We’re back in our home in Gatlinburg, Tennessee, right at the entrance of the Great Smoky Mountains National Park. That means a lot of fall hikes through the woods for us, and, let’s face it, we ain’t no spring chickens so we’re at risk for sprains, strains, and other ortho injuries more than ever.

Your muscles, bones, and joints give the body strength, support, and movement. The amount of work these structures are called upon to perform over a lifetime is pretty impressive, and like any other moving parts, are subject to stress and wear.

Off the grid, the group medic can expect to be constantly bombarded with patients that present with sprains, strains, and even fractures. In most cases, full recovery can be expected but, in others, there could be permanent loss of function.

JOINTS

A joint is the physical point of connection between two bones. It allows for a certain range of motion. The components include:

• Ligaments: Ligaments are fibrous tissues that connect one bone to another, oftentimes across a joint.

• Muscles: Muscles are elastic bundles of protein soft tissue that function to produce force and motion.

• Tendons: Tendons are cords of strong fibrous tissue attaching a muscle to a bone.

• Fasciae (fa-sha): Fasciae (singular: fascia) are similar to ligaments and tendons in that they are strong fibrous connective tissue.

Tendons join muscles to bone, ligaments join bone to bone, and fasciae often surrounds muscles and other tissues in “compartments.” Injuries to bones themselves can involve bruising (bone contusions) or actual breaks (“fractures”), something we’ll discuss in other articles.

The tissue damage we’ll discuss here include:

• Sprains: A sprain is an injury where a ligament is excessively stretched or torn by forcing a joint beyond its normal range of motion.

• Strains: Strains occur when a muscle or its tendon is partially torn as a result of an injury.

• Ruptures: A rupture is a severe, often complete tear through a ligament or muscle.

SPRAINS

Joints provide mobility and locomotion and can bear an incredible amount of stress without mishap. When ligaments are torn, sprains occur. Most common sprains involve the ankle, wrist, knee, and fingers. The most likely signs and symptoms are:

• Bruising

• Swelling

• Pain

Some categorize sprains as Grade I, II, and III based on the amount of tearing.

Treatment for most sprains is relatively straightforward and follows the easy-to-remember R.I.C.E.S protocol: Rest, Ice, Compression, Elevation, Stabilization.

REST: It’s important to avoid further injury by not stressing the injured joint. In some circumstances, you may not have a choice, but continued strain will cause further damage to the weakened ligament. Cessation of whatever activity led to the injury will give the best chance for a full recovery.

ICE: Cold therapy decreases both swelling and pain. The earlier it’s applied, the more effect it will have in speeding up the healing process. If you’re in the wilderness, you might have to stick your ankle in a stream to get some cooling action. The medic should always have a supply of “shake and break” cold packs in their medical kit. Cold therapy should be performed several times a day for 20-30 minutes or so each time. It’s most effective in the first 48 hours after the injury. This is followed each time by applying compression.

COMPRESSION: A compression bandage is useful to decrease swelling and should be placed after each cold therapy. This will also help provide support to the joint. After applying some padding to the area, wrap an elastic (“ACE”) bandage around the injured area and some space below and above it (described below). The wrap should be tight, but not uncomfortably so. Any tingling, increased pain, or numbness tells you that the wrap is too tight and should be loosened. Excessively tight wraps also may affect the circulation: You may notice the fingertips or toes becoming white or even blue. Loosen immediately.

ELEVATION: Elevate the sprain above the level of the heart. This will help prevent swelling at the site of the injury. Swelling (also called “edema”) is caused by fluid that pools where the inflammation is and where gravity will allow. By elevating the leg, you allow the fluid to process itself back into circulation and aid the healing process, or at least not impede it.

STABILIZATION: Immobilizing the injury will prevent further damage. This may be accomplished by the compression bandage alone or may best be supported with a splint or a cast. Such a strategy will help support the patient who is unable to place much weight on the joint. Splints may be commercially produced, such as the versatile SAM (Structural Aluminum Malleable) splint or be made of casting material (without surrounding the entire limb). They may also be improvised with sticks and cloth or pillows and duct tape.

