Sports Injuries – Taking the Strain out of Exercise

Unfortunately, as more and more health-conscious people increase their levels of regular activity, so are sports-related injuries becoming increasingly more common. Around 11 per cent of all injury-related visits to emergency departments are sports-related (Ann Emerg Med, 2001; 37: 301-8). Injury can occur to anyone of any age and of any level of fitness, and the problem is becoming so extreme that some authorities believe that the cost – in terms of medical treatments as well as loss of mobility and productivity – may negate any benefits gained from the exercise (Inj Prev, 2003; 9: 99-100, 100-2). In the US, for example, sports-related injuries are now more common than automobile accidents (Inj Prev, 2003; 9: 117-23).

Most sports injuries involve cuts, abrasions, blisters or bruising. But strains – that is, injuries to muscles or to the places where muscles become tendons – and sprains – that is, injuries to ligaments, but sometimes to other connective tissues such as tendons and the capsules surrounding joints – are also very common, accounting for 31 per cent of all injuries.

Mild or minimal sprains, with no tearing of the ligament, usually produce a mild tenderness and some swelling. Moderate sprains, where the ligament has been partially ruptured, will produce obvious swelling, bruising, significant tenderness and functional difficulties, such as walking or lifting, depending on the location. Severe sprains, such as when the ligament is completely torn from the bone (known as ‘avulsion’), will make walking impossible and produce marked swelling, internal bleeding and joint instability.

In almost all cases, the treatment of minor sprains and strains will usually follow the tried-and-tested method known as RICE:

• Rest – reduce or stop using the injured area for 48 hours. If you have a leg injury, you may need to stay off it completely
• Ice – put an icepack on the injured area for 20 minutes at a time, and do this four to eight times per day. Use a coldpack, icebag or a plastic bag filled with crushed ice, wrapped in a towel
• Compression – of an injured ankle, knee or wrist can help to reduce the swelling. This can be done using bandages such as elastic wraps, special boots, air casts and splints
• Elevation – keep the injured area raised to above the level of the heart, using a pillow to help elevate an injured limb.

But what happens next, particularly your choice of pain-reliever, is key in terms of whether you will heal slowly or quickly.

Conventional approaches

Typically, a doctor might prescribe a non-steroidal anti-inflammatory drug (NSAID) – such as aspirin or ibuprofen – for sports- and exercise-related injuries, particularly when inflammation is present. NSAIDs can provide quick temporary relief from pain and inflammation, and they are generally safe to use for up to a few days at a time. However, when used chronically, these medications can bring on many complications. For example, NSAIDs are irritating to the stomach and, based on extensive clinical evidence, can cause microscopic gastrointestinal bleeding in virtually everyone after a relatively short period of use. These bleeds can progress and cause ulcerations and other gastro-intestinal problems when used over extended periods of time.

Moreover, the metabolism of the cartilage may be impaired and the degenerative process accelerated with the use of drugs like aspirin and ibuprofen.

Other conventional approaches include topical rubs containing menthol, which produce a temporary and paradoxical hot-and-cold sensation that helps to relieve the pain of muscle strain. For severe pain, prescription medications, such as paracetamol (acetaminophen) combined with codeine or with hydrocodone may be recommended. Strains may also be treated with muscle relaxants such as cyclobenzaprine (Flexeril), carisoprodol (Soma) and baclofen (Lioresal).

However, some of these approaches may not reduce the inflammation or get rid of the problem. They may lessen or even deaden the pain, but this doesn’t mean the injury has healed. Continuing to exercise a muscle that is injured can make the problem worse.

Pain is an important mechanism as it lets us know when something is wrong in our body. It makes much more sense to repair the damage rather than to simply ignore the injury that is present.

Aspirin vs enzymes

In this respect, more than any other branch of medicine, sports medicine has been quick to adopt the concepts of holistic healing. The need to get athletes back on their feet as quickly and in as good a shape as possible has meant that sports physicians have been driven to embrace the idea of working with the body, and not against it.

A good example of this is the increasingly widespread and popular use of proteolytic enzymes – substances that digest protein – to prevent and also heal athletic injuries.

Enzymes control the chemical reactions that take place in all organisms; they build new proteins, cells, tissues and organs. They also act as catalysts, working in a ‘lock-and-key’ fashion to change the structure of molecules by splitting them or combining them. More than 3000 different enzymes have, so far, been identified in the human body.

All living material contains enzymes, and supplements derived from a variety of sources can mimic some of the body’s own enzymatic activities. Enzymes such as bromelain and papain are derived from pineapple and papaya (paw-paw), respectively. Other enzymes, such as amylase and lipase, are derived from bacteria whereas others, including trypsin, chymotrypsin and pancreatin, are taken from animal, usually porcine, sources.

Though not a feature of conventional treatment, the therapeutic effectiveness of enzymes is so well understood in sports medicine that Olympic athletes in many countries rely on them to aid stamina and healing.

Research into enzymes stretches back 40 years or more (Clin Med, 1968; 75: 35-42). Supplemental proteolytic enzymes have been shown to support and accelerate the natural inflammatory process without letting it get out of control. By using enzymes such as bromelain, papain, trypsin and chymotrypsin, athletes can reduce inflammatory damage, and speed the healing of bruises, swelling and other injuries (Am J Physiol, 1997; 273: G139-46; Fortschr Med, 1995; 113: 303-6; Med Sci Sports Exerc, 1992; 24: 20-5). Specifically, enzymes can:

• break down proteins in the blood that cause inflammation, and facilitate their removal via the bloodstream and lymphatic system
• remove fibrin, the clotting material that prolongs inflammation
• clear away oedema (excess water retention) in the areas of inflammation
• counteract chronic, recurrent inflammation, a primary cause of chronic degenerative joint diseases.

