Is It An 'Itis'? Understanding Soft Tissue
Having been a human massage therapist since 1985 and an equine therapist since 1986, the most common misconceptions I hear on a daily basis are those of soft tissue conditions. The following information will help shed a little light on the differences between some soft tissue conditions and the severity in which they can occur. The treatments mentioned are similar in application and, for the most part, can be used on horse or human.
A common misunderstanding, and understandably so, is the distinction between tendonitis, bursitis, strain and sprain. In soft tissue we find them all, but let's take a minute and differentiate. Remember that the suffix 'itis' means 'inflammation of' (to flame within). Inflammation is a natural, immunological defense mechanism that the body initiates to protect itself from invasion by foreign organisms and to repair tissue trauma. It is characterized by redness (increased local blood flow to bring in nutrients and white blood cells, and to take out toxins), heat (temperature increase to make an unfriendly environment for invaders), swelling (to minimize mobility), and pain (to discourage use and allow healing). In healthy individuals this natural inflammatory process continues until all damaged tissues or invading pathogens are removed (usually a matter of about 5 days), and is followed by an influx of fibroblasts that continue to repair the injury and form a healed scar.
In the acute stage, when trauma first occurs (which can range from micro-trauma to a severe rupture), we want to apply cold - whether it's hosing or an ice application - to prevent bleeding, hematoma, and excessive swelling. All degrees of injury can pose problems, and inflammation can be excessive or become chronic and lead to other issues, so cooling the inflammation is often desired. As the injury becomes less acute, we can still use ice in different durations. In the transition stages to becoming chronic, or approaching the final stages of healing, we can alternate heat and ice. The body has natural healing powers, and we can work with them - and time is the true healer.
R.I.C.E. can be your best friend in most circumstances,
whether a strain, sprain, or 'itis', as inflammation is present
Rest - Rest as prescribed with very light activity (when ready), to insure circulation.
Ice - Ice should be applied immediately to reduce swelling and inflammation.
Compression - When ice is applied, the area should be compressed or appropriately bandaged.
Elevation - Once the other steps are complete, the area should be elevated at or above the level of the heart if possible.
However, there are varying degrees of injury and each one needs to be treated specifically and individually, with the guidance of a professional in many cases. Be sure that optimum nutrition in appropriate quantity is provided to insure maximum healing.
Following an injury, proliferation (healing) takes place. During and after healing, rehabilitation must take place. This strengthening phase is necessary to restore motion, flexibility, coordination, proprioception, and power. If done ineffectively, 'frozen joints' and arthritis (inflammation of joints) can occur and varying degrees of proprioception may be lost.
Tendonitis – inflammation of the tendon
A tendon is the soft tissue attachment that connects muscle to bone. It has great tensile strength and is largely responsible for limiting the amount of injuries that could occur to muscle. There are many response mechanisms in the musculotendinous junction that are partially responsible for sending signals to the central nervous system. This helps to inhibit injury due to a reflex response. Tendonitis is generally caused by overexertion, too much exercise too soon, repetitive work demands, or a prolonged tension on a muscle or around a joint.
Treatment for tendonitis:
In the acute stages, tendonitis responds well to:
(a) Ice applications - either by ice massage or ice pack (See ICE.)
(b) Active rest - Give the affected area adequate rest but at the same time keep some movement going to keep circulation maximal.
(c) Friction massage or cross-fiber friction (massage applied across rather than along muscle fibers) - This will help to create hyperemia (increased blood flow) by broadening and separating the muscle fibers while breaking up adhesions. It also helps to stimulate the production of collagen, which is a protein that is essential in soft tissue repair. (It is very important to remember that when a tendon heals, the collagen that creates scar tissue is not as strong as the type 1 collagen that was initially present.) In the early stage of healing, the inexperienced person should only massage areas surrounding the injured site - not directly on the site itself. As the site heals, cross fiber massage to the musculotendinous junction will insure some elasticity to the muscle and tendon.
(d) In certain circumstances, the veterinarian may prescribe wrapping, setting, or bandaging the affected limb. This can be very beneficial if done properly. In horse or human, if the bandage is too tight, the problems that could arise can be even more devastating than the original injury.
