The body’s soft connective tissues (such as muscles and ligaments) are generally exposed to stress throughout life. Such structures respond and adapt to the usual amount of stress exposure. Damage occurs when soft tissues are exposed to higher-than-usual stress levels. This can be a single, sudden, excessive stress, or it can be the result of repetitive stress to the muscle or ligament. In either case, the doctor of chiropractic must determine how the damage occurred, and then make appropriate recommendations (rehab following rest, for example) to help the body heal the injury and to prevent a recurrence.
Problems can also develop when these tissues are not exposed to sufficient regular stress to maintain functional health. It’s important to recognize that the soft tissues in the body are normally used in a range of intensity, and that categorizing a patient’s level of use helps in the planning of care and exercise regimens.
The Range of Soft Tissue Use
What we usually consider to be normal use is in the middle of the usage range. At one end is paralysis, where soft tissues are completely unused. Close to paralysis is immobilization, such as in use of a cast or bed rest. The difference between these is that paralysis lacks a neurological stimulus, called “tone,” which is present in immobilized (yet still neurologically intact) muscles and skeletal ligaments.1 Next is sedentarism, when the ligaments and muscles are used only minimally. This is also called the “disuse syndrome”.2 This condition is, unfortunately, becoming more common in all age groups in our rich, advanced society, which has so many labor-saving devices. Normal use can vary widely, but requires the intermittent and regular exercise and use of all muscles and ligaments. Those who are employed in active (often blue-collar) jobs and people who engage in regular, active recreational pursuits fall into the strenuous use category. And then there are the athletes, who are always trying to improve and push their limits by specifically building and strengthening their muscular and skeletal ligament tissues.3 Athletes are at the far end of the continuum, demonstrating the body’s response to progressive overload.
Damage through Overuse
The muscles and ligaments in any of the above categories can be overused and damaged. Less stress is needed to cause injury to tissues in the lower use end of the continuum. After several days of immobilization, or when someone has been on bed rest or is a couch potato, even mildly strenuous effort can be too much. Fitness protects from some injuries, especially overuse conditions of the spine. Athletes, who are regularly pushing their muscles and ligaments, are most likely to end up with either overuse or acute injuries. There are two major categories of excessive stress to ligaments and muscles—repetitive use (chronic, over time),4 and sudden injury (strain or sprain) with tissue tearing.
Repetitive overwhelm. When muscles and ligaments are stressed, they respond by repairing and strengthening. In some cases, however, the physical stress occurs so frequently that this process is overcome, resulting in damage. Examples include runners who quickly increase their mileage, workers who are placed in a new position which requires repetitive movement or bending, and athletes who practice throwing to the point that they injure their shoulders. Even someone taking up walking after years of standing on rigid flooring can quickly overwhelm the foot’s ability to strengthen, developing plastic deformation of the plantar fascia with arch collapse.
Acute injury. Of course, trauma to a ligament or muscle is a single episode of stress which causes damage. When a muscle or ligament is torn, there is immediate pain, followed by swelling and loss of function. Around the spine, this is often a complex injury, since it is inevitable that several layers of both muscles and connective tissues will have been damaged (a “strain/sprain” injury). Understanding of the healing response is necessary for good management of acute injuries to muscles and ligaments, wherever their location.
Healing Response
Whether damaged by repetitive overuse or by acute injury, muscles and ligaments will heal most rapidly and completely when they are cared for properly. A brief period of “relative rest” is important, the amount depending on the extent of injury. This may require a brief period of immobilization of the damaged region, followed by gradual reintroduction of movement and activity.5 Then, reactivation is necessary; this usually requires specific exercise instruction and expert guidance. The patient should be encouraged to return to the level of pre-injury, and then advised on preventing further injury, either by providing additional response time or by improving muscle strength and balance (or both). Exercise tubing (with areas targeted for rehabilitation) and a wobble board are usually helpful adjuncts.
Occasionally, ligaments become damaged and deformed to the point that full repair is not possible. In these cases modification of stress may be necessary, either through changes in activities or through the use of supports, such as knee braces or custom foot orthotics.
Conclusion
It is vitally important to understand the status of a patient’s muscle and ligament tissues prior to injury. It is also necessary to realize how these tissues became overwhelmed. Was it from an acute injury, or can a history of repetitive insult be uncovered? Once the doctor of chiropractic has the information for the “start point” and an understanding of the method of stress damage, proper care can proceed rapidly. This is what separates caring doctors of chiropractic from those providers who prescribe drugs or bed rest for ligament and muscle injuries. TAC
Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B., founded the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave., Ridgefield, WA 98642 or by e-mail at [email protected].