The First 96 Hours.. One Word Ouch!!!

Wednesday, July 20th, 2011 At 6:31 pm

Day One:

Immediately I jump to my feet and do a quick scan of my body.  Everything was where it should be.  I thought to myself, “Hey, I am OK.  I should be able to work tonight, because I have a full schedule.  Heck, I should be able to do anther lap.”  This time the voice of denial, which is a close cousin of optimism, was overshadowed by the voice of reason and his brother reality.   The right shoulder and elbow began to ache.  I picked up my bike and began the long walk of shame home.

It really is amazing how the human brain and body works.  That seemingly limitless energy I had only minutes ago, is now gone,  and I was working on the reserve tank.  My son, Johnny, will tell you when the gas gauge says empty, you still have at least one more gallon left. (This knowledge will come in handy when he is a teenager driving home from school.)  As I walked the mile or so home, I considered all the things I must do to prepare the business and family for an injured Dr. John Doepper/Dad.  I wish I could remember everything I considered.  (I think I solved the federal debt crisis, I just cannot remember the plan!).  I went from a brief moment of despair and the old “Why did this have to happen”, to a moment of “I am extremely lucky, I could have really been badly hurt”.  I am awake, coherent, and walking with my bike home.  I have an amazing work environment with talented professionals who will easily take over my responsibilities to insure the quality of care we strive for at Capitol Rehab for our patients.

And, my amazing wife will not only take care of the daily responsibilities, but is also not afraid to mow the lawn.  So I made it home and called Michelle.  My only fear was to break the  news to my children.  Nicole, my daughter, answered the phone.  ” Nicole, I am sorry, but I have some bad news.  You and Johnny have to come home, you cannot go to Chuck E. Cheeses today.”  Surprisingly they handled it well.  “Oh, and by the way, Daddy fell off his bike…but is OK”.

Now I have to take care of the injury.  I decided I did not have to go to Urgent Care or the Emergency Room.  I am not bleeding to death, do not require emergency surgery, and do not have any head trauma. The limited time these life saving doctors have should be reserved for those in need of their expertise.  Besides, I knew I would wait 4 hours to have them X-ray my arm and tell me I need to see an orthopedist.  I waited until the next day to be referred for the X-ray and consulted with an orthopedic surgeon to review said X-ray.

So I applied Basic Orthopedic Rehab Procedures 101, also known as RICE.  Rest, Ice, Compress, and Elevate.  This mnemonic is extremely important in the acute phase of treatment and is based on the basic understanding of the phases of healing.  Chiropractic and Physical Therapy is applied to help promote these phases and is important to understand.  So I will break them down.

Phases of Healing

Acute Phase:

This is what happens immediately after the injury to about 72 hours later:  An inflammatory response that causes swelling, redness and warmth around the injured area.  This is your body’s way of protecting itself.  The swelling causes stabilization in the area and brings healing properties to the injured area.  This is why my arm started to stiffen up quickly and why it would not move.   The area gets warmer because blood is being pooled in the area.  This blood brings those healing properties that kill any bacteria and remove any debris that is building up.  So swelling is very important.  But equally important is to help swelling move in and out.  Thus, the Ice and Elevation.  Ice causes a vasoconstriction that slows excessive swelling, followed by a vasodilation that then increases the flow.  But this flow is more controlled.  Swelling is like water, it is essential for life.  But as any resident of Sioux City, Iowa that has had to sit back and watch the Missouri River engulf their town will attest, too much water is not always a good thing.  Excessive swelling, and stagnant swelling, can actually break down healthy tissue. During the acute phase I recommend RICE.  Ice in 15 minute increments, 3-6 times per day, immobilize the area, rest, and elevate when possible.  I did all this and used a sling for the first 48-72 hours.

After 48 hours, I removed the sling and switched to a compression sleeve.  I generally recommend my patients keep it in a sling for up to 2-4 weeks, but I am being aggressive.  Old school would immobilize for 6 weeks.  This is a safe way to eliminate re-injury or exasperate the current injury.  But, realize, by immobilizing, you are slowing down the movement of swelling in the joint and, just as the rising Missouri River, increase the time it will take to recover.  There is a fine line between too much movement and not enough after 72 hours.  So for patients I recommend the bracing for a week up to 4 weeks, based on the severity of the injury.  However, I do recommend they start therapy after 72 hours to help the transition from the acute phase to Phase 2: Regeneration Phase.  There is tons of literature showing early passive motion is one of the best therapeutic interventions that can be taken early after the injury.  It is essential your Doctor refer you for Therapy.