(e) Anti-inflammatory - If needed, a veterinarian may prescribe an anti-inflammatory to reduce inflammation and pain.
If symptoms persist for more than a week and you suspect tendonitis, contact your physician or veterinarian. If caught and treated early, tendonitis usually responds well. If not caught early, one can expect excessive scar tissue formation, limited range of motion, or other injuries arising from compensatory issues throughout the body.
Bursitis - inflammation of the bursa
The bursae are small sacs located strategically throughout the body in joints. A bursa acts as an absorber or buffer to keep the joint moving smoothly and lessen the chance of friction or irritation. It becomes inflamed with over-use or under-use. This condition would be easily recognized, as the individual would not want to use the affected area or joint due to severe discomfort. This is called protective splinting or compensation. Due to the body's ability to compensate, a secondary problem can easily become of primary concern.
Prolonged tendonitis can result in bursitis, due to the fact that the individual would be limiting his movement due to pain. Full range of motion (R.O.M.) is essential for peak performance and injury prevention. Bursitis does not respond as quickly as tendonitis in most cases. It is also not treated as easily by the layperson.
When a joint is not performing optimally, the bursa or cartilage can be worn and the result can be bone against bone. As mentioned earlier, proper nutrition is a key factor here. One must consider that conventional painkillers can sometimes have an adverse effect as the patient may use or overuse the limb due to the fact that feeling is diminished. Use of homeopathy in this case should not be overlooked. There are many conventional and homeopathic remedies that can be utilized as effective anti-inflammatories. Supplements such as glucosamine, MSM and chondroitin can also assist in the smoothness of joint function, repairing of cartilage, and overall increased joint function.
Treatment for bursitis:
(a) Ice massage is definitely an option you would want to choose early to try to control the inflammation. In some cases, ice may be very uncomfortable in the treatment of bursitis. It would be wise to consult the doctor or veterinarian in this case to get a definitive diagnosis. Bursitis can occur alone and not in conjunction with tendonitis or arthritis.
(b) Active rest. If a body part or joint is protected long enough, movement can become inhibited and result in (for example) frozen shoulder in a human or affected flight arc in the equine. This is an unfortunate situation that can, in many cases, be avoided. This again, is why active rest is so important.
(c) Massage, mobilization to restore free range
of motion, and stretching can be very helpful in the rehabilitation
stages. It must be noted that all of these should be employed lightly
as bursitis generally responds best to anti-inflammatories, rest
and gentle movements at first.
(d) To help the individual move more comfortably (where sufficient lubrication exists), anti-inflammatories can sometimes be the best course of treatment and may be prescribed by a physician or veterinarian. In severe or chronic cases that cause constant pain, restriction or discomfort when movement is still advised, the physician/veterinarian may suggest a cortisone shot.
Prognosis is generally good if the patient follows instructions and keeps subtle movement and adequate circulation going in the area on a regular basis.
Strain and Sprain
First, let's differentiate between the two. For
years, I have heard people talk about their calf sprain, or their
horse's hock strain. While most lay people speak in terms that they
think are correct, many are not. I have found that the best way
to teach people to remember the difference is to associate strain
with tendon (notice the T is underlined) and sprain with ligament,
and remember that tendon and muscle are connected.
A strain is trauma to the muscle or musculotendinous unit from violent contraction or excessive forcible stretch.
A sprain is trauma to the ligaments.
One must remember that these are clearly different conditions, and that the severity of each can differ.
Tendon/Muscle Strain or Pull
Common causes of muscle or tendon strain include
but are not limited to:
(b) too much too soon
(c) training on uneven terrain
(d) a sudden jerk reflex to avoid an injury or accident.
In most cases, these are the easiest to treat,
given that the severity of the injury is minimal. The severity is
graded, similar to ligament grades, in degrees of 1, 2, and 3.
Muscle soreness - This is the most common and least severe degree of muscle condition. After all, when introducing new or increased exercise into our, or our horses', daily routines, it is to be expected. It is in effect also necessary to experience some 'hurt good' or burn. Why? Because in order to build muscle, energy has to be applied against a resistance. Also, it must be realized that each time you work and fatigue a muscle, minute muscle tearing occurs. There is also a synthesis that the body goes through to rid itself of inferior tissues and metabolic waste. Most of the soreness that will be experienced after exercise is termed Delayed Onset Muscle Soreness (D.O.M.S.). This usually occurs 48-56 hours after strenuous exercise and diminishes in a couple of days.
