By Joseph Accursio NP
Is getting more active part of your resolution for the upcoming New Year? If your goals include a new work out routine, running, playing and taking risks, then it's important to be mindful of potential injury to your joints. Here’s a quick guide to injury identification, initial treatment, and when to seek a higher level of care. We will discuss the lower extremity joints – knees, ankles and feet.
A brief classification scheme before we begin:
Strains – injuries to a muscle or a tendon (which connects muscle to bone). Unless there’s obvious deformity from a complete tendon or muscle tear, these injuries present with localized soreness that gets a little worse before it gets a little better, maybe some mild swelling, maybe some mild bruising, and fairly rapid recovery.
Sprains – injuries to ligaments (or bone-to-bone connectors). These injuries are generally more severe than strains because ligaments recover more slowly and, dependent on how serious the sprain, there can be some temporary or permanent laxity leftover. These injuries present with fairly localized soreness and swelling, bruising and there may be a feeling of instability at the site of injury. A sprain is also dangerous because the load meant for the injured joint will shift to another structure, potentially causing strain and soreness in another location.
Contusions – another term for bruising. There are deep and superficial contusions, though these will generally resolve without complication after initial pain, swelling and darkening of the skin at the site (note that healing times for contusions or any injury may be increased with the use of anticlotting drugs or blood clotting disorders).
Fractures – broken bones. Treatment will vary dependent upon the site, type of break, precise location of the break and the age and health status of the injured person.
First thing to note, most injuries that occur without a significant mechanism (such as a fall from a height, high speed injury or crash of some sort) are NOT going to be serious, and will respond well to RICE (rest, ice, compression and elevation). Even in the case of serious injury, RICE therapy is going to be the initial treatment, along with pain control, splinting and expert consultation.
How then do we determine severity of injury? There are some rules out there that clinicians use to decide whether or not an x-ray is necessary – the Ottowa rules. These are easy to apply, BUT can be made difficult in the case of acute (“right-now”) injury, because pain and swelling inhibit the ability to make a determination. Here are the rules in short, for each joint:
Ankles – if either of your “ankle bones” hurt AND you have well-localized bony tenderness at the site of injury, you need an x-ray;
Feet – if the middle of your foot hurts AND you have bony tenderness on the outer (lateral) aspect of your foot or bony tenderness at the navicular bone (extra bone or piece of cartilage located on the inner side of the foot just above the arch), you need an x-ray;
Knees – if you’re over 55 years old, if you have well-localized pain in your kneecap, if you have tenderness on palpation below the knee at the lateral (outer) aspect of your leg, or if you can’t bend your knee more than 90 degrees, you need an x-ray.
A general rule for all joints: if you can’t bear weight now and in the urgent care or emergency room for 4 steps, you likely need an x-ray.
Again, these criteria are great but the elicited tenderness has to be when pushing on a bony surface, not on swollen and bruised skin.
Recapping, most injuries are not severe and will respond well to RICE as discussed above. When you ice something, BE DILIGENT! That doesn’t mean 10 minutes and you’re done. To be effective, ice 20 minutes on, 20 minutes off, as much as you can stand it for the next 48 hours. Take Tylenol or ibuprofen as directed if you need it. Give RICE a try for 5-7 days. If you’re getting better, keep on. If not, follow up with a doctor. Remember, if ever you are unsure of how to proceed after a non-emergent injury, you can consult one of BitMED's physicians for recommendations!
One more very important point – Don’t return to activity until you’re 100% absolutely-like-brand-new recovered. An injury is one thing, but compounding a second injury on an unstable structure can cause big problems. It’s not worth the risk.