SPRAINS

The osteopath is often called upon to treat sprains of various

sections of the body as well as to relieve after effects of fractures

and restore function to the part. The osteopathic treatment is very

effectual; therefore, an outline of the purpose and method is given.

Sprain is defined by Dorland as “the wrenching of a joint with partial

rupture or other injury of its attachments, and without luxation of

bones.” From an osteopathic viewpoint the above definition is not

fully explanatory, for there is in most cases a partial luxation of

the bones. The most common cause of a sprain becoming chronic is the

presence of partial bony displacements. Rupture of tissues may be the

cause of a chronic state but is not nearly so frequent as the bony

dislocation. In most sprains, the wrenching causes a displacement

of the bony tissues, which may or may not return to normal position

and relation. The function of the muscles is not primarily to hold

the bones in place; this is left to the ligaments, so when a wrench

of a joint is so severe as to cause rupture of muscles or tearing of

ligaments, partial luxation of the bones is almost certain to follow;

and even where such damage does not occur a change in the relation of

the bones is a frequent occurrence.

Unless a sprain can be seen very early it may be difficult to detect

just what has happened; whether it rests with a rupture of the areolar

and connective tissues, a displaced cartilage, tendon, or bone, a torn

ligament, or ruptured muscle. Hemorrhage and swelling take place so

rapidly that no time should be lost in critically examining the joint.

When in doubt as to the structural disturbances, particularly in acute

cases if there is a possibility of a fracture, and in chronic cases any

supposition that tubercular involvement is present, have a radiographic

examination.

There is comparatively little to be found in medical literature

relative to the =pathology= of sprains. Probably Moullin in his

excellent monograph on Sprains has given as good an outline as can be

found[41]. He says that “generally speaking, the tissues on one side

of a joint are overstretched and torn; those on the other compressed

and crushed together; but there is always so much twisting, and such

a difference in the strength and power of resistance of various

structures, that unless the part is examined with the greatest care it

is almost impossible to say what actually has given way.” Hemorrhage

due to torn vessels is the cause of most of the swelling within the

first few hours. Later on, there is considerable lymph mixed with the

blood. There is not only extravasation of blood into the surrounding

tissues but also into the synovial wall and cavity. This causes

considerable irritation and pain owing to the roughening of the

membrane, and the joint becomes inflexible. And if the joint or any

strained tissue is kept too long at rest the mass becomes organized and

is the cause of much discomfort and annoyance.

Similar changes may occur in the bursæ due to the extravasated blood.

Strong ligaments may be torn across, but not frequently. The tear

is usually a separation from the bone. Occasionally interosseous

ligaments, as for instance in the knee, may be injured.

The muscles may be severely torn, but more often they are “hurt by

their own sudden and spasmodic effort at recovery than by anything

else.” In a few cases the tendons and muscles will be found bruised,

lacerated, and dislocated.

The veins occasionally rupture and thus results more or less effusion,

so that rigidity and edema may persist for a long time. The bones are

very frequently damaged. This may be a simple bruising of the tissue

but more often, as osteopathic diagnosis shows, there is partial

displacement of the bony structure.

A point of great importance that every experienced osteopath will

agree to is the following from Moullin: “Diseases of the spine, hip,

and other joints in children may be due, in great measure, to some

constitutional taint, though it is open to question whether the

influence of this is not overrated; but it is quite certain that the

immediate starting point in nine cases out of ten is some chance

sprain, often so slight as scarcely to have been noticed at the time.”

Before treating a sprain there are one or two points the osteopath

should carefully note: first, that there is no complicative fracture;

second, in children that there is not an epiphysial separation; and,

third, note peculiarities of a constitutional character that would

complicate matters. Whatever is done, always give the patient the

benefit of the doubt.

If the patient can be seen early, before swelling has reached the

maximum, many times a very quick cure can be secured. Do not at

once put the part at rest and apply cold, but examine the sprain

most carefully and thoroughly and readjust first of all any bony

defects; then replace the softer tissues if displaced, and next relax

contractions; follow this by light massage and passive movements to

reduce and combat hemorrhage and swelling. This treatment alone in

a fair percentage of cases will be all that is necessary provided

frequent subsequent treatments of massage and passive movements are

continued to reduce and counteract inflammation and to prevent rigidity

and stiffness of the softer tissues. Where the osteopathic treatment is

distinctly indicated is in the readjustive manipulation. This is the

reason why the treatment is so efficacious, and the patient is cured in

a fraction of the usual time, and few sprains result in complications

and become chronic. In sprains that have become chronic there will

be found almost invariably some osseous tissue slightly displaced.

After correcting this, apply careful and thorough manipulation and

massage and movements to break up adhesions, to remove effusions and

extravasations, to relax muscles, and to promote normal circulation.

Care should be taken that there are no displaced cartilages, ligaments,

tendons, or muscles.

