How To Heal Injuries
General principles for healing all types of injuries
Posted December 3, 2009
Injuries to the musculoskeletal system come in two basic types: acute traumatic and chronic overuse. The tissues predominantly involved include bones, ligaments, tendons, muscles, and bursae, though which bears the greatest brunt of injury in any particular circumstance will, of course, vary. Common locations for these types of injuries include the back, neck, shoulders, knees, ankles, and feet.
Treatments differ slightly depending on the location of the injury and which specific tissue type suffers the greatest impact. In general, for acute musculoskeletal traumatic injury (excluding broken bones) we try to make the injury "NICER"—that is, we use NSAIDs, Ice, Compression, Elevation, and Rest, all of which are designed to reduce the early phase of inflammation present in acute traumatic injuries. While making an injury "NICER" may or may not speed healing (see below), it almost certainly will improve pain.
In chronic overuse injuries, however, inflammation may not actually play a significant role, which may explain why NSAIDs in that setting, while often useful for reducing pain, are often unhelpful in actually healing the injury itself. When tendons injured chronically from overuse, for example, are viewed under the microscope we see very little inflammation. As a result, the term "tendinopathy" is now preferred over "tendonitis" to suggest the pain may be coming from microtears or some other mechanism besides inflammation.
The main therapeutic treatment I apply to most musculoskeletal injuries, whether acute or chronic, is the simplest: rest. Whenever you develop force across an injured tissue, you're almost certainly retarding its healing. Some musculoskeletal injuries can take literally years to heal completely (I once injured my shoulder bench pressing and had to wait three years before I could bench press again without pain). Sometimes rest can only be enforced by applying a splint (such as to the wrist in order to prevent force being delivered across the elbow during wrist extension in tennis elbow). Patients—especially active, athletic ones—typically hate hearing they need to stop using the injured tissue even for a little while. But it's far better to stop using it—even for months, if need be—than suffer an injury that takes years to heal. How do you know you're adequately resting an injury? It's easy. Don't do anything that causes it to hurt...
...with one possible exception. Studies of patients with Achilles' tendinopathy have shown improved healing from eccentric exercise. Eccentric exercise involves lengthening a muscle against resistance (in other words, a controlled lowering of a weight) compared to shortening a muscle against resistance (as when you curl a dumbbell with your bicep to your chin, for example). Some degree of discomfort during the eccentric training of these patients' Achilles' tendons was actually associated with faster recovery times. Studies showing the benefit of eccentric exercise for other types of tendinopathies are beginning to appear as well, suggesting its prudent use for other tendon injuries seems reasonable. Be careful to reserve this modality for chronic overuse injuries, however, in which acute inflammation is less likely to be playing a role as the cause of pain and under the supervision of your doctor and/or physical therapist.
Physical therapy, by the way, consisting of stretching and strengthening exercises is usually quite helpful at improving pain and joint range of motion if appropriately timed and done on a regular basis. Though modalities such as ultrasound and iontophoresis have been shown to improve swelling and inflammation at a microscopic level, little if any evidence exists that they actually speed healing.
NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil, Motrin) have played a role in treating musculoskeletal injuries for decades, but data proving their effectiveness in speeding healing (compared to providing pain relief) is surprisingly scant. In fact, even though some studies suggest their use results in a speedier return to normal strength in the short term, their use may actually retard healing in the long term.
NSAIDs provide two independent effects: pain relief and reduction in inflammation. However, these two benefits occur at different dosages. For example, ibuprofen can provide pain relief at just 400 mg/day but only at 1800 mg/day does it provide an anti-inflammatory effect. Pain from a musculoskeletal injury may or may not be caused by inflammation (see above), but NSAIDs can provide pain relief from injury without reducing inflammation, or in the absence of inflammation, via reduction of prostaglandin production in the central and peripheral nervous systems. However, such mechanisms almost certainly don't speed healing.
Many people don't know that NSAIDs come in different classes. NSAIDs from one class may be of tremendous benefit in controlling your pain but not help someone else at all and vice versa. In general, if one NSAID isn't working to reduce your pain, switching to another one from another class might help. Check with your doctor to identify which NSAIDs come from classes other than the one you're currently taking.
