The Dragontree

As it warms up outside and everyone becomes more active, we in medical field see an increase in injuries, and sprains are a big one. For years, those of us in Chinese Medicine have winced at the recommendation of ice for sprains, since it goes directly against the way our system deals with injuries. But, it has been the standard of care for about four decades, so our protests fell on mostly deaf ears.

However, recently the coaches and trainers who deal directly with pro athletes, who need them back on the field ASAP, started to do things differently. Being more concerned about a fast recovery than just about anyone in the medical field, they began questioning conventional care. When they paid attention to what happened when ice was and wasn’t used, and they found it was a detriment to rapid healing. Now we have research that backs this up.

Ankle sprains are an exceedingly common injury. It’s almost unusual for there not to be at least one sprain during any game that involves running up and down a field. Ligaments are strong cords of tissue that attach bone to bone. They don’t have much flexibility, and they don’t stretch and contract like muscles and tendons. When they’re over stretched by bending a joint beyond its healthy limit, their fibers tear, and we call this a sprain. Any joint could theoretically suffer a sprain, though the most common are the ankle, wrist, knee, finger and toe. Many back injuries probably involve some spraining, as all the vertebrae are connected by small ligaments.

Sprains are classified based on the extent of damage. A first degree sprain involves minimal tearing and bleeding. A second degree sprain involves tearing of many fibers of the ligament and significant bleeding (under the skin). A third degree sprain involves a complete tear of a ligament. A third degree ankle sprain usually requires surgery to reconnect the torn ligament, but first and second degree sprains are often managed with home care and then rehabilitation.

Traditional treatment for a sprained ankle (assuming it’s not a third degree tear, which is uncommon) is known as R.I.C.E., which stands for Rest, Ice, Compression, and Elevation. The term was coined by Gabe Mirkin, MD, in 1978 in The Sports Medicine Book. Rest (immobility) is intended to prevent further injury, ice is meant to reduce pain and swelling, compression (wrapping the joint tightly) is intended to reduce swelling, and elevation (keeping the joint above the heart) is also meant to reduce swelling.

As you can see, RICE strongly emphasizes managing the swelling. This swelling (part of the inflammatory process) occurs through the activity of the immune system. After cells are damaged at the site of the injury, there is a massive influx of immune cells. Ice and compression inhibit circulation by constricting vessels, and elevation is meant to inhibit the influx of fluid by working against gravity. The result of this form of treatment is that most sprains take weeks or months to heal, often with lasting problems in the joint.

The reason this approach never made sense to me all is because of a fundamental principle of Chinese Medicine: all pain is caused by stagnation, and healing occurs through the restoration of movement or flow (circulation). This is an important concept for everyone to understand – both laypeople and medical practitioners. Every aspect of RICE aims to inhibit flow.

In the case of a sprain with swelling, the stagnation is initially quite pronounced. The joint is engorged with fluid. Although ice, compression, and elevation may help to halt the influx of fluid to begin with, the thinking behind these therapies is that the body is doing something wrong and this immune cascade should be interrupted. But the problem is not with the influx of fluid – the body is sending in fresh nutrients and a clean-up crew, and in actuality, this form of inflammation is a vital part of the healing process – it just needs our cooperation to assist in keeping the fluid moving.

Much of the fluid build-up in a sprained joint has to be drained through the lymphatic vessels, which have no central pump like the heart is to the blood vessels. Lymph returns to the trunk by the pumping action of muscle contraction. As muscles contract, they squeeze lymph along the lymph vessels (due to valves in these vessels, the lymph can only move in one direction). So, you can see that immobility – as through rest, ice, and compression – might not be a good idea. Through these practices, whatever stagnant fluid is congested in the joint tends to remain there. Studies now indicate that ice causes fluid congestion by inhibiting its evacuation and actually causing back-flow of fluid from the lymphatic vessels into the tissue that it’s attempting to drain from.

Acupuncturists employ heat and acupuncture to promote flow; this greatly speeds up the healing process. Conventional doctors tend to say, “Don’t use heat – it promotes swelling,” because it encourages vessels to open, but this opening means that heat encourages circulation – it keeps the healing process moving. Topical herbs further enhance healing, and in addition, we encourage the patient to move the affected area. We don’t want the patient to cause further injury, but there’s a big difference between being gentle to the injured area and completely immobilizing it. Movement promotes clearance of cellular debris and accumulated lymph; brings in a greater supply of oxygen and nutrients; and also ensures more constructive healing, less scarring, and more functional scar tissue.

Not only have innovative trainers and medical practitioners begun to question the validity of RICE (most specifically the Rest and Ice parts), even Dr. Gabe Mirkin himself just wrote an article called “Why Ice Delays Recovery.” They’re approaching the treatment of sprains differently and are often getting much better results. One of the leaders of this movement, a trainer named Dick Hartzell, has pioneered a technique for treating sprained ankles that involves tractioning the ankle (pulling the foot away from the body using elastic bands) while the patient moves the ankle continuously. Often, the sprain is better within a matter of minutes, hours, or days, rather than weeks or months.

Instead of RICE, more trainers and doctors are beginning to use METH. No, I don’t mean they’re taking amphetamines. METH stands for Movement, Elevation, Traction, and Heat. Only the elevation aspect of RICE (the part I found least objectionable) is preserved. So, If you suffer a sprain, I highly encourage you to get medical attention, but first, try one of the Muscle Melt formulas I developed if it’s available. Second, avoid the ice and anti-inflammatory drugs. Third, keep gently moving the affected part. At the beginning this is usually best done without putting weight on it. Fourth, see a competent acupuncturist (we fix sprains fast). And, fifth, be prepared to surprise people when you heal much faster than they expect.

Be well,

Dr. Peter Borten