“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.”)
Well, the good news is that there hadn’t been a significant injury on the basketball team in nearly four months. The bad news is that this time the affected player is our most consistent and perhaps best all-around player: Ray Spalding.
Ray Spalding appeared to injure his leg in the second half of February 3rd’s game against Florida State. He received some treatment on the sideline before returning to the court briefly, but he was not able to finish the game.
At this time, all we know is that Spalding has a sprained ankle and is listed as day-to-day. Diagnosis is typically done by physical exam or X-ray.
Symptoms and Anatomy
Typical symptoms of an ankle sprain are pain and weakness of the joint with difficulty standing, as well as swelling and potentially bruising. Lateral ankle sprains are the most common; this occurs when the foot is inverted causing the ankle to roll outward. This over-stretches and tears the outer (lateral) ligaments. Usually the calcaneofibular ligament is most affected, but the anterior talofibular ligament can become injured as well. Medial ankle sprains are less common, but they can occur especially if there is contact and weight near the ankle. When the ankle rolls inward, the deltoid ligament (which is the confluence of three individual ligaments) is injured. High ankle sprains are usually identified as such, but in those cases, the injury is to the anterior inferior tibio-fibular ligament and surrounding tissue.
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 ankles and other ligaments are never quite the same after healing.
Typically, the RICE protocol is utilized – rest, ice, compression, elevation. The goal is to reduce swelling and pain and take weight off the ankle to allow it to heal on its own. Pain medication may be prescribed, and physical therapy is often appropriate to ensure balance, proprioception, and flexibility return. Severe tearing generally requires surgery.
Dr. Colby’s Treatment
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. The good news is that Ray’s initial prognosis is day-to-day, meaning it is likely not severe enough to expect him to miss weeks of practice. While we would love to see him tomorrow against Syracuse, I know Fred Hina won’t let him play before he is ready. Get well soon, Ray!