Strain/Sprain is ONE Syndrome
Not Two Separate Pathologies
And Is Permanent
By Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
Citation: Studin M., Owens W. (2017) Strain/Sprain Is One Syndrome, Not 2 Separate Pathologies and is Permanent, American Chiropractor 39 (2) 26, 28, 30-31
According to the National Institute of Health’s, National Institute of Arthritis and Musculoskeletal and Skin Disorders:
A sprain is an injury to a ligament (tissue that connects two or more bones at a joint). In a sprain, one or more ligaments is stretched or torn. A strain is an injury to a muscle or a tendon (tissue that connects muscle to bone). In a strain, a muscle or tendon is stretched or torn. (https://www.niams.nih.gov/health_info/sprains_strains/sprains_and_strains_ff.asp)
Historically, doctors of all disciplines in the clinical setting and lawyers in the medical-legal arena have erroneously attempted to separate them into 2 distinct injuries allowing a false conclusion to be derived in either prognosis or legal arguments when considering connective tissue pathology as sequella to trauma.
Solomonow (2009) wrote:
There are several ligaments in every joint in the human skeleton and they are considered as the primary restraints of the bones constituting the joint. Ligaments are also sensory organs and have significant input to sensation and reflexive/synergistic activation of muscles. The muscles associated with any given joint, therefore, also have a significant role as restraints. In some joints, such as the intervertebral joints of the spine, the role of the muscles as restraints is amplified. The role of ligaments as joint restraints is rather complex when considering the multitude of physical activities performed by individuals in routine daily functions, work and sports, the complexity of the anatomy of the different joints and the wide range of magnitude and velocity of the external loads. As joints go through their range of motion, with or without external load, the ligaments ensure that the bones associated with the joint travel in their prescribed anatomical tracks, keep full and even contact pressure of the articular surfaces, prevent separation of the bones from each other by increasing their tension, as may be necessary, and ensuring stable motion. Joint stability, therefore, is the general role of ligaments without which the joint may subluxate, cause damage to the capsule, cartilage, tendons, nearby nerves and blood vessels, discs (if considering spinal joints) and to the ligaments themselves. Such injury may debilitate the individual by preventing or limiting his/her use of the joint and the loss of function. Pgs. 136-137
While ligaments are primarily known as mechanical or supportive structures responsible for joint stability, they have equally important neurological functions. Anatomical studies have shown that ligaments in the extremities and the spine are endowed with nerves called mechanoreceptors. The presence of such that sense and send neurological information to the spine and brain in the ligaments confirms that they contribute to proprioception (feeling and analyzes one’s physical positon in space and time) and kinesthesia (similar to proprioception but can maintain feeling in these nerves even with aberrant neurological imput elsewhere) and also has a distinct role in reflex activation or inhibition of muscular activities.
Simply put, the nerves in ligaments attempts to alter muscle activity to prevent further biomechanical failure and pathology (bodily injury), which effects one’s ability to move in a balanced homeostatic manner leading to further functional loss in a short amount of time. The presence of such nerves in the ligaments confirms that they contribute to proprioception and kinesthesia and have a distinct role in reflex activation or inhibition of muscular activities. Therefore, the muscles and tendons (which are inherent in muscular activity), are responsive and dependent upon ligament activity in function with both normal and pathological (inclusive of trauma) activities.
Solomonow (2009) also reported that as far back as the turn of the last century, that a reflex may exist from sensory receptors in the ligaments to muscles that may directly or indirectly modify the load imposed on the ligament. A clear demonstration of a reflex activation of muscles finally provided in 1987 and reconfirmed several times since then. It was further shown that such a ligamento-muscular reflex exists in most extremity joints and in the spine.
A Single trauma according to Panjabi (2006) can cause either a tear in the ligament called laxity or a subfailure injury of the spinal ligaments and injury to the mechanoreceptors embedded in the ligaments and the following cascade of events occur: pgs. 669-670
NOTE: The subfailure injury of the spinal ligament is defined as an injury caused by stretching of the tissue beyond its physiological limit, but less than its failure point.
Simply explained, when there is a ligament injury or sprain, the nerves in the ligament fire signals that go to the central nervous system and causes the muscles to react as compensation to bodily injury to stabilize the structure. That in turn sets up another cascade of problems if not compensated for or repaired as the muscle spasticity cannot maintain itself for long periods of time and goes into a posture of tetanus, or perpetual spasm until the lactic acid builds. This is followed by the muscle failing and putting the entire structure in a chronic biomechanically unstable position and causing the bone to remodel or become arthritic.
