LIgament/Tendon Injuries & Injection Techniques
Ligament Injuries
People usually seek out my services for chronic symptoms after trying other treatment approaches, often with limited success. For many of these clients with chronic symptoms I began to see a reoccurring pattern: muscle weakness/pain, poor joint control/stability, poor proprioception (balance, coordination, "muscle awareness" ) as well as muscle tightness and/or excessive joint mobility. Coincidentally, I have also experienced similar deficits with my own injury history. Through my research, experience and observation I've concluded that injuries to ligaments often produce multiple, functional deficits and symptoms, and if left untreated can lead to chronic pain, disability and poor athletic performance.
Anatomy of a Ligament
Basic anatomy teaches that ligaments are tough, dense fibrous structures that bind bones together, yet allow for joint translation. When ligaments are injured - stretched primarily, they do not return to their original length - they lose their structural integrity. Since they are so dense, blood supply necessary for healing isn't always adequate. This means a joint that was once stable and mobile now has excessive movement and this excessive movement leads to multiple symptoms.
To understand this in simple terms think of any moving, mechanical component like hinges on a door or the steering mechanism in your car. Proper functioning of these components is dependant on exact fitting tolerances that allow good mobility between the pieces (joint). If there is excessive joint movement (poor fitting tolerances) the forces acting on the joint will not be properly dissipated or transferred, instead the joint will eventually break down from excessive movement between the parts. In other words the door will no longer open or shut right and your car won't travel in a straight line.
Unlike a car your body has a complex communication network in your nervous system. With the injured ligaments and excessive joint forces your nervous system responds by sending pain signals from the injured ligaments and joint stresses, triggering muscle tightness which can be a compensatory response for the lack of joint integrity. The most significant issue I see is muscle function is inhibited leading to weakness, atrophy and poor joint control. This process unfortuantely reinforces the vicious cycle of continued ligament stress and joint degeneration. This makes sense from a practical standpoint however. It would not be safe for you to drive your car fast or on a twisting road if your steering mechanism was damaged and loose. The body shuts down muscle function as a way of preserving and protecting itself from future injury by limiting how much force your muscles can generate. This is why ligament injuries are so devastating to athletes who require maximal exertion, joint control and endurance.
The Injury Process
So how do these injuries happen? Most often it is an acute, traumatic episode like a fall, car accident or sports injury where ligaments/joints undergo excessive force that stretches them beyond their elastic tolerance. The other scenario is a repetitive strain type of injury like poor postural habits where progressive joint forces over time lead to lengthened ligaments. People that practice stretching exercises like yoga, gymnastics and dance are more susceptible to injuring ligaments. There are genetic and constitutional predispositions as well. Women are generally more flexible and have less muscle mass than men. Women also have hormones that effect ligament tension (SI joint pain being common for pregnant women as the result of ligament relaxation and the added stresses of carrying a fetus.)Young adults and children are generally "looser" and some people are just born with more joint mobility.
Ligament Injury Diagnosis & Rehab
The difficulty with treating these injuries first of all lies in the fact that minor to moderately severe ligament injuries are not easily identified with diagnostic equipment or appreciated by many health care providers as a significant component in muscluloskeletal pain scenarios. Treating ligament injuries with manual therapy techniques such as joint mobilization will be marginally successful without a rigorous exercise program. Chiropractors traditionally treat joint subluxation - joint misalignment by manipulating joints back into "proper" alignment. Ligaments are the primary restraint to joint movement and position. As stated above joint position is dependant on ligament tension, muscle function and nervous system function. A joint will not stay in proper alignment without addressing these multiple factors.
My Approach to Ligament Injuries
In my practice I place great emphasis on assessment techniques that determine ligament, joint, muscle and nervous system function. My treatment approach utilizing manual therapy, movement reeducation, body awareness and exercise can be effective in treating ligament injuries. However, considering the insidious nature of the injury process it can take a very motivated individual (athlete) a long time to see significant improvement on more severe cases. And then there needs to be consistent, diligent efforts made to maintain whatever level of function has been attained. It is a constant effort fighting against the body's inherent nervous system response to shut down function. My frustration with the lack of significant progress with these cases has led me to consider the role of ligament/tendon injections as an aid in accelerating recovery from these injuries.
SI Joint Ligament Referral Pain Patterns
This illustration shows the diverse symptom presentation from an injury to the various pelvic ligament structures. It is no wonder that SI jpoint injuries manefest as complex, regional symptoms and dysfunction. It is important to note that the site of referral is also the site of a pain experience which is often quite distant from the original locus of injury. The referrred pain will also cause secondary disfunction in the muscles and area of referral which in turn leads to altered movement patterns. It is quite common for someone with an SIJ injury to also have calf, foot pain and faulty foot mechanics (hyper pronation). In this chart notice how the SIJ ligaments refer to the calf and plantar surface of the foot.
Injection Techniques
Below are a few injection techniques utilized for soft tissue injury and healing. What I find promising about these techniques is that they are specific to the site of injury. Ligaments can be massaged (superficial ones) and manipulated through joint movement or stabilized through exercise but if the ligaments are injured these techniques do not trigger enough of a healing response. And in the case of joint manipulation, the risk is that the joint will continue to be hypermobile due to continual joint manipulation. Both prolotherapy and plasma rich platelet injections are relatively benign substances that have small risks associated with the procedure.
These injections are not magic bullets.The medical science community has both pro and con opinions and research regarding these techniques. My opinion is that all injuries have multiple factors and appropriate therapy should include addressing as many of these factors as possible. The ultimate success of these techniques depends on many factors: location and severity of injury, diet and lifestyle factors, as well as how the whole injury/treatment process is managed through ergonomic aids, activity modification and exercise. My motto is to treat the whole person not just the site of pain.
