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Ligaments are cable-like structures, which hold your bones together and allow you to walk and move without failing apart. Ligaments are flexible, but they do not stretch very far. Injuries - such as when you sprain a ligament, twist a knee, take a bad fall, suffer a whiplash, or lift an object which is too heavy - can tear or fray these cable-like structures. These injuries set up a healing process called inflammation to repair the injured ligament. You know this process is happening when you feel the pain, heat, note swelling, and cannot move the injured joint.
If the healing process is completely successful, then the ligaments will be returned to their normal strength and length, and you can return to your normal activities. If this healing process does not completely work, the ligaments may heal stretched. This "stretched out" ligament will lead to a situation which can cause pain and discomfort with movement.
Causes & Development
When a ligament is "strained" or injured, some of the strands or threads which make up the cable become over-stretched and broken. The torn or strained ligament is really millions of tears of these strands which are molecules of collagen.
Signs & Symptoms
Loose ligaments allow the joint to move beyond its normal range of motion. The abnormal motion allowed by the strained ligament will produce painful sensations and make you aware of the problem. These sensations also include feelings of "numbness and tingling" and a phenomena of referred pain. This referred pain is created by the ligament laxity around a joint but is felt at some distance from the injured joint.
The abnormal joint movement also creates many protective actions by adjacent tissues. Muscles will contract in an attempt to pull the joint back to the correct location or stabilize it to protect it from further damage. We then feel the muscle spasms which are related to the ligamentous laxity.
Treatment & Prevention
There is a tendency to treat the muscle spasms as the primary cause of the problem and many medical treatments may be directed toward the muscular spasms, and not to the primary cause: the ligamentous strain. If the joint is slightly out of place because of the ligamentous laxity, it may respond to manipulative care. Such manipulative techniques will often give good relief and sometimes permanent relief.
If lax ligaments can lead to muscle spasm, loss of movement, and all sorts of painful sensations and feelings, what can be done? The only non-surgical treatment for this ligamentous strain or laxity problem is called prolotherapy. In order to understand prolotherapy, one must understand how the body heals ligament damage normally. This healing process is called inflammation.
Inflammation has several distinct phases: the acute inflammation phase, the granulation phase, and the remodeling phase. This "Healing Cascade" is basic to all injuries regardless of the site or tissue. These three phases each have their own cellular and chemical processes and changes. Each phase is dependent upon the previous phase for initiation of the next step.
Understanding inflammation is key to gaining an insight into how prolotherapy works. The first phase is called acute inflammation and is about one hundred hours long. This step begins at the time of the injury, when the ligament and the adjacent cells are broken open and their contents spill at the wound site. The ligamentous and cellular debris and a number of chemicals in the fluid or plasma around the broken-open ceils attract an influx of white blood cells called leukocytes. Their job is to clean out the bacteria and prevent infection at the injury site. Many of the chemicals released during this phase will be broken down into messengers or chemical signals that tell cells to become active or inactive during this phase of inflammation. Some of these chemicals are called prostaglandins, which can cause pain at the injury site.
The leukocytes also secrete hormones which attract an important cell called the "macrophage". The arrival of the macrophages at the injury site signals the beginning of the next phase in the healing process, the granulation phase. As the macrophages arrive at the injury site, they begin to "clean up" the area through a combination of digesting the broken-down cell parts and secreting enzymes, which break down many of the damaged ligament molecules. The macrophages also release a number of hormones which will bring more cells to the injury site.
The macrophages also release chemicals (growth factors) which stimulate the growth of new blood vessels, intercellular matrix, and the cells that will make new ligaments. These specialized cells which make ligaments are called fibroblasts. The fibroblasts will be responsible for the actual repairing of the sprained ligament. The combination of all of these cells and the new blood vessels being formed causes the thickness and fullness that can be felt at the injury site. The granulation phase will be present for ten days to two weeks.
Fibroblasts will find the site where the ligamentous structures attach to the bone: the fibro-osseous junction. The fibroblasts will be stimulated, or "turned on", to make new ligaments by chemicals and hormones that have been released by the incoming macrophage. When the fibroblasts are "turned on", they rapidly make massive amounts of the basic building blocks of ligaments: collagen.