Proteolytic enzymes are also of interest because of their ability to support, enhance, and regulate the circulatory and immune systems – factors that help to optimise performance during sports.

Nevertheless, for years, enzyme use fell out of popularity, due in part to the fact that many are natural substances that pharmaceutical companies cannot patent and, therefore, profit from. However, new formulations now involve patented combinations of several types of enzymes that deliver standardised levels of activity (see box, page 2) so, once again, this kind of treatment has become fashionable.

Over the years, several trials have reported faster recovery from athletic injuries, including sprains and strains, and an earlier return to activity using trypsin/chymotrypsin (Penn Med J, 1965; Oct: 35-7; Br J Clin Pract, 1970; 24: 375-7; S Afr Med J, 1971; 45: 181-3), papain (Curr Ther Res, 1969; 11: 621-4) and bromelain (Practitioner, 1967; 198: 547), or a combination of these enzymes.

Even better, enzymes compare very favourably to NSAIDs – often besting them in clinical trials. One double-blind study compared an oral preparation containing bromelain, trypsin and rutin with an NSAID (diclofenac) in 73 patients suffering from osteoarthritis of the knee (Clin Drug Invest, 2000; 19: 15-23). After three weeks, it was found that the enzyme mixture was as effective as the NSAID in significantly reducing pain – by around 80 per cent. This decrease in pain was sustained for four weeks after the treatment had ended. Enzyme therapy also produced fewer adverse effects.

Another study comparing the same combination of enzymes with various NSAIDs found similarly positive results (J Assoc Phys Ind, 2001; 49: 617-21).

Finger on the trigger

Other alternative measures have plenty to offer active men and women who sustain musculoskeletal injuries during sports or exercise. Chiropractic, hyperbaric oxygen and massage, among others, can help get athletes off the NSAID treadmill and back into action (see box, page 3). Acupuncture, however, appears to work most closely with natural body processes to relieve pain and encourage healing.

Acupuncture, a traditional Chinese healing practice, involves inserting hair-thin needles into specific anatomical points to redirect the body’s flow of energy, or qi (pronounced ‘chee’). Since 1997, acupuncture has been recognised by the US NIH (National Institutes of Health) as a valid treatment for a range of painful conditions, including tennis elbow, fibromyalgia, low-back pain and carpal tunnel syndrome (JAMA, 1998; 280: 1518-24). The technique appears to activate the body’s natural painkillers by causing the release of the morphine-like endorphins (Life Sci, 1979; 25: 1957-62).

The good news is that acupuncture doesn’t just cover up pain. Numerous studies have documented its effects on circulating hormones such as ACTH, cortisol and growth hormone (Lancet, 1979; 2: 535-6; Int J Neurosci, 1980; 10: 95-7; Life Sci, 1983; 32: 1705-9), thereby affecting inflammation and tissue healing.

Acupuncture now encompasses the Western discipline ‘trigger-point therapy’, commonly used in sports medicine.

Trigger points are irritated points in muscles that often refer pain to other parts of the body. In some ways, trigger points are the muscle equivalent of a stress fracture in bone.

A good example is tennis elbow, where trigger points in the forearm muscles cause the problem. Chronic spasm of these muscles puts tension on the elbow tendons, leading to pain and inflammation. If these particular trigger points are not treated, the tennis elbow will not get better, or will return as soon as the patient returns to regular activity.

In general, trigger points respond to traditional massage, but practitioners have found correlations between trigger points and acupoints used in traditional Chinese medicine (J Alt Complement Med, 2003; 9: 91-103). In trigger-point acupuncture, the practitioner palpates the muscles to find tender areas, then inserts the needle there. While this may seem like a Western corruption of a traditional practice, in fact, the Chinese also have a name for these points – ah shi, which translates to ‘that’s it’.

For low-back pain, needling these trigger points works just as well as injecting steroids, with much less post-injection soreness (Spine, 1989; 14: 962-4). Similarly, it is effective for neck and knee pain, too (Pain, 2002; 99: 83-9; Acupunct Med, 2003; 21: 32-5).

Sports medicine is not traditionally known for it’s holistic attitude towards its patients. More often than not, sports medicine has involved a ‘patch ’em up and send ’em back out on the field’ attitude.

Professional athletes, looking for cures that work with, not against, their bodies are leading the way in exploring gentler more effective alternative treatments.

What holistic medicine brings to the arena of sports injuries is the notion that the body is always striving towards wellness. A gentle nudge – for instance, from enzymes or trigger-point acupuncture – may be all that is needed to set it off on the road to recovery.

In an effort toward standardisation, many manufacturers are starting to use FIP units – the amount of enzyme activity according to the test methods of the Federation of International Pharmaceutics. There are no officially recommended dosages for proteolytic enzymes, but you may wish to consider these guidelines:

• bromelain: unless otherwise prescribed, 80-320 mg (200-800 FIP units) two to three times daily
• papain: higher doses are more effective; try a dose of 1500 mg/day (2520 FIP units)
• trypsin/chymotrypsin: there are no standard recommended doses for these substances. Often, they are included in smaller amounts in bromelain/papain combinations. Trial and error may be necessary.

Combination brands have the advantage of being manufactured to deliver a consistent level of activity. Look for a brand that is ‘enteric-coated’ – which means that the formulation is protected against digestion in the stomach for optimal delivery of the enzymes to the intestines, where they can perform their actions.

Two other studies also reached the same conclusions (Br J Sports Med, 1998; 32: 212-4; Clin J Sports Med, 1999; 9: 221-7), suggesting that starting out slowly and building up activity gradually may be just as effective as a full stretching routine before exercise. Likewise, gradually winding down towards the end of your exercise routine may help prevent pain afterwards.