Sprains and Strains In 1994, on a September hunt in the Alaskan peninsula for Barren Ground Caribou, Dr. Greg Bonham, a good friend of ours, found himself sharing a spike camp with me. This was first of many successful hunts with Mr. Phil Shoemaker and his lovely wife Rocky who are the owners of Grizzly Skins of Alaska (GRIZSKINS@ATT.NET). The scenery was fantastic when the less then desirable weather cleared. Each morning after a quick breakfast we would cross some open tundra in our hip waders and begin our ascent up one of the shale covered mountains which surrounded us and start glassing. Frequent rain, coupled with loose shale and steep angles, present the ever present danger of an unexpected fall. Unfortunately, Dr. Bonham with rifle in hand and loaded with a full frame pack became the other guy enduring a fall down a steep fifteen foot embankment. After our guide and I reached him, we were relieved to find all of his extremities pointing in the correct position with no new bends and angles. We helped him to his feet only to find that he had a lot of discomfort in his right knee when bending it or putting weight on it. So after sitting him back down, I examined his knee. Luckily, all four ligaments were intact. Next order of business was to breakout the rudimentary emergency medical supplies in which a large elastic Ace bandage had been packed. The plan was to wrap his knee securely, offload all his gear out of his frame and pack it into ours. We would carry his rifle for him, cut him the thickest and straightest alder branch we could find for him to use as a cane and proceed back to camp for him to put his leg up. There he could rest and take some medication. Well, being Dr. Bonham, he agreed to all of it with exception of us carrying his gun and going back to camp. He insisted we continue on with the hunt, unloaded his gun and used it as a cane. He hobbled up and down those mountains with a swollen, painful knee, not only the rest of that day but for three more days all the while we carried all his gear in our packs. That made for some heavy packs because one never travels on foot in Alaska without everything you need to stay over night a few days since a serious storm can blow in without warning and frequently does. Undiscouraged, the fourth day of the hunt found us up the steep side of one mountain facing the equally steep side of another mountain that laid across a deep ½ mile wide canyon. Low and behold there was his bull across the canyon, a monarch of a caribou tending to his harem. How to get to them was now the question as they were slowly feeding along the bottom 1/3rd of the facing hillside. We would have to quickly descend down this mountain, cross a gorge and rapidly ascend the other side to be able to get in position to get a shot before the caribou walked off. This was a daunting physical challenge for anyone with all his extremities in good shape let alone someone with a bum right leg. After discussing the only plan, Dr. Bonham got up and headed downhill in full stride, full of determination, adrenaline and motrin. Not only did we make it down and across the canyon gorge but we motivated our carcasses up the other side in record time. With just a few seconds to spare, the massive bull and his harem appeared on a flat in front of us. Dr. Bonham, wasting no time, downed him with one shot. After the celebration and pictures, came quartering and skinning of the animal. The miraculous healing of Dr. Bonham’s right knee had occurred and so we packed all three frame packs for the hike out. But, as soon as he got under his loaded frame pack, the pain and inability to bend it came rushing back. Now it was back to the same old thing, our guide and me with now two extra heavy packs to hike out. All ended well though. Greg took a great caribou under difficult circumstances and I was successful the next day on a near B&C record book caribou. Thankfully, Dr. Greg Bonham who happens to be a well respected chiropractor here in Columbia, S.C., made a full recovery and continues to hunt with us to this day. Sprains and strains are very common injuries that occur from the physical stresses placed on the skeletal system from trauma, unsteady footing, slips, and awkward or too heavy lifting. Let’s start with definitions. Tendons are fibrous tissue that connects muscle to bone. Ligaments are fibrous tissue that connects bone to bone. A SPRAIN refers to the stretching or minor to moderate incomplete tears of ligaments. A STRAIN on the other hand refers to stretching or minor to moderate incomplete tears of tendons and muscles. The most common sprains and strains occur in the low back, ankles and knees so we will focus on these injuries. By far the most frequent sprain/strain type injury to the lower extremity is “twisting” one’s ankle. This is an actual sprain of the ligaments that connect the inside and outside end of the two long shin bones (tibia and fibula) to the bones on both sides of the foot. It occurs when we roll the foot over forcibly either to the inside (inversion – most common) or the outside (eversion). This stretches the taught ligament usually causing a disruption in its fibers (a tear). More rare and more severe sprains result from pulling part or even all of the ligaments attachment point (insertion) away from the bone. In either case, the result is immediate pain, difficulty weight bearing, and gradual swelling. Bruising is a sign of a more severe injury such as a significant tear or detachment from the bone. The treatment is simple and easy to do. First, minimize weight bearing, (easy since it hurts to bad to walk on anyway). Second, apply a cold compress and elevate the leg to reduce the swelling. This cold treatment is useful only for the first day or so. Third, wrap it securely with and Ace bandage to stabilize the ankle and/or splint it if needed. Forth, days to weeks later, do range of motion exercises with the ankle when healing permits you to do so. Fifth, wear some type of lace up boot to add support to the ankle when it heals enough to begin weight bearing. Six, let go of macho tendencies and use a cane/crutch if it is a significant injury. Common sense dictates that you avoid uneven surfaces, inclines as well as rapid steps until you are really good to go. Remember Murphy’s Law! – If it can happen it will and in this case to the same ankle. Now for the two golden questions we always get asked, One: How do I know if I need to see a doctor? Well, if your foot lies in a definitely abnormal position after the injury (i.e. you can see the bottom of your foot while your leg is pointing straight away from you), you need to seek professional medical care. Less extreme disruptions that require medical attention also result in an abnormal position of the foot as the structural integrity of the skeleton has been compromised. Two: How long will it take to heal? This answer is a little more complicated. When you strain a muscle (disrupt