The third phase of healing is called "wound contraction". During this phase, the new collagen deposited at the injury site will be organized into a new ligament. The fibroblasts make single long molecules which, when outside of the cell, will begin to entwine around each other, forming what we call a collagen fiber, which is a "triple helix" of these molecules. The individual molecules are held together by strong chemical bonds, As the collagen fibers wind around each other, they begin to contract and the molecules become shorter and tighter. Water is squeezed out (like squeezing a sponge), which also causes shrinkage. As the millions of collagen fibers lose water and shrink, the ends of the ligament will be slowly pulled together and the laxity will decrease. We can see this in the healing of a skin wound as the edges of the wound pull tightly together near the end of the healing process.
During the third phase of the healing process, all of the cells originally present to "clean up" the wound are recalled by the body. All that is left at the injury site are the fibroblasts which have been "turned on"and are secreting the collagen and other substances which will be used to increase the integrity of the injury site. The third phase of inflammation lasts for a number of weeks, and the "new ligament" tissue will not reach its maximum strength for several months.
Ligament Injection Therapy
Now that it is understood how inflammation works, we can really understand what we need to do to create inflammation. Ligament injection therapy simply stimulates this healing process in a more controlled and less violent way than occurs during trauma in an automobile accident, slip or fall, twist or athletic injury. The technique of creating this inflammation and the creation of collagen is done by injecting proliferants. Proliferants are nothing more than irritants. These irritants are enough to break open the surface of the cell walls and allow the spilling out of their contents into the immediate and adjacent tissue spaces near where the fibroblasts reside at the junction of the ligament and the bone. This then stimulates the healing cascade.
A number of different proliferants may be used which are capable of causing this process. Osmotic shock agents are dehydrating agents that remove the fluids from the cells around the injection site. In the modem Orthopaedic medicine practice, this osmotic shock agent is primarily a concentrated solution of glucose, glycerin, and a very small amount of phenol. It is called "P2G".
Sodium morrhuate is another frequently used proliferant. This drug is the same long fat molecule that makes up the cell wall. When injected in dilute amounts it stimulates the production of the prostaglandins or the chemical messengers of inflammation. Sodium morrhuate is extracted from cod liver oil and has the same chemical formula as arachidonic acid.
All of these proliferants are injected at the fibro-osseous junction with a large amount of local anesthetic, usually Procaine. The discomfort of prolotherapy, because it is an "artificial" injury, is an important signal that healing is under way. The pain, swelling, heat and the redness caused by the injections are all signs that the underlying cellular and chemical processes of 200 million years of evolution are safely underway. The body's pain signals can be listened to, and as the pain decreases the joint movement can increase.
Why is this secondary treatment needed? If this process is a natural on in the body, why did it not do the job correctly the first time? Medical physicians do not understand all the reasons. Some of the more likely causes are: initially, there was continued joint displacement following the injury and the ligament healed in the "longest possible length" position, the nutrition of the patient during healing was inadequate, the genetic tendencies to heal are not complete, or that the healing process was itself suppressed by such medications as aspirin.
Aspirin and other nonsteroidal anti-inflammatories (NSAIDs) can knock out or surpress the healing response by interfering with the prostaglandin growth factor pathways. These drugs are frequently prescribed because they are thought to be safe and a conservative treatment modality. However, research has shown that aspirin is not without significant side-effects concerning inflammation. In addition to well-documented adverse effects this medication has upon healing in the stomach, they may directly inhibit the healing of injured ligaments.
Prolotherapy is not a new technique. Ligament injection therapy is 2,500 years old. Prolotherapy was first used by Hippocrates on Olympic javelin throwers who occasionally dislocated their shoulders. It was used to treat hernias before modern surgical techniques became available.
Prolotherapy is now gaining wider acceptance for painful musculoskeletal and ligamentous problems and has demonstrated long-lasting results.
The Safety Of Ligament Injection Therapy
Treatment with prolotherapy is not without risk. Since the intent of the technique is to create inflammation, pain, swelling, and redness the result can sometimes be more than anticipated. The injections are also painful because the placement of the needle at the fibro-osseous junction is also a tender site. Since the skin is broken with a needle, infection is a possibility, but very few infections have been reported. Serious complications are very rare. Deaths have been reported from prolotherapy, but not in the last 25 years.