It is well to keep in mind that the osteopathic readjustive

manipulation is not an exercise or movement, but definite, specific

correction of the tissues anatomically. Do not treat the displacement

by any general “pommelling,” but apply the mechanical principles

indicated as in any dislocation. This will mean much to the patient in

more ways than one, and especially so should the sprain be so severe

and complicated as to demand anesthesia for correction.

There is no objection to the employment of cold and heat; in fact, both

are beneficial. Cold to prevent extravasation and swelling, and heat to

remove and relieve the same, is a sound and practical method. But do

not apply a wet bandage. Pouring cold water over the sprain is the best

method; even better than immersing the part. An ice bag is another good

way to apply cold. When the skin begins to look blanched and dull the

maximum amount of benefit has been secured. Heat at the very first may

be employed instead of cold, for it has a tendency to prevent bleeding

and inflammation, but the temperature of the application must be hot as

can be borne or else the desired effect will not be obtained. Later on

to relieve pain and rigidity, and to relax the muscles so that a better

circulation will be secured, moderate heat will be beneficial. Then the

application of heat and cold alternately will be of service, employed

as a douche for a tonic effect, when the part is weak, inactive,

and powerless after the elapse of several days. It should always be

remembered that the employment of heat and cold is only of temporary

benefit, so if used too long opposite effects to those desired will

result.

Bandaging the sprain may be helpful, but not always. Great care should

be taken as to how pressure is applied. Bandaging from periphery

toward the trunk, seeing that the bandage is smooth, and padding all

depressions so that the bandage does not touch bony prominences only,

are necessary. Unless the bandage is applied so that an even pressure

is secured, the material used not too warm, and the bandage attended to

each day, the effectiveness will amount to but little.

Next, do not make the mistake of resting the injured joint too much.

The function of a joint is movement, and it has been observed that

prolonged rest of a healthy joint may result in rigidity, stiffness,

and distension of the soft part, and even serious organic changes

in the ligaments, synovial membrane, and cartilages have occurred.

Consequently continued passive movements should be kept up from the

inception of the injury, although it must not be carried to extremes

so that inflammation, hemorrhage, or laceration will be aggravated.

Moullin says: “As a rule, passive movement may be commenced from the

second day with the certainty of preventing adhesions, and without

the least fear.” Osteopathically, with due attention to readjustive

manipulation, and care as to correct position and rest, passive motion

will be allowable usually from the first day.

There is much corroborative evidence in current medical literature that

bears in a general way upon part of the foregoing. The International

Text Book of Surgery says: “Massage should begin early, in order to

avoid, as far as possible, weakness of the muscles, and to ensure

security to the position of the joints by the retention of a proper

tone in them;” besides, early movement tends to reduce the effusion

into the tendon sheaths around the articulation, which in some cases,

particularly the ankle and wrist, may be a very prominent feature. The

Reference Hand Book of the Medical Sciences voices the same opinion;

and Mumford is referred to as follows: “Immobilization for more than

a few days, as under the older methods, is objectionable because

adhesions are apt to form, thus causing impairment of function, and

because when there is a =tubercular taint=, proper conditions for a

localized tuberculosis are established.” Among other statements Holder

Sneve in the Journal of the American Medical Association of June 1,

1901, says: “Immobilization of muscles is not rest. On the contrary,

in all sprains the muscles should have passive exercise the first few

hours and days, and active exercise after that. In the majority of

cases active exercise should be instituted from the beginning. The

plaster cast should not be used at all, even in cases where we have a

fracture, unless it be impossible to maintain a proper position of the

joint.”[42]

Again quotation is made from Moullin. These quotations are taken

from the chapters on Manipulation and Massage. It will be observed

he makes a distinction between the two methods. And the osteopath

should carefully keep in mind not only the difference between the two,

but beyond these the more fundamental treatment, readjustment. The

characteristic feature of osteopathy is anatomical readjustment, and

this in sprains should be supplemented by massage (superficial work),

and also manipulation (deep and more or less forcible work) in order to

remove stiffness, rigidity, and fibrous ankylosis.

The following is relative to forcible manipulation: “Manipulation

is much more useful than division; it can be employed for such a

variety of purposes. In the early stages it prevents the occurrence of

stiffness or the formation of adhesions. Later, when the swelling and

heat have disappeared, it is no less successful in restoring freedom

and ease of movement, and afterward, when all mechanical obstructions

have been cleared away by its use, it is one of the most effectual

methods known for bringing back the circulation and nutrition of the

part, and giving again to the muscles and nerves the energy which has

so long been wanting....

“To carry this out effectively two things are needed beyond all others.

The one is a sense of touch so delicate that it can appreciate the

least resistance or irregularity of movement; the other an accurate

knowledge, not merely of the ordinary anatomy of the part, but of

the different degrees of tension that fall on the ligaments in every

position of the limb.

