Monday, November 20, 2006

Will you have R.I.C.E. or M.E.A.T. with that injury?

This isn't about diet. It is about what to do when injured. That's an important subject for me right now because I injured my right knee. But isn't racewalking an injury free sport? Says who? Maybe injuries aren't as common as in other sports but they do happen.

So--what to do about this sore knee?

R.I.C.E. stands for Rest, Ice, Compression and Elevation. This is probably the most widely known injury treatment. It starts out with as much rest as possible. Next, put something really cold on the sore knee. What that does is make the blood flow away from the injury and numbs the nerves in that area. Compression, like wrapping up the knee, gives it some support and also constricts blood flow. Elevating is also perscribed to keep the blood from pooling around the injury. So it looks like the main thrust of this treatment is to take it easy and stop the blood flow.

M.E.A.T. is for Movement, Exercise, Analgesics and Treatment. I just found out about this when searching around the Internet on the Caring Medical & Rehabilitation Services website. (By the way, while I find some of their work provocative some of it like Prolotherapy and the Hauser diet looks suspect to me.) It isn't something totally new to me, when I had my knees looked at by Dr. Robert Klapper I was introduced to his book, "Heal Your Knees," and he perscribes exercise as a way to prevent or at least postphone surgery. Movement and exercise don't mean to keep doing what got you injured in the first place, it means keep active. Dr. Klapper recommended that I cross train. This morning I rode around on my bicycle and my knee was fine--until I got off the bike that is. I also did the stretching exercises and that went fine. Tomorrow I plan to do strength training. In other words, I'm continuing with all activities except for racewalking until my knee stops hurting. I'll get back to analgesics for a moment and get into the treatment. My self-diagnosis is that I stressed my ligaments and caused some tearing. In order to the body to rebuild these tears it needs a good blood supply--wait, that's the opposite of what R.I.C.E. is doing. In order to try this out I ran to the pharmacy and bought a heating pad with vibrating massage action. It sure feels better than a bag of ice on my knee!

Oh, and one treatment to avoid if at all possible is cortisone shots. That's the first thing Dr. Klapper told me when he found out I was there with sore knees.

Now what about analgesics? The most common pain reliever for knee injuries seems to be ibuprofen and that's exactly the type of medication that is not recommended in the documents I've been reading. Here's what is on the Caring Medical website has about pain relievers:
Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit for soft tissue sports injuries, both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.

If that isn't scary enough, here is an excerpt from a USA Track and Field document called Fluids On Race Day:
Recent medical research has shown that non-steroidal anti-inflammatories (NSAIDs) like Advil, Motrin, Aleve, ibuprofen, naproxen, etc. may be harmful to runners' kidney function if taken within 24 hours of running; acetaminophen (Tylenol®) has been shown to be safe. These NSAIDs are thought to increase the possibility of hyponatremia while running long distances due to their decreasing blood flow to the kidneys and interfering with a hormone that helps the body retain salt. Therefore it is recommended that on race day (specifically beginning midnight before you run) you do not use anything but acetaminophen (Tylenol®) if needed until 6 hours after you have finished the race, are able to drink without any nausea or vomiting, have urinated once, and feel physically and mentally back to normal. Then, an NSAID would be of benefit in preventing post-event muscle soreness.

And to think I was popping ibuprofen pills and the slightest tinge of pain. Acetaminophen isn't giving me the strong pain relief that I was getting from ibuprofen but I'm going to stay on this new course and hopefully my knee will repair itself stronger this time.

In the meantime, I'm not doing any racewalking--hopefully for just a little while.

Here is the entire text of the MEAT vs. RICE Treatment article and here is the science that supports it.
MEAT vs. RICE Treatment
Traditional modern medical treatment for acute injuries, such as those that occur during active sports, usually receive the RICE protocol. In fact, it’s become a standard for sports injuries and pain management. RICE, by the way, stands for Rest, Ice, Compression and Elevation. A “P” is occasionally added to the equation. It stands for Protection, and consists of bracing or taping the area. In addition, most injured individuals are also encouraged to take anti-inflammatory medications. Unfortunately, in order to help heal injured ligaments and tendons, there couldn’t be a worse approach. Read on to find out how the RICE protocol came about, why it’s counterproductive to healing and why the MEAT (Movement, Exercise, Analgesics and Treatments) protocol is the best way to heal weakened and injured ligaments and tendons.


The RICE protocol
Ligament sprains are often accompanied by quite a bit of painful swelling, also called edema. A key premise of the RICE treatment is that this swelling is harmful to the tissue and needs to be minimized. In fact, sports medicine specialists and athletic trainers have fallen into the trap that muscles are like tendons and that tendons are like ligaments. Yet that couldn’t be further from the truth. Understanding the difference between ligaments and muscles is crucial to understanding why the RICE treatment is totally inappropriate for healing tendons and ligaments.