Prolotherapy has proven a safe therapeutic technique in well trained hands, but is not easy to learn. The prolotherapist must have training in the form of workshops, apprenticeships, and be a true student of functional anatomy. Prolotherapy done by trained hands is an effective treatment method for the pain and dysfunction of ligament laxity.
In Summary
In summary, accidents which cause ligament strains are normally healed by a process called inflammation. Inflammation is a multi-phased process, but the end product is the production of collagen which will form the threads of a new ligament. As the collagen losses water, it shrinks, becomes shorter and tends to pull the two ends of the ligament together. If this process is incomplete, the joint may remain in an abnormal position and this causes pain, numbness, and muscle spasms. Prolotherapy is an injection technique whereby drugs are injected at the fibro-osseous junction, which causes inflammation and the subsequent stimulation of fibroblast to make new collagen fibers. The technique is painful but safe and effective in decreasing the pain of abnormal joint movement or ligament laxity.
References & Further Information
All of the below references are available at the CU Medical Center Library or at the Tattered Cover Bookstore in Denver.
- Caillier R. Neck and arm pain, FA. Davis, Philadelphia, 1991
- Greenman PE., Principles of Manual Medicine, Williams and Wilkins, Baltimore, ME, 1989
- Cyriax, J. Textbook of Orthopedic Medicine, Bailliere Tindall, London, 1982
- Clark RAF Hanson P.M. The Molecular and Cellular Biology of Wound Repair, Plenum Press. 1988
- Lewis G.P Mediators of Inflammation, Wright, Bristol, 1986
- Iverson O.H. Cell kinetics of the Inflammatory Reaction, Springer. Verlag, Bedim 1988
- Dorman T.A., Ravin T.H. Diagnosis and injection techniques in Orthopedic Medicine, Williams and Wilkins, Baltimore MD. 1991
- Hackett G. S. Ligament and Tendon Relaxation treated by Prolotherapy, Charles C. Thomas, Springfield, IL 1958
- Dorman T. (Ed) Prolotherapy in the Lumbar Spine and Pelvis, SPINE: state of the Art Reviews: 9:p.2, Henley & Belfus, Philadelphia, 1995
- Klein, R.G et al. A Randomized Double-Blind Trial of Dextrose- Glycerine-Phenol Injections for Chronic Low Back Pain. J. Spinal Disorders, 6:pp.23-33. 1993
- Schwartz R.G. Prolotharapy: A Literature Review and Retropsective Study, J Neurol Orthop Med Surg, 12:pp.220-223, 1991
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Signs, symptoms & indicators of Torn, weak, or Stretched Ligaments or Tendons:
Risk factors for Torn, weak, or Stretched Ligaments or Tendons:
Recommendations and treatments for Torn, weak, or Stretched Ligaments or Tendons:
KEY | | Strong or generally accepted link |  | | Proven definite or direct link |  | | Highly recommended |
GLOSSARY
Acute
An illness or symptom of sudden onset, which generally has a short duration.
Anesthetic
Agent causing loss of sensation by neurological dysfunction or a pharmacological depression of nerve function.
Bacteria (Bacterial, Bacterium)
Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.
Collagen
The primary protein within white fibers of connective tissue and the organic substance found in tendons, ligaments, cartilage, skin, teeth and bone.
Enzymes (Enzyme)
Specific protein catalysts produced by the cells that are crucial in chemical reactions and in building up or synthesizing most compounds in the body. Each enzyme performs a specific function without itself being consumed. For example, the digestive enzyme amylase acts on carbohydrates in foods to break them down.
Fibroblast (Fibroblasts)
Any cell or corpuscle from which connective tissue is developed. Fibroblasts produce collagen and elastin.
Glucose
A sugar that is the simplest form of carbohydrate. It is commonly referred to as blood sugar. The body breaks down carbohydrates in foods into glucose, which serves as the primary fuel for the muscles and the brain.
Granulation
Pink, fleshy overgrowth of capillaries and collagen within a wound.
Hormones (Hormone)
Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.
Leukocyte (Leukocytes)
A white blood cell which appears 5,000 to 10,000 times in each cubic millimeter of normal human blood. Among the most important functions are destroying bacteria, fungi and viruses and rendering harmless poisonous substances that may result from allergic reactions and cell injury.