In general, after an acute musculoskeletal injury, I will recommend NSAIDs at anti-inflammatory level doses for brief periods on a scheduled basis (1-2 weeks at most) and then on an as-needed basis for pain control thereafter.SPECIFIC
What follows is intended as a broad discussion of the most common types of musculoskeletal injuries. You should take care not to conclude that any pain you may be experiencing could only be coming from the diagnoses discussed below, nor should you use this discussion as confirmation of a diagnosis you may be considering yourself without consulting your own doctor. Having said that, once a clear diagnosis is made, you may find the principles below helpful:
- The back. Literally 90% of all back pain has a benign course and is due to acute or chronic musculoskeletal strain of one of the connective tissue elements of the spine (often as a result of the smallest of actions, like leaning forward to pick up the salt, or sneezing, sometimes preceded by heavy lifting, sometimes not). The remaining causes include an assortment of age-dependent diagnoses like herniated disks, spinal stenosis, and, rarely, metastatic cancer. When people acutely injure their backs, 80-90% have near complete resolution within 12 weeks (which means, unfortunately, 10-20% take longer and sometimes go on to develop chronic low back pain). While many advocate immediate physical therapy, I don't. In my experience, during the early phase of back injury, physical therapy is as likely to worsen the pain as it is to improve it. I recommend avoiding heavy lifting (or any lifting if possible), sleeping flat on your back with a pillow under your knees to keep them at about 10-15 degree angle (it's amazing how easy it is to re-injure your back—or neck, for that matter—during sleep. If you wake up feeling like your pain is back to square one, it's probably because you slept in a position that put strain on the injured tissue), avoiding ice (unlike musculoskeletal injuries in other areas of the body, injured tissue in the back is usually too deep for the cold to reach; it often just induces muscle spasm which increases pain), and using heat immediately to reduce muscle spasm. Pain will often refer down one or both legs from back strain, almost always stopping above the knee. This is entirely different from radicular pain, which usually goes below the knee and may suggest a herniated disk. Even if you have a herniated disk, however, unless you have uncontrollable pain or muscle weakness, the treatment is the same as for musculoskeletal back strain: rest. Enforced bed rest, however, has been shown to actually retard recovery from acute musculoskeletal back pain. If you're in too much pain to get out of bed, by all means, stay there until you're not—but otherwise, don't put yourself to bed.
- The shoulder. Though many elements in the shoulder (the joint with the widest range of motion and therefore greatest susceptibility to injury) are at risk for injury, the two most common injuries are usually, though not exclusively, overuse injuries: subacromial bursitis and rotator cuff tendonitis. Though patients often have difficulty telling these two injuries apart (symptoms of both include pain when abducting the arm) an experienced physician can easily distinguish them on physical exam. Subacromial bursitis is usually amenable to a cortisone injection plus physical therapy, while rotator cuff tendonitis is usually treated with physical therapy alone (you can't and don't want to inject a tendon).
- The hip. There are, in general, 5 causes of hip pain, diagnosable by single physical exam maneuver: the examiner simply asks the patient to point with their index finger to the exact location of pain. Depending on where they point, the cause of hip pain will be: quadraceps tendonopathy, trochanteric bursitis, pain localized to the hip joint itself (usually from arthritis), sacroiliitis, or low back pain. Sometimes a leg-length discrepancy causes hip pain and can easily be solved by wearing a heel lift. Trochanteric bursitis can usually be cured with a single cortisone shot. The other types of injuries usually require NSAIDs and/or physical therapy.
- The heel. The most common cause of heel pain in adults is plantar fasciitis. The most common presentation involves heel pain that's worse with the first step of the morning (getting out of bed) but which improves modestly as the patient walks on it early in the day and then gets bad again near the end of the day. Flexible heel inserts combined with NSAIDs, a night splint, and a reduction of walking help. In recalcitrant cases, a steroid injection into the sole of the foot may be necessary (and really hurts).
Intriguing studies have been done on the effects of magnets on musculoskeletal pain. One well-done pilot study looked at the effects of magnets on muscle "trigger point" pain in patients suffering from post-polio syndrome and showed clinically significant improvement with the application of commercially available magnets. Another study of the effects of magnets on back pain, however, failed to show any benefit (though the authors of the study speculate this could have been because the magnets they used might not have been strong enough for their fields to actually reach the injured back tissue, which often lies quite deep in the body). In any event, short term exposure to magnets of strengths up to 80,000 Gauss (far stronger than commercially available magnets) is considered safe so with little risk of harm and some data suggesting benefit (in muscle belly pain, at least) magnets might be worth trying for some.
Many claims have been made about the beneficial effects of acupuncture, but in at least one well-done randomized controlled trial its affect on chronic low back pain was shown to be due to the placebo effect. (Which is not to say acupuncture is without effect at all. It has, for example, been shown to reduce nausea and vomiting in early pregnancy).
The preceding discussion was intended only to scratch the surface of the more common musculoskeletal injuries and to describe the treatments that have the greatest weight of evidence for their effectiveness, recognizing there still remains more we don't know than we do about how to heal musculoskeletal injuries. In general, we can consider the human body to be mostly endowed with the mechanisms necessary to heal the injuries described above and that much—though by no means all—of what we need to do is simply get out of the body's way and take care not to do things that actively work against it's efforts to heal itself (this excludes, of course, circumstances in which surgery is required, which was outside the scope of this post). Some chronic injuries, however, resist even the best attempts to heal them, making prevention the best strategy for dealing with them. Thus, if there's any one principle to take away from this discussion it would be this: whenever you injure yourself, rest, rest, rest.
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