Tong zhi bu tong; Bu tong zhi tong.
“Where there is free flow, there is no pain; where there is pain, there is no free flow.”
It’s officially football season, and the Cards are finally back on the field. I’ll be doing injury reports for significant injuries again this season, and unfortunately, they tend to come more frequently on the gridiron. For the second straight year, a major defensive contributor will be sidelined for a while after some bad luck in the season opener. Let’s get into it.
Keep in mind that UofL does not issue detailed information about player injuries, so what I’ll be describing are common and likely conditions based on the information released.
Jon Greenard left Saturday night’s game against defending national champion, Alabama, in the first quarter with what was later reported to be a wrist ligament injury. Upon emerging from the locker room, he remained on the sideline with his wrist wrapped.
The exact diagnosis has not been stated, but a “wrist ligament injury” is most likely a tear of one or more of the palmer radiocarpal ligament, radial collateral ligament, or ulnar collateral ligament.
Symptoms and Anatomy
Typical symptoms of a ligament tear are pain, weakness, and lack of mobility in the joint, as well as swelling and bruising. Grip strength and finger articulation could also be compromised with an injury of the wrist. This is a fairly common football injury due to the frequency of players going to the ground and bracing their fall with their hand. We call this a FOOSH injury, or “falling on outstretched hand.”
The radial collateral and ulnar collateral ligaments of the wrist prevent the hand from deviating too far to one side, stabilizing the wrist joint. The palmer radiocarpal ligament is a collection of smaller bands that form the membrane of connective tissue allowing for the majority of the wrist joint’s movement. The official statement on the injury was vague enough that tendons in the forearm that control finger and thumb flexion could also be affected, but beyond an injury requiring surgery, this doesn’t change the treatment strategy significantly.
**This next paragraph explaining the way the body heals connective tissue was in a previous article, but feel free to revisit it.
[Tendon and ligament sprains are grades on a 1-3 scale, with 1 being microtearing in the fibers of the connective tissue and 3 being a complete tear of the ligament. Ligaments are largely comprised of collagen fibers classified as Dense Regular Connective Tissue (DRCT). These fibers are bundled together parallel to one another and are designed to have great tensile great to resist pulling in one direction – the normal movement for that joint for which that particular ligament is responsible. Rolling the ankle or putting any type of torque force on a ligament may result in injury because the DRCT are not equipped resist unnatural twisting of the joint. When this type of injury occurs, the body remodels the tissue to be partially comprised of Dense Irregular Connective Tissue (DIRT). The fibers are laid down in a non-parallel, multi-directional fashion to protect against multi-directional pulling. The result is a joint that is better able to resist moderate torque forces but with less tensile strength and flexibility due to the DIRT fibers being shorter. This is why injured ligaments are never quite the same after healing.]
Just as I discussed in the article about ankle sprains the RICE protocol is typically utilized – rest, ice, compression, elevation. The goal is to reduce swelling and pain and limit weight bearing to allow it to heal on its own. Pain medication may be prescribed, and physical therapy is often appropriate to ensure articulation, grip strength, and flexibility return. Severe tearing generally requires surgery.
Dr. Colby’s Treatment
The way I would approach treating this injury is the same as all ligament injuries. The only real difference being the location of the acupuncture points utilized. Obviously, with a wrist injury, the focus would be more hand and wrist points. As Greenard is reported to be out “for a while,” this is a case I would be more aggressive with. Getting aggressive with acupuncture means using electrical stimulation with the needles. This more intense stimulation helps to reduce pain and swelling, as well as increase circulation and healing of injured tissue. It’s a great rehabilitative technique. With the ligaments of the hand and wrist being so small, and blood flow to ligaments being so limited, acupuncture is great to get into those cramped areas, and doing a nightly herbal soak of the hand would really expedite healing.
**As I mentioned, the overall approach is similar to injuries we’ve previously discussed in this article series, so continuing reading this section for a refresher.
My training very much disagrees with the RICE approach, most notably the ice part. Modern sports medicine is finally starting to catch up with the 5000 year old principles of Traditional Chinese Medicine, too. (Here’s the doctor who coined RICE updating his protocol in light of new research http://www.drmirkin.com/fitness/why-ice-delays-recovery.html). The whole point of healing injured tissue is creating more circulation in the area. The site of trauma has stagnant blood and other tissue debris, and we want to move that out as soon as possible. Swelling is actually the first step in the process as the body sends everything it can think of to tend to the injury. Icing prevents the first responders from arriving on the scene, and ultimately the cold hinders circulation. The creek freezes in the winter, after all.
We absolutely want to maximize circulation in the area as soon as possible because ligaments do not inherently have good access to blood flow. Blood vessels do not interface with dense connective tissue the way it does with our muscles and organs. This is why the healing of ligament injuries takes so long, and the ice prolongs the healing further. The best way to deal with an acute injury apply an herbal poultice with ingredients designed to invigorate blood flow. This will help with the pain and swelling without allowing cold to penetrate into the joint space and cause more stagnation. If there is significant heat coming off the wounded area, then cold-natured herbs can be employed. This helps to reduce the heat signs without adversely affecting the temperature and blood flow. A no-ice strategy is also appropriate for post-game rehabilitation. Liniments and poultices have been used for centuries by martial artists in the course of their training.
Because there is not an acupuncturist on the sideline (yet!), let’s assume the acupuncture treatment would come hours or days after the initial injury. This is typically the case with my non-athlete sports/orthopedic injury patients, too. At that point, the swelling should be somewhat controlled, whether ice or herbal therapies have been used, and bruising should be evident if the injury is severe enough. The same principles apply to the acupuncture treatment: invigorate blood flow to relieve pain and heal the tissue. In addition to identifying and needling the affected ligaments and associated acupuncture channels, acupuncture points specifically gear towards increasing tendon strength and flexibility would be used. I would also want to strengthen the body’s ability to create blood and various joint fluids to ensure that the tissues are well-nourished, moistened, and lubricated.
There are various food therapy options as well to ensure tendon and ligament strength and elasticity. The best way to nourish the body’s vital substances is to use a substance – ingest something – to refill the reservoir. If you need protein, eat protein. If the body needs more blood, eat foods that engender blood: meats, red-colored fruits and vegetables, dark, leafy greens, etc. The choice herbal formula for this condition is called Yi Guan Jian, which means “Linking Decoction” referring to it’s ability to treat all the connective tissue that links the body together. I personally use it for rehabbing sports injuries but also preventing injury in patients who are very active or undergoing training regiments. I would love to see the whole team on this formula to protect against and minimize injuries.
Depending on the stage of the sprain, the recovery time can be anywhere from days to weeks. A tear that requires surgery will obviously take longer – weeks to months. It’s sounding like this is significant enough that the coaching staff isn’t ready to discuss time tables, so I’d wager we’re looking at several weeks before Greenard is fully healed. Wrist and hand injuries tend to take longer in my experience because it’s difficult to isolate affected tissues. There will be some soreness for a while to work through. Take it one day at a time, Jon, and get well soon!