Liver (Hepatic)
The largest and one of the most complex organs of the body, the liver is responsible for much of the metabolism of fats, proteins and carbohydrates. It is the site of much of the body's detoxification. It is connected very closely with digestion and the regulation of blood sugar, among many other functions. Found behind the ribs on the right side of the abdomen, it has many important functions such as removing harmful material from the blood, making enzymes and bile that help digest food, and converting food into substances needed for life and growth. Hepatic: Pertaining to the liver.
Macrophage (Macrophages)
An immune system cell that scavenges bacterial and other foreign material in the blood and tissues. It is a mature form of what is released from the marrow as a monocyte. A macrophage lives long, can digest much detritus, and is able to wear particles of odd food on its outer membrane. This allows T-cell and B-cell lymphocytes to taste the particle (an epitope) and form an antibody response. Further, these macrophages, traveling as monocytes, will take up permanent residence in many tissues, providing them with immunity. They line the spleen, form the cleansing Kupffer cells in the liver, make up the "dust cells" that protect the lungs, protect the synovial fluids of the joints, and form the microglial cells that provide protection to the brain and nerve tissues. Essentially the macrophages clean up messes and act as the intermediates between innate and acquired immunity.
NSAID (NSAIDs)
Non-steroidal anti-inflammatory drug.
Prolotherapy
A single or series of injections that stimulates the body to regrow, tighten, and strengthen ligaments or tendons. It is unequaled for pain relief and restoration of normal function for any body joint where connective tissue is weak or has been damaged.
Prostaglandin (Prostaglandins)
Any of a class of physiologically active substances present in many tissues, with effects such as vasodilation, vasoconstriction, stimulation of the smooth muscles of the bronchus or intestine, uterine stimulation; also involved in pain, inflammation, fever, allergic diarrhea, and dysmenorrhea. A potent hormone -- similar in structure to an unsaturated fatty acid -- that acts in extremely low concentrations on local target organs; first isolated from the prostate.
Sodium
An essential mineral that our bodies regulate and conserve. Excess sodium retention increases the fluid volume (edema) and low sodium leads to less fluid and relative dehydration. The adult body averages a total content of over 100 grams of sodium, of which a surprising one-third is in bone. A small amount of sodium does get into cell interiors, but this represents only about ten percent of the body content. The remaining 57 percent or so of the body sodium content is in the fluid immediately surrounding the cells, where it is the major cation (positive ion). The role of sodium in the extracellular fluid is maintaining osmotic equilibrium (the proper difference in ions dissolved in the fluids inside and outside the cell) and extracellular fluid volume. Sodium is also involved in nerve impulse transmission, muscle tone and nutrient transport. All of these functions are interrelated with potassium.
Spasm
Involuntary contraction of one or more muscle groups.
Stomach
A hollow, muscular, J-shaped pouch located in the upper part of the abdomen to the left of the midline. The upper end (fundus) is large and dome-shaped; the area just below the fundus is called the body of the stomach. The fundus and the body are often referred to as the cardiac portion of the stomach. The lower (pyloric) portion curves downward and to the right and includes the antrum and the pylorus. The function of the stomach is to begin digestion by physically breaking down food received from the esophagus. The tissues of the stomach wall are composed of three types of muscle fibers: circular, longitudinal and oblique. These fibers create structural elasticity and contractibility, both of which are needed for digestion. The stomach mucosa contains cells which secrete hydrochloric acid and this in turn activates the other gastric enzymes pepsin and rennin. To protect itself from being destroyed by its own enzymes, the stomach’s mucous lining must constantly regenerate itself.
White Blood Cell (WBC, White Blood Cells)
A blood cell that does not contain hemoglobin: a blood corpuscle responsible for maintaining the body's immune surveillance system against invasion by foreign substances such as viruses or bacteria. White cells become specifically programmed against foreign invaders and work to inactivate and rid the body of a foreign substance. White blood cells are composed primarily of neutrophils, monocytes and lymphocytes. Lymphocytes are either T-cells or B-cells. T-cells (CD3 cells) are divided into T-helper (CD4 cells) and T-suppressor/cytotoxic (CD8 cells) cells.
Last updated: Apr 13, 2008
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