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!

My Broken Arm

Tuesday, July 19th, 2011 At 12:52 pm

I was feeling so good that I decided to extend my normal bike workout form 2-3 laps to 5. My energy was so good I  decided to extend my course to also include a yet uncharted trail. Do you know when you are about to do something, and you hear that little voice whispering in your ear? This little voice was screaming at the top of its lungs, STOP!!!! But my energy and ego completely ignored the little guy who seemed to say to himself, “OK don’t listen to me, I am only omniscient”.

So instead, I increased my speed. I turned a sharp corner to see the trail as it takes a 90 degree turn. Essentially, I was running out of road but had plenty of speed. So reality hits. The svelte 25-year old triathlete, with cat-like reflexes I envisioned, transforms back to a 43-year old with the reflexes of a speedy snail.  My choice was to take a header into a tree or brake hard and do an awkward flip over the handlebars. I choose the latter. So here I am flying through the air like Wile E. Coyote after the Road Runner has removed the ACME rocket from beneath his legs. I land on my extended right arm and attempt a “graceful” tuck and roll. (Let’s just go with it for now).

I stood up and said to myself, I think I am alright. The only difference now is that little voice is now loud and clear. I have been treating orthopedic injuries for 15 years and I know what I probably did. You cannot catapult 210 lbs up into the air, and come down stiff-armed without some injury. I also felt the compression in my elbow and shoulder. I just hoped the damage was not a displaced fracture that would require a long term cast. I also know I should not try to diagnose myself.

So, to jump ahead a day, it turns out I have a compression fracture of my radial head (elbow) as well as excessive swelling in the elbow joint.  And a lot of soft tissue damage.  I also have a mild whiplash and a subluxed rib head. So much for the graceful tuck and roll.

I have decided to blog this event for the benefit of my patients. To share my experiences.  I want to document how I manage my injury and the benefits of rehabilitation through the stages of recovery. I will try to cover the most frequently asked questions such as; when to ice and when to heat, do I need an MRI? How long should I expect recovery to take? When do I start exercise? Should I brace or cast or not at all?

I welcome any questions you may have, and will keep you informed on a daily basis. Tomorrow, I will break down the first week from what I did immediately after the wreck, to my visit to the orthopedist today. I hope you find it interesting and I look forward to getting back to 100%.

John Doepper DC

The Best Exercise for Tennis Elbow

Monday, November 15th, 2010 At 9:47 pm

The season of golf & tennis has come to a close for many of you.  Some of you are very familiar with the  symptoms of Tennis Elbow (Lateral Epicondylitis by the medical profession).  This is a common condition when mild symptoms can be inconvenient but in severe cases, disabling.  It is usually caused by inflammation in the elbow, specifically at the point where the muscles controlling wrist extension and finger movements connect to the elbow.  This inflammation is due to overuse or a change in activity or intensity.  

As a rehabilitation specialist, I found that the best treatment for this is receiving specific myofascial release techniques to the lateral and medial elbow combined with eccentric loading exercise. (Specific massage by a trained professional)  This ”eccentric loading”  exercise is where the muscle and tendons acts as brakes, slowing or resisting a movement.  A recent study (at the Nicholas Institute of Sports Medicine and Athletic Trauma) found that lateral epicondylitis subjectively responded well with eccentric loading vs. placebo groups 76% vs. 14% respectively.   In other words, it can be helped with proper therapy and exercises.

Below is a video of my innovative “RELEE” exercise which stands for Reverse Eccentric Load Elbow Extensors. This is an example of one of the exercises we perform at our clinic.  These exercises along with manual and some passive modalities are very effective for our patients with this particular elbow pain.  You may need to watch it a few times to get it right – it is important to do each component correctly if you wish to be effective. 

2 times a day is a good start, as this gets easier you can slowly increase the number repetitions 12, then 15, then 20.

Start off slowly, you may be sore afterwards.  You should only increase the repetitions when you can do so with the same post exercise soreness that you had at the previous level. Just remember this exercise is not magic, pain relief won’t happen overnight, but it works effectively in conjunction with our myofascial release techniques.  

Mike Gerometta, MS, ATC/L, CSCS