Steroids
Cortisone injected into joints is a common treatment approach for joint pain. Cortisone is an anti - inflammatory medication and it is helpful in reducing pain and increasing range of motion when the primary pain generator is inflammation. Cortisone is not as effective at treating mechanical pain - pain associated with aberrant joint movement (posture/alignment) and associated soft tissue stresses related to joint alignment. For this reason cortisone injections into the SI joint for example, typically provides short term relief since the primary pain generator in SI joint pain is due to ligament injury and aberrant joint mechanics and not inflammation.
It is common knowledge to apply ice to injuries and to administer anti - inflammatory pain medication for almost all experiences of physical discomfort. Applying ice after ankle sprains and tendon pain (tendonitis) are examples. There is a growing body of research and information however that is critical of this practice. Instead of creating a positive, supportive role in soft tissue healing, the excessive use of ice and anti - inflammatory medication has been shown to inhibit soft tissue healing. This makes sense since inflammation is the bodies natural healing response, inhibiting this natural reaction seems counter intuitive.
The frequency of cortisone injections: how many injections per year and how many times administered into the same site is also a controversial matter. There are studies that show too many cortisone injections can damage soft tissue like articular cartilage, possibly leading to long term degenerative changes (arthritis).
Prolotherapy
Prolotherapy involves injecting the injured tendon/ligament or other soft tissue with a dextrose solution which in turn triggers a local inflammatory reaction. Healing of the injured tissue is facilitated by promoting growth factors.
My own experience with prolotherapy
I received prolotherapy injections for my own ligament injuries: AC (shoulder), medial collateral ligament/MCL (knee) and sacroiliac ligaments. The knee and SI joint were old/chronic injures and both were in pretty stable condition. The AC injury was more acute though it was several months since onset (weight lifting, bench pressing with moderate weight,). I did not experience significant pain in the AC or SI area post injection. My theory was that these joint have very little mobility and were doing well to begin with. The MCL injections did produce sharp pain and stiffness in knee range of motion that lasted 48hrs. The knee is a very mobile joint so the stiffness seemed normal/appropriate.
After several months post injections these areas were functioning well with limited pain. I am still extremely diligent about performing stabilization exercises for all these joints however. I can still trigger pain in these ligaments if I overdo certain exercises or if I am not diligent about maintaining excellent biomechanics/joint alignment. For instance I am very cautious about my running form and how my foot strikes. A little bit of pronation, knee adduction or pelvic drop can stimulate pain in my medial collateral ligament (knee). While cycling I have to be careful about how much force I exert on the pedals particularly while climbing/hard efforts. I have learned how to perform an abdominal brace while keeping my back very straight (multifidus, erector spinae activation), I also utilize my hamstrings to pull on the pedal versus strictly pushing. Little changes in muscle activation can play a significant role in symptom reduction and improved function.
I would pursue prolotherapy again as part of my injury management strategy if I (re)injured my ligaments.
Links
This web site has good, basic information about prolotherapy.
www.prolotherapy.com
This article was the cover story of BioMechanics magazine
Sweet Relief Prolotherapy
This website has an incredible wealth of information about SI joint injuries and related treatments in pdf format. http://www.kalindra.com/sacroiliac2.htm
Platelet Rich Plasma Injections
With this procedure your own blood is drawn and spun in a centrifuge to separate the plasma from the white and red blood cells. This plasma is then injected into the site of injury. Similar to prolotherapy growth factors are stimulated to heal and repair damaged tissue. This is a new procedure to me and I do not have any experience with it nor do I know anyone who has directly experienced it. An internet search will turn up quite a bit of information .
Tendonitis or Tendonosis?
For years I treated, with limited success, what I thought was tendonitis using a standard protocol of massage, rest and stretching. My own experience with lateral elbow pain convinced me that inflammation could not be the main issue since ice, acupuncture and rest did little to alleviate my longstanding symptoms. Even basic rehab literature says inflammation from injured soft tissues is generally short lived. So why does tendon pain persist so long if it is not caused by inflammation?
Inflammation is a key component of acute injury scenarios and the initial stages of injury healing. If the injury is a mild or moderate sprain/strain to soft tissues the inflammatory phase lasts about 1 - 2 weeks. During this time scar tissue forms and continues to become thicker and stronger over time, effectively repairing and replacing the damaged tissues.
Recent research has shown that longstanding tendon pain may
not inflammatory in nature. Progressive micro trauma and a failed healing
scenario can lead to a degenerative tendon process termed tendonosis.
Since the pain and limited joint mobility and strength is from tendon
damage and degeneration, treatment protocols that encourage rest, ice
and anti inflammatory medications will be marginally successful.
Eccentric Exercise
New research is advocating a specific exercise protocol that includes eccentric strengthening exercises to stimulate tissue repair and strengthen the tendon. Eccentric exercise means that during the lifting of a weight the focus is on slowly lowering the weight down.This lowering phase places significant stress on the muscle/tendon unit because they are lengthening under load. This treatment approach goes against the old saying "No pain, no gain" since the exercises specifically target injured tissue with the goal of making them more resilient, stronger. Exercising into a painful area may seem counter intuitive to many but the treatment protocol works for not only tendonopathies but for muscle strains and ligament sprains where a focused bout of exercise stimulates repair and increase overall comfort.
For more information about tendonosis check out this web site: http://www.tendinosis.org