“Each joint requires a different kind of manipulation according to its

construction....

“There should be no jerking. The movements must be vigorous and

forcible, but perfectly smooth; and they must be carried out

thoroughly, the joint being moved to its full extent in all directions

that are natural to it. Each kind of action should be combined

successively with the rest, one by one, so that the tension may fall in

turn upon all the different parts of the capsule.

“Movements which are especially restricted or painful, of course

require most attention, but the others, though they may not be affected

to the same extent, are not to be neglected. It sometimes happens if

these are dealt with first, that a considerable proportion of the main

obstruction is cleared away, as it were, by side attacks, so that when

its turn comes it yields more readily than it otherwise would.

“Recent slight adhesions give away at once without a sound, though the

sensation is generally conveyed to the hand. When they are older the

noise may be as loud and clear as when a bone is broken....

“The after treatment of these cases (cases where there has been

tearing and breaking of adhesions) should be in all respects the same

as that of a recent sprain, only if passive motion at an early date

is advisable to prevent the occurrence of stiffness in the one, it is

absolutely necessary in the other.”

The following pertains to massage of sprains: “Massage, in the strict

sense of the term, is a great deal more efficacious, especially with

older sprains. Its action is not limited to the skin and superficial

structures. These undergo immense changes, it is true; they become

softer and finer while under manipulation; their strength and

elasticity increase, the extreme tenderness diminishes, and the natural

appearance and texture return. The surface loses its dry, harsh

character and becomes warm and moist again; the livid bluish color

gives away to a brighter hue, and the deeper layers of fibrous tissue

yield and stretch, so that the hide-bound, shrunken condition that is

often present after long disuse gradually passes off. But the good

effect is not by any means limited to, or even most conspicuously shown

by, this. When properly carried out, massage exerts a simultaneous

influence on muscles, nerves, and vessels; in fact, on all the tissues

within its reach.

“The circulation is the first thing to feel its power. It has already

been explained how, after prolonged rest, the blood, as it were, lies

almost stagnant in the tissues, slowly circulating through them, and

neither giving them sufficient for their nutrition, nor removing from

them the waste products of their action. This is changed at once. The

life of the part is quickened. The veins and absorbents are emptied

first, and the fluid they contain driven out into the heart, which

fills more rapidly, and contracts more vigorously and firmly. Then

the pressure falls in the smaller vessels, and the tiny irregular

spaces, full of lymph, which extend in all directions through the

tissues. These, in their turn, are compressed and mechanically emptied,

their contents being driven on into the empty vessels, from which any

backward flow is prevented by the valves. The circulation becomes more

rapid; nutrition is carried on with greater energy, and the actual

amount of the blood in the tissues at any one time so much increased

that they become full and soft to the touch and regain the even and

rounded contour of active health....

“It is most essential to commence as gradually and as gently as

possible, working on the deeper tissues only after the more superficial

ones have become thoroughly accustomed, and have been unloaded of their

surplus fluid. The skin, the soft subcutaneous tissue, the muscles,

and the deeper layers, must all be worked in turn. Nor should the

manipulation be confined to the injured part. In a sprain of any

standing, the whole of the limb is affected more or less. It is usually

better to devote attention first to the parts nearer the trunk than to

deal with those around the injured area, and only afterward, when the

circulation is thoroughly reestablished, to manipulate the joint itself.

“The tendency is to make the sittings last too long. Deep manipulation

itself rarely requires more than =five minutes=; but in dealing with

a recent injury it may be advisable to spend a longer time than this

over the friction and other preparatory measures, so that a quarter

of an hour soon passes by. When the tenderness is very great, and the

amount of swelling excessive, much longer than this may be necessary,

but short, frequently repeated sittings are of greater benefit than one

long one. A skillful operator, too, will often effect more in a few

minutes than an ordinary rubber will in as many sittings.”

A summary of the general treatments of sprains would be as follows:

1. Readjustment of parts and removal of obstructions. Osteopathy is

especially adapted in these cases, for two of the primal therapeutic

factors in all cases from an osteopathic viewpoint are to readjust the

anatomical and to remove obstructions. One should constantly keep in

mind, “a temporary displacement followed immediately by a return to

place, constitutes a sprain.” The osteopath often finds that a perfect

returning does not take place, and even remote lesions may affect a

joint.

2. Manipulation, and massage of soft tissues, to restore circulation

and to prevent and remove debris from rupture of vessels and

inflammatory products.

3. The employment of cold, heat and pressure, and a certain amount of

rest.

4. Anatomical readjustment and manipulation in chronic cases to break

up adhesions, remove exudates, overcome the organized products of

inflammation, and cure synovitis.

5. Movements both passive and active to stimulate and exercise

functions of the joint.