*On a side note.  I did have an Orthopedist review my X-ray and inform me it was stable.  He further advised that I did not need a cast or surgery.  This is an important note because immobilization is essential to allow an unstable fracture to heal.  So, just as I did, check with an orthopedist to make sure you are stable, do not require surgery, and do not have the type of fracture that will require long term immobilization.  Once the facts are established, then that is when your Physical Therapist, like we have here at Capitol Rehab, comes in.

Repair Phase (Regeneration) (72 hours to 6 weeks)

This is when the inflammation has gone down and your body begins to repair the injured area.  Your body will begin to lay down collagen to replace the damaged tissue structure.  Oxygen and vitamin C are necessary to aide in the collagen formation.  I provide my patients with Electrical Stimulation and Ultrasound, which will help promote the circulation.  I also apply light myofascial release (specific massage) to help this collagen formation and improve Lymph drainage.  Easy pain free movement, perhaps only passive during this period, is essential.  I visited Mike Gerometta, Garrett Sanders, DPT and Dr. Ricci, at my clinic at 48, 72 and 96 hours for this care.  The structure of the collagen is unorganized at this point.  Or as I tell people, clumped up. The myofascial work and supervised, almost pain free exercise,  promotes better formation.  I see patients 3 times per week for the first 3 weeks.

Remodeling Phase (3 weeks up to one year)

Once the collagen has been regenerated in the second phase of healing, it is weak and disorganized.  The collagen is similar to sticky glue at first.  It needs to be molded in certain alignments so it is able to perform the functional capabilities of the tissue it is replacing.  During this phase you may feel pretty good and perhaps be virtually pain free.  Don’t be fooled!  Do not let pain be your only guide.  This phase is largely one of an improvement in the quality, orientation and tensile strength of the collagen. It is during this phase we increase the amount of very specific exercise to help create strong and functional tissue.  This is essential to prevent weakness, chronicity and compensatory injuries.  Generally care is reduced to twice a week and more home exercises are incorporated.

First 96 Hours

Pain: 4/10 with spikes of 9/10

Swelling: Severe at 24-48 hours moderate at 72 hours

Prognosis: Guarded

Days 5-7:  Tomorrow’s Topic: A visit to the orthopedist and my aching back!

Top 5 Runners Injuries AKA The Big 5

Monday, March 15th, 2010 At 2:17 pm

The days are warmer and the birds are back.  It is actually light when I get home from work.  What does this mean? For me it means running season.  The 5ks, 10ks, and marathons are all scheduled.

Don’t let the possibilities of running injuries stop you from all the fun! Here are the 5 most common runners injuries  AKA *The Big 5* to watch for:

1. Runners Knee/Chondromalacia Patella
   This is pain under and around the knee cap due to improper tracking  between the condyles of the knee.  It causes wearing of the underside of the knee cap and often leads to disorders of the knee such as tendonitis and other inflammatory disorders.
2. Plantar Fascitis
   This is an inflammatory disorder of the plantar fascia.  The plantar fascia is a band of tissue, much like a tendon, that runs from your heel to the ball of your foot.  A common complaint is pain upon waking in the morning.  Patients report the first few steps are very painful. It is also aggravated after running, walking, or standing for long times.
3. IT Band Syndrome
   This is also an inflammatory disorder of the a tendon that runs from your hip to your knee. It commonly cause hip and knee pain. If you’ve had this one you know how painful it can be.
4. Achilles Tendonitis
   This is inflammation of the achilles tendon.  The achilles tendon connects the calf to the heel. I commonly find this Inflammatory disorder with plantar fascitis.  Inflammation weakens connective tissue and can lead to achilles rupture.  Not good!
5. Shin Splints
   Generally it is inflammation of the posterior muscles behind the shin bone. It is caused by improper foot mechanics. Other muscles around the shin may also be affected such as the anterior tibialis muscles.

Do you notice a pattern here?

The common denominator is inflammation. Commonly Doctors are quite familiar with this pattern and treat the inflammation through rest, immobilization and NSAIDs ( non-steroidal anti-inflammatories).  If this does not work many times they do use cortisone through injections.

Why is this not enough?

That is because every condition that was described above is simply an explanation of the symptoms.  They are all describing the result of injury and the course of treatment only addressed the symptoms.  Little or no attention was put into the “cause” of the problem.

If the doctor or patient are pro-active they may seek out physical therapy.  A successful plan of therapy will address the actual cause of the symptoms not just the resultant symptoms.