of proteolytic enzymes has also been demonstrated to reduce the incidence and severity of injury. In one study, 225 boxers were given proteolytic enzymes and another 225 were given placebos before bouts. Incidence of hematomas in the enzyme group was 3.1% versus 8.0 % in the placebo group.
Proteolytic enzymes have been found to speed healing of strains, sprains, hematomas, lacerations, bruises, abrasions, and fractures. Many studies have shown these enzymes to speed healing from a variety of surgical procedures, as well. To summarize, use of proteolytic enzymes can reduce pain, swelling, loss of function, and time to full recovery. They also limit scarring and adhesion, resulting in healthier healed tissue. Proteolytic enzymes should be preferred over non–steroidal anti–inflammatory drugs, which can slow repair and weaken healing tissues.
Proper use of quality proteolytic enzymes can be expected to cut healing time in half. It is important to start dosing as soon as possible after injury. According to Dr. Anthony Cichoke, an authority on enzyme therapy, "The sooner the ‘reaction cascade’ can be interrupted, the lesser will be the secondary results of the injury and the shorter will be the convalescent period." Proteolytic enzymes need to be taken in large doses because their absorption is poor. Taking a mixture of proteolytic enzymes is more effective than single enzymes. The best–researched enzymes for healing injuries are bromelain, papain, trypsin, chymotrypsin, and pancreatin. Typical dosing, depending on a variety of factors, is one to ten tablets taken three to six times a day. Therapy should continue for about a week. It is critical to take the enzymes on an empty stomach: half an hour before meals or two hours after eating. To take advantage of the preventive properties of proteolytic enzymes, take them one–half to several hours before engaging in training or competition. Contraindications to the use of proteolytic enzymes include hemophilia, anticoagulant therapy (use of blood thinners), pregnancy, and allergy to sources of the enzymes (bromelain is from pineapple, papain is from papaya, and trypsin, chymotrypsin and pancreatin are derived from pork). Intestinal gas and loose stools are the only side effects occasionally attributed to enzyme therapy and are dealt with by lowering the dose.
My own experience with proteolytic enzymes has been good. Some cases have not responded at all while results in other cases have been phenomenal. I attribute most of the difference in effects to disparity in quality from one brand to another. The formula I have been using for the last several years is Pro–Trauma. In addition to proteolytic enzymes, Pro–Trauma contains curcumin, magnesium, vitamin B5, valerian root and other herbs, and homeopathic ingredients such as arnica. A friend of mine, who is a carpenter, came to me for treatment of lower back pain. He mentioned that the day before he had accidentally shot a nail into his hand with a nailgun. He removed the nail himself. I examined his hand and found it to be red, hot, swollen and tender–obviously inflamed. I had him start taking Pro–Trauma immediately and instructed him in continued use. Within twenty–four hours, his hand was virtually back to normal!
3. BIOFLAVONOIDS AND OTHER PHYTOCHEMICALS.
There are a variety of compounds isolated from plants that possess anti–inflammatory activity and can play a role in healing athletic injuries. Citrus bioflavonoids have been demonstrated to accelerate the healing process. Bioflavonoids strengthen capillaries (thereby reducing swelling), reduce production of several inflammatory chemicals, inhibit enzymes that degrade connective tissues, and neutralize free radicals. Prophylactic use of bioflavonoids produces very similar results to the proteolytic enzymes; injury incidence, severity and time to heal are greatly reduced. Also like the proteolytic enzymes, bioflavonoids speed healing by about fifty %. Combining proteolytic enzymes, bioflavanoids and vitamin C produces synergistic effects. Proanthocyanidins from grape seeds are another class of bioflavonoid with powerful anti–inflammatory and healing qualities. Use of other phytochemicals, such as curcumin also can be expected to accelerate healing. Bioflavonoids and other phytochemicals are most important to use during the inflammatory phase but can be continued throughout the entire healing process.
4. TRAUMEEL OINTMENT.
Traumeel ointment is a homeopathic cream designed for topical application to injured tissues. Its use in accelerating healing is supported by published research and I personally can attest to its effectiveness. Traumeel can be used several times daily for the first week or so to reduce inflammation and pain.
5. NUTRIENTS AND NEUTRACEUTICALS FOR REPAIR.
Assuring adequate status of all nutrients can optimize the repair and remodeling phases of healing. The most scientific approach is to evaluate the unique nutritional requirements of the athlete, through laboratory tests, to determine which nutrients are needed. Alternatively, a complete and powerful multivitamin–mineral supplement can be used. I recommend Multigenics Intensive Care from Metagenics. Additional supplements of vitamin C can also be used. If bone fracture is present, I also suggest Microcrystalline Hydroxyapatite Concentrate (MCHC), a special form of calcium. Cal Apatite from Metagenics is one of the few quality MCHC supplements available. When connective tissues have been injured, additional supplements can help. Connective tissues include bone, tendon, ligament, and other joint structures. Glucosamine and chondroitin sulfates are building blocks of these connective tissues and, when taken in supplemental form, stimulate synthesis of new connective tissues. I had a patient who underwent surgical repair of a torn Achilles’ tendon. His surgeon told him to expect to be on crutches for about three months. I had this patient take a nutritional formula called Collagenics Intensive Care, which contains glucosamine sulfate, proanthocyanidins, vitamin E, zinc, manganese, copper, and a special form of vitamin C with bioflavonoids. To his surgeon’s surprise, after just one month he was walking without crutches!