SPRAINS VS. FRACTURES

We are often asked how to tell the difference between a sprain and a fracture. Sometimes it’s quite easy, as when, due to trauma, a straight bone is suddenly “zig-zag” in shape. Many times, however, it’s hard to determine without modern diagnostic tests (not an option in long-term survival). Look for one or more of these signs:

• A sprain will generally have less pronounced swelling and bruising than a fracture.

• A person can usually walk a few steps both immediately and an hour later with a sprain. A fracture is generally so painful that no pressure may be placed on the injury at all.

• Sprains are rarely associated with breaks in the skin, but fractures may (an “open” fracture”).

• Sprains involve joints. Injuries in the middle of a bone are more likely fractures or other injuries.

• Swelling on one side of, for example, an ankle is more likely to be a sprain. Swelling on both sides suggest a fracture.

• A fracture may show motion in an area beyond the joint (if your finger suddenly has five knuckles, you probably broke it).

For sprains, Ibuprofen serves as an excellent anti-inflammatory and pain reliever. Natural remedies may also help. The green underbark of willow, aspen, and poplar trees contains salicin, a natural pain medicine from which the first aspirin drugs were manufactured.

Most sprains, (such as wrist and ankle sprains) commonly heal well over time using the R.I.C.E.S. protocol, pain relievers, and a lot of rest. Others, however, such as severe knee sprains with torn or ruptured ligaments, may heal completely only with the aid of surgical intervention. It’s important to get joint issues dealt with while there is still a functioning medical infrastructure in place. During uncertain times, you (and your joints) want to be in the best shape possible to face the challenges ahead.

STRAINS

By far, the most frequently seen strain will be to the back muscles. Strains, especially back strains, involve injury to the muscle and their tendons. As the lower part of the back holds the majority of the body’s weight, you can expect the most trouble in these muscles.

Some of these injuries are preventable with simple precautions:

• Start the day with stretching exercises to increase blood flow to cold, stiff muscles and joints.

• When lifting a heavy object, such as a backpack, keep the back straight and let your legs perform the work.

• Objects should be close to your body as you lift them (don’t reach).

• For packs, keep the weight on the hips rather than the shoulders.

• If you are on rocky or unstable terrain, consider using a walking stick for balance.

Remember, any weight-lifting action that you perform while off-balance is likely to result in a strained muscle. Treatment involves cold packs to decrease swelling for the first 48 hours or so. After that, heat packs may be more effective in providing pain relief. Ibuprofen is an excellent anti-inflammatory and pain reliever for these types of injury. For muscle injuries, prescription relaxants such as Diazepam (Valium) or Cyclobenzaprine (Flexeril) will also provide relief. Assuming these are not available, the victim will benefit from massage of the strained muscles.

RUPTURES

For all ruptured tendons, begin with the standard RICES protocol. Ruptures of particular muscles/tendons require proper positioning. For front upper leg (quadriceps) injuries, stabilize with the knee straight. For a biceps (front upper arm) rupture, immobilize with the elbow at 90 degrees.

Although some ruptures are best treated with surgical repair, lesser strategies may work for certain injuries off the grid:

-Achilles tendon (back heel area). Immobilize the area so that the foot is pointing down for 8-12 weeks.

-Biceps ruptures. The affected arm is stabilized with a sling at a 90 degree angle. Recovery without surgical intervention often ends with decreased strength and the inability to go from a palm-down position to a palm-up position (supination).

-Rotator cuff injuries. The rotator cuff is made up of several muscles and tendons that keep the upper-arm bone (humerus) in the shoulder socket. Chronic damage is often treated without surgery, as a percentage of symptoms will decrease with time. Sudden tears are more complex.

-Quadriceps (front upper leg) tears. Quadriceps tendon injuries may be immobilized for about 6 weeks, or at least until the patient is able to raise the affected leg without discomfort for two weeks.

It should be noted that recovery from these injuries varies from individual to individual and can be prone to re-rupture. In normal times, most are treated surgically, especially in younger patients. Failure to do so often leads to reduction in strength and range of motion of the affected extremity.

Preparedness folk needs to be at 110 percent efficiency when the you-know-what hits the fan, so do everything possible to “tune up” orthopedic injuries before a disaster occurs. The last thing you need is a bum knee in times of trouble.

Joe Alton MD

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