=The Spinal Column.=—The osteopath is especially cognizant of the

fact that many sprains occur to the spinal column. These may affect a

single joint, or more or less of a section may be involved. The bones,

ligaments, tendons, muscles, or spinal cord may be found injured. Even

distant organs, through involvement of the circulation to the cord, or

through irritation or impingement of spinal nerves and sympathetics,

are frequently disordered. It is not necessary to go into detailed

description, for the points bearing upon this will be found under

Osteopathic Diagnosis, Etiology, and Technique, and the general

description will, also, apply. Readjustment, strapping, heat, massage,

manipulation, ironing, stretching of muscles, fomentation, etc., have

their place. There is no doubt that sprains, strains, and blows to the

spinal column are the cause of many spinal disorders and consequent

visceral disturbances.

=The Ribs.=—Sprains of the vertebral ends frequently occur, resulting

in a partial luxation, stretching of ligaments, contraction of muscles,

and exudative formation in the joint structures, which often is the

cause of irritation to the sympathetic nerves. The costal cartilages

are frequently strained, and may so irritate the intercostal nerve as

to cause considerable pain both locally and reflexly. The treatment is

essentially one of replacement, and relaxation of the softer tissues.

Adhesive strips to limit movement due to respiration may be helpful.

=The Innominata.=—Sprains of the innominata are also commonly met

with. Besides being a source of discomfort to the patient they are

an important cause of pelvic disorders and leg affections. Partial

displacements are the rule, the correction of which gives quick relief.

Where there is considerable spasm of muscles, examine carefully the

lumbar alignment. In chronic cases fibrosis of muscles and adhesions

may complicate matters.

=The Hip Joint.=—Sprains involving the hip joint may be readily

corrected, and again may be the exciting cause of serious involvement.

Previous tubercular disease can be aggravated in this manner, or

syphilitic changes in the joint disturbed. Care should be taken

that there are no complicating displacements of the innominata or

irritations to the spinal nerves. Possibly the hip may be so strained

as to cause a twist of the femur in the socket and thus simulate a

partial dislocation; this, in fact, would probably be termed a partial

dislocation. Strain of one set of muscles about the hip joint is

somewhat rare, and spinal lesions may disturb the innervation to one

set of muscles. In cases of =intracapsular fracture= considerable can

be done by careful massage and manipulation after union has taken

place, to secure greater freedom of movement and strength of the limb.

Likewise in =hip-joint disease=, after the disease is healed, massage

and manipulation will be very beneficial. Care must be taken if the

treatment causes spasticity of the muscles; this shows the treatment is

irritative and should be stopped until the spasticity has ceased. Where

the limb is shortened from either hip-joint disease or intracapsular

fracture apparent lengthening may be secured by careful abductive and

hyperextensive stretching.

=The Knee.=—The knee is the most complicated joint, and sprains are

apt to be very serious. The usual treatment for sprains is employed.

Occasionally the semilunar cartilages are displaced and may be a

source of difficulty in diagnosis; likewise injuries to the patellar

tendon and lateral ligaments. Another joint frequently overlooked is

the innominate. In a number of knee cases that terminate in chronic

synovitis there will be found a displacement of the innominate that

is preventing recovery. A villous synovitis may arise in strains from

faulty posture, especially in the obese. Injury to the hip-joint, also,

may cause strain or irritation at the knee. Occasionally tender points

about the knee, especially at the inner side, are due to irritation at

the hip, or possibly from the spine. Referred pain of the knee joint is

of frequent occurrence.

=The Ankle and Foot.=—The ankle is often sprained. One should examine

carefully for a possible fracture of the malleolus, and for fracture of

the tibia. There may be a dislocation of the fibula, also a separating

of the tibia and fibula at the ankle. The common bony displacement

takes place between the astragalus and os calcis. Then the cuboid is

frequently displaced, and occasionally the navicular. The treatment

should first of all be directed to correction of the osseous lesions.

The arch of the instep may be weakened from the ligamentous strain and

be an immediate step in the production of =flat foot=. Teall is of the

opinion that lumbar and innominate displacement are common predisposing

causes. Faulty position of the foot in walking may be an underlying

factor.

=Bunions= result from a malposition of the joint. =Morton’s disease=

due to a pinching of the metatarsal nerve will often yield to

osteopathic treatment alone. There is generally displacement of the

metatarsal bone. A pad worn directly under the painful point will be of

benefit. In many of the local neuralgias, some anatomical displacement

will be found as the exciting cause. =Hammer-toe= if not complicated

with gout, rheumatism, etc., will yield to treatment if kept at

persistently, otherwise surgical interference will be necessary.

Likewise various deformities of the foot and resulting neuralgias

may be traced to local sprains, ill-fitting shoes, or anatomical

maladjustments higher up of such a character as to affect the pedal

circulation.