its fibers) it only takes a few days to heal satisfactorily but unfortunately, tendons and ligaments heal much slower, even from minor injuries. Take for example professional football players. If they break a bone early in the season, they will return to play that same year most of the time. If they strain a muscle they will be back playing within a week or two. But if they tear a ligament usually they are finished for the season despite aggressive rehabilitation two to three times per day. So expect it to heal slowly with the ability to walk on flat, even surfaces in a straight line being the first ambulatory function you will recover. Gradually this will expand into turning, followed by uneven surfaces and finally graded inclines. Overall, even with minor ankle strains it could take a few months to regain total function. The knee, although a much bigger and stronger joint, is still susceptible to injuries but usually requires more then a simple twist to injure it. The knee, believe it or not, only has four ligaments compared to scores in the foot. It has one ligament on the inside (MCL – Medial Collateral ligament), one on the outside (LCL – Lateral Collateral ligament) and the two in the middle well known as the ACL (Anterior Cruciate ligament) and the PCL (Posterior Cruciate ligament). Each ligament functions to prevent your knee from bending in any other direction that you normally do not see it in. Significant twisting or forcible hyperextension/flexion injuries can sprain one or more of the knee’s ligament as well as injure the cartilage (meniscus) within the joint. So, as with the ankle, after a significant sprain to the knee, the pain, swelling, limited mobility and/or bruising ensues. The treatment for a simple sprain of the knee is the same as the ankle with the exception that instead of a lace up boot to add stability, you can use any of the over-the-counter knee braces that help to stabilize it. The rate of healing is not much better then the ankle so expect a slow recovery. If you notice your lower leg has the ability to move in directions you were not able to do previously, you need to seek professional orthopedic care. This is a bad sign and suggests a complete tear or avulsion/detachment of one of the ligaments has occurred causing gross instability of the knee which may require surgical correction. If your knee becomes grossly swollen, that indicates a large fluid collection within the joint space most likely because of bleeding. In this case you also need to seek out professional help. The suggestion to seek professional help in the above two scenario’s is really almost a waste of ink because the pain you would be in would be all the motivation most need to find a doctor. Again, during the healing process be careful, remember Murphy’s law. Now onto low back sprains/strains. It is a daring exercise to attempt to condense all that has been researched on this subject, but here goes. Fortunately, without some kind of serious trauma, most low back pains come from strains of the muscles not sprains (ligamental injuries) and/or from an unexpected shift of a disc or one of the vertebral bodies (back bones) in relation to the next. All of which then causes the secondary muscle spasm, low back tightness, and pain experienced as a back strain. More complicated is pain radiating down the leg. This occurs if something has shifted and impinged one of the nerves that go into the leg. The most common one being the L5-S1 nerve, better known as the Sciatic nerve which travels down the back of the legs. Remember, if you have sharp or burning pain in your leg after you have “thrown” your back out, it simply means you have pinched that nerve at its origin in the low back (your brain tells you the pain is in your leg but there is really nothing the matter with your leg). Next, we can tell you that over 90% of new acute low back pains that we see in the office are not from people trying to lift up the back end of a car or perhaps a moose quarter. They occur when we go to bend in an awkward position to pick up a toothpick or some light weight object. What happens is that the unusual bending position causes something to shift (a disc or vertebral body) or a mild muscle strain (tear) occurs with the ensuing problems described above. That is why the correct lifting position stressed at all work places is important no matter what the weight that is being lifted. Obviously what works at work, is what works at play…Don’t be the other guy who hurt their back in the wilderness bending over to pick up a shell! Treatment obviously depends on the severity and type of injury. For a simply muscle strain (tear) which generally stiffens up slower and does not have pain radiating into the legs; rest, heat, over the counter anti-inflammatory medications (Advil, Motrin, Aleve) are primary. Medications for muscle spasm (some of which are available over the counter) are also helpful to aid in a quick recovery. Avoid cold compresses because it only increases muscle stiffness and tightness. This is the opposite of the advice given for sprains! If you felt/heard something “move”, with or without pain shooting into one or both of your legs, the likely problem is a disc or vertebral body shifted. This pain is immediate and contrasts to the more gradual onset of muscle strain type pain. Now, we know we are likely to lose our key to the medical society wash room, because medical doctors are supposed to dislike chiropractors and visa-versa but there have been many studies done showing that chiropractors are significantly more successful in treating this type of low back pain then physical therapy, primary care doctors or orthopedic doctors visits alone. We have had great success in referring these types of patients to good chiropractors. Sure there are bad chiropractors out there running all sorts of scams, but (and here goes the key for sure) there are loser medical doctors as well. Do you know what they call the fellow that graduates last in their medical school class? They call him doctor. So go to someone with a good reputation that will spend some time with you. The same type of medicines as listed above, heat, and rest in low back muscle strains are indicated here also. To prevent recurrence of disc or vertebral bodies from slipping out of place in the future, low back strengthening exercises should be begun regularly. This will strengthen and tighten the ligaments which in turn reduce the ability of the discs and vertebral bodies from shifting. Finally, in the case of trauma (i.e. falling off a ladder , off/out of a moving vehicle, down a mountain embankment) all bets are off and a full evaluation with X-rays and possibly an MRI are indicated before any type of self-directed treatment. Emergency evacuation with careful attention to not moving the head and neck are indicated and beyond the scope of this article. We hope this has been helpful. As always be safe and enjoy the outdoors.