Several different physiotherapy treatments can enhance the healing process. Different forms of electric stimulation and ultrasound can be used throughout all phases of healing. Microcurrent stimulation, for example, has been demonstrated to enhance local protein synthesis and ATP production. Microcurrent stimulation also restores the body’s normal electrical fields, which are disrupted by injury. Animal studies have found microcurrent stimulation to cut healing time in half. Ultrasound has a number of beneficial effects. It can be used to degrade inflammatory compounds and to pump edema out of the injured tissues during the inflammatory phase. During the repair and remodeling phases, it can be used to cause deep heating, which produces enhanced circulation in the treated area. Ultrasound helps to normalize metabolism by enhancing ion (charged particle) transport across cell membranes. Ultrasound is also of value during the repair phase because it increases the body’s manufacture of collagen, the primary connective tissue protein. Ultrasound treatment should also continue during the remodeling phase because it increases the extensibility of collagen, producing a more functional healed tissue. Some other physical medicine treatments of value in healing athletic injury include other forms of electric stimulation (such as Russian stimulation, which can be used to strengthen muscle), magnetic therapy, and various forms of traction.
Chiropractic can be expected to both help prevent and heal injuries. Numerous studies have found chiropractic treatment to enable injured people to return to work in half the time of those receiving standard medical treatment. When a joint is not functioning properly, the nerves supplying the joint relay this information to the rest of the nervous system. This results in localized muscle tension, reduced circulation, pain, and other adverse effects. Tissues in such a condition are more likely to become injured and to heal from injury less completely. What’s more, when one joint malfunctions it negatively effects other joints. In this regard, a recent study found that chiropractic treatment applied to the neck improved hip joint flexibility! Similarly, having a hyperpronated ankle (one that collapses inwardly) has been associated with increased incidence of knee cruciate ligament injuries. Ankle hyperpronation can be corrected by use of custom–made foot orthoses (innersoles for the shoes).
Massage is another treatment to consider in enhancing recovery from injury. Massage increases circulation and lymphatic flow, thus enhancing waste removal from tissues. A specialized chiropractic soft tissue treatment called Active Release Technique can produce remarkable results in relieving pain and restoring function in many chronic injuries. It is extremely effective in breaking up tissue adhesions and restoring full musculoskeletal function. It has been documented to speed recovery in nerve entrapment syndromes (such as carpal tunnel syndrome). Cross friction massage is another valuable treatment modality. It passively stretches tissue, prevents excessive cross–linking of healing connective tissue fibers, enhances circulation, and helps improve flexibility of the treated tissue. It is especially good for improving healing of tendons and ligaments.
8. REHABILITATIVE EXERCISE.
Although rest is important during the inflammatory phase, prolonged inactivity can impair and delay healing. If the injury is not too extensive, it is usually a good idea to continue aerobic and resistance exercise and stretching for the uninjured parts of the body. This is certainly true beginning with the repair phase of healing. Additionally, exercising the same tissue on the uninjured side of the body will actually benefit the injured side because of left to right side connections in the nervous system. For example, if an athlete has a strain of the right biceps muscle, exercising the left biceps will strengthen the right side to some degree.
Early on in the repair phase of healing, Continuous Passive Motion (CPM) of the injured tissue should be instituted. Continuous Passive Motion involves movement of the injured area without the athlete actively contracting the musculature. CPM can be performed manually by a therapist or by special equipment. CPM improves circulation, aids exchange of nutrients and waste products from joint structures, helps reduce adhesion formation, and encourages newly formed connective tissue fibers to be aligned in the proper direction.
Also early in the repair phase, the injured area should be exercised isometrically. Isometric exercise involves static contraction of muscles; in other words no movement is involved. This way the damaged tissue can be strengthened without aggravating the injury. As time goes by, isometric exercise can be replaced by pain–free range of motion, isotonic exercise. Isotonic exercise can be accomplished by use of weight machines, dumbbells, elastic bands and more. It is important to return the injured tissue to normal strength.
Proprioceptive or balance training is also important for some injuries, especially those involving immobilization of the lower extremity (leg) for prolonged periods. Proprioception, which is the body’s ability to know the position and movement of its parts, is impaired by immobilization such as casting. Balance training can help restore normal proprioception and avert re–injury.
Finally, stretching the entire body is important. Not only should the injured tissue be stretched, beginning in the latter part of the repair phase, but the antagonistic muscle must also be flexible to allow normal strengthening of the damaged muscle. This entire process of rehabilitation should be performed under the care of a qualified licensed practitioner.
9. OPTIMIZE HEALING POTENTIAL.
Healing Potential is a term I use to encompass all the various physiological factors that play a role in musculoskeletal healing. These factors include nutrient adequacy, pH balance, inflammatory/anti–inflammatory balance, hormonal status, free radical/antioxidant balance, mental–emotional state, circulatory function, fitness level, biomechanics, and immune status, at time of injury. For example, if one eats a pro–inflammatory diet (consisting of excessive red meats and dairy products with inadequate fruits, vegetables, and omega 3 fatty acids [found in cold water fish]), any injury sustained will take longer to heal. Additionally, more frequent and more severe injury can be expected from what would otherwise have been well–tolerated traumas. Healing Potential can be optimized by working with a qualified healthcare professional who can evaluate and treat these various areas.