Muscles, because of their good circulation, heal quickly and rarely cause a long-term problem, whereas ligaments, due to their poor blood supply, often heal incompletely and are the cause of most chronic sports injuries and pain. And while the accumulation of fluids, or edema, can in fact be harmful to muscles in the form of compartment syndrome, this does not apply to ligament and tendon injuries. Compartment syndrome occurs when swelling due to an injury places pressure on the muscle tissue, which decreases circulation and healing, which cause further swelling due to fluid accumulation, which decreases healing even more. This vicious cycle can lead to permanent muscle, nerve or circulation damage, which is why the RICE treatment has become an established protocol for muscle injuries, but unfortunately has inappropriately been applied to ligament injuries as well, which operate under an entirely different set of circumstances.

Ligaments are the small and mighty bone binders – they bind together bones at the joints. They are made of collagen, one of the strongest substances in the human body. Ligaments normally receive blood vessels from small arterial plexuses from the joints, but they themselves have essentially no blood vessels. If the blood vessels from the small arterial plexuses are sheared as the result of an injury, the limited blood supply that ligaments get is completely cut off. Furthermore, the blood supply to the ligaments is the poorest at the point where the ligament attaches to the bone, called the fibro-osseous junction. This point is also the weak link in the ligament-bone complex, and the area most commonly injured during sports and responsible for most lingering sports injuries. And this is the exact site where Prolotherapy is administered! But we’re getting ahead of ourselves. Let’s briefly review why the RICE protocol is inappropriate for ligaments.

Why RICE prevents healing
All of the components of RICE – rest, ice, compression and elevation – are designed to decrease swelling, and pain, by decreasing the circulation to the area, which is exactly what ligaments need to heal faster. Rest, compression and elevation, that is, immobilization, is extremely detrimental to joints and ligaments. It lowers the metabolic rate in the area. Ligaments heal slowly by nature, and they take twice as long to heal if immobilized. The fibro-osseous junction, the principal site of Prolotherapy treatments, heals even more slowly. Ice has a similar effect. And while lowering the temperature of an area is critical for certain surgeries and limb-salvage operations, where a lowered metabolism can mean the difference between success and failure, this is not so for injured ligaments. Ice leads to lower temperatures, which leads to lower metabolism, which leads to slower healing! And to make matters worse, injured athletes often continue their activities after getting “relief” from RICE, making themselves susceptible to further injury. Here’s why. The colder a ligament, the less force is needed to deform it, which is one of the reasons many athletic injuries occur in cold weather. In summary, anything that decreases the metabolic rate or blood supply to ligaments, such as rest, immobilization and ice, will further promote the decline of the ligaments, and profoundly delay their healing.


The MEAT protocol, and why it promotes healing
The more conservative, and effective, treatment for acute injuries to ligaments and tendons is the MEAT protocol. As mentioned earlier, MEAT stands for movement, exercise, analgesics and treatment. While immobility is detrimental to soft tissue healing, movement is beneficial because it improves blood flow to the injured area, removing debris. One of the effects of movement is the generation of heat, which increases blood flow. This is why the application of heat is also recommended for ligament and tendon injuries. Gentle range-of-motion exercises also help improve blood flow to the injured area. Natural analgesics, or painkillers, such as proteolytic enzymes, which break down proteins, aid soft tissue healing by reducing the viscosity, or stickiness, of the extracellular fluid. Examples include bromelain (from pineapple), trypsin, chymotrypsin and papain (from papaya). Reduced viscosity of the extracellular fluid in turn increases nutrient and waste transport from the injured site, reducing swelling, or edema. In other words, natural analgesics decrease the painful swelling of soft-tissue injuries but do not stop the natural inflammatory reactions that lead to healing, unlike anti-inflammatories, which can actually hinder healing. Narcotics such as codeine may also be prescribed short term for very painful injuries. In the short term, they are very helpful because they relieve pain without interfering with the natural healing mechanisms of the body. In fact, our bodies produce our own narcotic, called endorphins, which are released in response to an acute injury to reduce pain. Other options for pain control include pain relievers that are not synthetic anti-inflammatories, such as Tylenol or Ultram. They help relieve pain without decreasing inflammation, a critical part of the soft-tissue healing process.


And finally, treatments are used to increase blood flow and immune cell migration to the injured area that will assist ligament and tendon healing. Treatments include physical therapy, massage, chiropractic care, ultrasound, myofascial release and electrical stimulation. All improve blood flow and help soft tissue to heal. If the treatment has not healed within 6 weeks, more aggressive treatments, including Prolotherapy, should be considered. Of course if time is of the essence, Prolotherapy is quite effective as an initial treatment for acute pain, particularly in the case of acute sports injuries. In summary, the MEAT protocol is more effective and expedient than the RICE protocol when it comes to healing ligament and tendon injuries.

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