According to Hauser ET. Al (2013) ligament instability in either subfailures or laxity are a clear cause of osteoarthritis. This is not speculative as the inured will develop arthritis in 100% of the time and is consistent with Wolff’s Law that has been, and continues to be accepted since the late 18th century.
Therefore, as per the above scenario, strain-sprain is an intertwined syndrome that cannot either mechanically or neurologically be separated and will cause arthritis in 100% of the post-trauma instance. How much arthritis and how quickly it will develop is dependent upon how much ligamentous damage there is.
Dr. Mark Studin (CLICK HERE FOR CV) is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He also coordinates a clinical rotation in neuroradiology for chiropractic students at the State University of New York at Stony Brook, School of Medicine, Department of Radiology. Dr. Studin is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at DrMark@AcademyofChiropractic.com or at 631-786-4253.
Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community. He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at email@example.com or www.mdreferralprogram.com or 716-228-3847
Ligament Pathology as Sequella to Trauma Coupled with Alteration of Motion Segment Integrity (AOMSI) or Ligamentous Laxity
By: Ray Wiegand, D.C.
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A good read to understanding alteration of motion segment integrity (AOMSI) is the article “Biomechanical Analysis of clinical instability in the cervical spine” White, et al., Clin Ortho Relat Res, 1975;(109):85-96.
AOMSI is a biomechanical analysis. It’s all about numbers that have clinical meaning and significance. Threshold values have been determined that quantify without a doubt the patient has serious injury. It is a test of structural integrity of the ligaments interconnecting the motion segments. In this case, structural integrity has to do with the material properties of ligament tissue. Those properties include strength and flexibility. When a material is both strong and flexible, it’s called a semi-rigid material. Strength is related to the composition of the material. Strength might be thought of as load carrying capacity before failure.
Ligament tissue has previously been bench tested to describe its physical characteristics of stress/strain. That is, given so much load (stress) how much elongation will occur (strain). During normal physiologic loads the ligament remains intact and recoils to its original length when the load is removed. If the load becomes too large the materials (ligaments) begin to yield. They go past their elastic limit. When this happens the (strained) ligament fibers will not return to their original shape. The ligament loses its restraining capacity to hold the joint in normal stabilization and hypermobility occurs.
The ligaments, if sufficiently strained or avulsed results in AOMSI. The following paragraphs illustrates that if AOMSI is found there must be gross destruction or yielding of multiple ligaments. We need to build a BIG motion segment with Velcro ligaments. When you tear them off, they make a really nice ripping noise. That drives home the point.
In the White et al work, they found that the motion segment stayed intact i.e., less than 11 degrees’ rotation (angualr mtion) and less than 3.5 mm translation, until they transected over 50% of the ligaments from an anterior or posterior approach. And when they transected from either approach the loss of stability was not linear but suddenly catastrophic. And they meant that suddenly the two vertebra totally separated in rotation or translation.
Suddenly Separated: pulled apart, head off of body, all neural components compromised, paralysis. Keeping that in mind, what are the injuries of someone just under the threshold? Severe to very severe. They stand the possibility of a serious event with much less force.
If AOMSI is detected, think about more than 50% of ligaments transected. That will start to explain the seriousness of the finding. In a patient/child that demonstrates hypermobility everywhere, then you take a statistical average of all segments, and look at the aberrant statistical finding if it exists. There are clues to injury everywhere when you understand what the numbers mean in reference to stability and function.
To diagnose ligament laxity, it is imperative that imaging be performed and a basic flexion-extension x-ray is all that is required. In today’s medical economy, advanced imaging of MRI or CT Scan, although accurate becomes an unnecessary expenditure and an x-ray renders very accurate demonstrative images to conclude a definitive diagnosis. In determining if there is an impairment, it is necessary to follow the AMA Guides to the Evaluation of Permanent Impairment as the 4th, 5th and 6th editions all render an impairment for AOMSI as sequella to ligament laxity, which is damage to the ligament from trauma.
This document is intended to serve as a simple explanation as to the severity of ligament damage and how to demonstrably diagnose the injury. It is also critical to remember that ligament do “wound repair.” In normal physiology, ligaments grow during puberty from cells within the ligaments called fibroblasts. They produce both collagen (white) and elastin (yellow) tissue, which gives the ligaments both tensile and elastic strength. Upon puberty the cells stop producing tissue and remains dormant. Upon injury, the fibroblast reactivates, but can only produce collage leaving the joint wound repaired in an aberrant juxtaposition (place) with poor movement abilities due to the lack of the requisite elastin. In turn, according to Hauser et. Al (2013) this leads to permanent loss of function of the ligament and arthritis of the joint. This is not a speculative statement; it is based upon Wolff’s that dates back to the late 1800’s and has been a guiding principle in healthcare for more than a century.