It is agreed that the major culprit of exercise-induced soreness is eccentric contraction, or negative (resistant) force. A good example of this would be if you performed a biceps curl and held it while someone tried to straighten your arm. While this is undoubtedly the best way to build strength, the muscle will be sore after a number of repetitions due to the fact that the muscle needs to contract and simultaneously elongate. As stated, it is ok to feel this type of soreness, but one must know when to back off, in order to avoid strain or pull.
Treatment: Given that the severity of the 'injury/discomfort'
is minimal, home treatment for you or your horse is generally safe
and effective. Here are a few tips:
(1) Apply ice through ice massage or packs several times during the first 48+/- hours. In the case of bursitis, you might want to consult a professional sooner. This would generally be recognizable as the pain can be much more intense than the other mentioned conditions. After that, given that the inflammation has subsided, you may alternate ice and heat.
(2) Massage with effleurage (long comforting strokes) and compression - first around the affected area and then lightly to the affected area as the healing process allows.
(3) Stretch the area... slowly and only to the individual's comfort tolerance. This will help send messages to the central nervous system (C.N.S.) that the healing process has begun.
(4) In persistent or painful cases, the physician may prescribe an anti-inflammatory or a muscle relaxant.
Grade 2 -
This is a more serious state in which there would be noticeable redness, swelling, heat or edema. Usually caused by a severe pull or muscle tear.
Treatment: In this case, you should wrap the area in ice immediately and follow the RICE steps. In the case of your horse, some of the newer hydrotherapy hoses and boots can be very effective. If the area remains acutely sore, get to the doctor for a diagnosis and treatment or call the vet immediately.
Grade 3 -
This is the most severe. A few injuries that could be considered a Grade 3 are contusion (bruise), rupture (a breaking apart of an organ or tissue), severe tear, or hematoma (a confined swelling of blood caused by a broken blood vessel).
Treatment: Get emergency care ASAP. These conditions are very serious and should be administered to by a physician or veterinarian.
Ligament Sprain or Tear
Ligaments are the fibrous, non-elastic tissues that hold joints in place. They function on a very limited blood supply; therefore, when a sprain or tear occurs, healing and rehabilitation can take quite some time. Sprains and tears in the joints occur when the ligaments are stretched beyond the limits they enforce on the joints. Ligament injuries are also graded in degrees of 1, 2, and 3.
Grade 1 could be a slight pull or sprain.
Treatment: Once severity has been determined, the affected part usually responds well to RICE, friction massage, and (possibly) light stretching. The physician or veterinarian will more than likely prescribe pain medication if needed. Once initially addressed, movement would be encouraged so as not to compromise R.O.M.
The proper amount of time should be taken in the healing process, because in ligament injury, particularly more severe cases, you (typically) won't get a second chance, if re-injured. As mentioned earlier, if the pain is masked through heavy medication, one will try to do more than they would be capable of at that time.
Grade 2 could be a tear or partial separation.
Treatment: A period of immobility may be required with elevating the limb, wrapping it in a bandage, or in extreme cases, a soft cast. In most cases, ice and some friction massage around the affected areas may be introduced (by a professional).
It is imperative that as soon as the immobilization is discontinued that the joint be allowed passive stretching or mobilization. This is important to regain proprioception (the body's ability to know where each part is at any given time).
This severity would usually be overseen by a physician, veterinarian and quite possibly a Massage or Physical Therapist. Strengthening exercises should be introduced as soon as the 'team' sees fit. Start very slowly at first and gradually increase.
Grade 3 is the most severe such as a severe tear, rupture or separation.
Treatment: Apply ice ASAP. The patient should be seen by the veterinarian, a physician or the emergency room immediately. The person or horse could be in severe pain or shock. The attending physician would first examine, order X-Rays, prescribe pain meds and refer the patient to an orthopedic specialist or vet that could offer a second opinion. The area in question would also be immobilized before leaving the hospital or during stall rest. Upon visiting the orthopedic or vet clinic, they would look at the X-Rays, determine the severity, refer you to a therapist or for surgery and schedule follow up treatments as necessary. If the situation were extreme, surgery may be warranted. In any case, the guidelines set by the 'team' should be followed and contact should be kept to insure full recovery.
In the case of a Grade 3 ligament injury, as well as the other before-mentioned, movement and circulation are imperative to the healing process.
Time Is the Healer
A general rule of thumb that has been around a long time is that full recovery (to the point at which very light exercise can resume) takes one month per letter. Of course, each case can differ depending on its severity. But, it is a good thing to keep in the back of your mind.
We must also consider that with the use of complementary modalities such as homeopathy [see NHM Volume 4 Issue 5], essential oils [see NHM Volume 3 Issue 6], herbs [see NHM Volume 2 Issue 5], and magnets [see NHM Volume 1 Issue 5], to name a few, and all the modern technological advances we enjoy, we can help the healing process. However, time IS the healer.
Bone - 4 months (up to 6 months)
Tendon - 6 months (up to 9 months)
Ligament - 8 months (up to 12 months)
Please remember that the guidelines mentioned in this article are not intended to take the place of proper veterinary or medical care. If you have any questions about an injury, contact your veterinarian or physician immediately. Help can be just a phone call away.
© Mike Scott 2002
About the author:
Mike Scott is a certified and licensed massage therapist who has human and equine clients all over the world. He has authored the book and video, "The Basic Principles of Equine Massage/Muscle Therapy". He also offers certification and seminars in Equine Massage/Muscle Therapy. Over the past few years, Mike has observed a growing need for proper saddle fitting in the horse and has studied saddle repair and bridle-making in England. He has also been accepted to and is attending the Master Saddlers Certification Program. Mike can be reached at firstname.lastname@example.org or you can visit his website at www.equinemmt.com.
Over the years I have found that ice is an athlete's best friend (human or equine). Many 'clients' feel they can't use ice because it hurts, burns or they just don't like it. These reasons could be valid but it must be realized that there are many ways to apply ice that are non-invasive, won't shock you, or won't burn.
It is also helpful to understand that to be effective
there are phases that the affected area will go through during proper
First - The area will feel the cold of the actual application.
Second - A burning sensation will be felt. If the proper precautions are taken first, such as covering the sensitive skin with a towel, this is normal. Wait it out for a few minutes.
Third - When the burning sensation subsides, it is common for the area to ache or throb.
Fourth - Lastly, one will feel numbness. Once this is achieved it is wise to stop in order to prevent cold related damage.
The duration of ice application can vary. It
is understood that '20 minutes on - 20 minutes off' repeated a number
of times, is most beneficial, particularly in the acute phase.
Ways to apply ice:
1. Some of the gel packs that are on the market
today are the best choice. Some conform nicely and anatomically
(with 'velcro') to specific body parts, as well as always being
available for icing or heated up in the microwave for heat applications.
2. You can also take some styrofoam or cardboard cups, fill them with water, and freeze them. When you want to ice massage an area, you simply take one out, peel the cup back about an inch or two and massage the affected area with the ice. The cup will insulate your fingers from the ice and is quite comfortable to hold for extended periods. Massage the area for approximately 10 minutes. When applying ice massage, keep the cup or ice cube moving slowly at all times. Do not let it stay in one place for a long duration. This can also be beneficial to slightly numb the area before an ice pack application.
3. As a last resort, have a large size bag of peas or corn in the freezer at all times. These conform nicely to body parts and can be used over and over again. The only draw back with this is that the contents tend to start thawing out after 6 or 7 minutes.
When ice is used, make sure that the patient does not have sensitivities to ice (rare), and use a buffer between the ice and the treated area, especially over joints and nerves, or in the case of any severe circulatory ailments.
In the event that your therapist will be treating an injured area with ice and then trying to restore free range of motion through specific stretches, make sure this is not performed aggressively while the area is totally numb. Though it is often indicated to do so, with passive movements in correct patterns of diagonals, spirals, circles and holds, extreme caution must be taken when stretching a numbed area due to the changes in the proprioceptors and collagen fibers during the icing. Don't try this yourself - leave it to the professional.