Imagining the Numskulls in the context of how bones heal

I don’t know whether you remember the Numskulls? This was a cartoon strip involving little people who lived inside the head of a person and did all of the hard work to make the person’s life function. 

I thought that they might be a helpful analogy for understanding why we really do need to give a broken bone the time to heal properly. So I created a couple of new characters:  

  • Mr(s) Preparation with a broom and all of the cleaning materials
  • Mr(s) Repair with a full tool-belt and DIY kit and team to help build the structure
  • Mr(s) Remodeller with the filler and sandpaper to make it fit in with the rest of the bone

Just like the healing of surgical cuts and tendons/ligaments/cartilage (covered in previous blogs) there are 3 phases, which I have added a little detail to below. Sadly all of this process goes a little slower when we are older (like most things!) – so worth adding a little extra time if you are older and ensuring that you pay even closer attention to the cues from your body.

  1. Reaction – with inflammation and initial tissue formation. The severed blood vessels in area of the break (or fracture – same thing) in the bone release blood into the area and this forms a clot very quickly (normally within a few hours). Then the first few days are characterised by a lot of inflammation as some of the body’s cells start to clear away the bone fragments and other damaged cells. In parallel, the new blood capillaries that have grown into the area bring the cells that start to build fibres to connect the bone and lay down the spongy bone structure.
  2. Repair – initially with a cartilage callus formation and then with bone: this stage starts after about 7-9 days and takes about 2 months to join the two ends together with a bony connection that has most of the bones original strength. During this time it hardens from being a fibrocartilaginous callus to a bony callus matrix, which evolves through two stages of bone hardening. This is often wider or thicker (so much so that you can feel this under the skin).
  3. Bone remodelling: The bony callus is remodelled over the next months (and often takes as long as 3-5 years) with the excess material on the outside and other locations being removed. There are also different layers of bone, so the remodelling gets back to the correct layering of these different types of bone – rather than the fast fix of the callus. Areas of well-healed breaks can remain uneven for years, but with 5-7% of bone mass being remodelled in the body each week, this will get fixed in time.

How is the fracture treated?

If you are lucky with your break, you have not got an infection in the fracture, and there is not the issue of the bone ends not coming together at all, or not coming together in the right way, or coming together too slowly.

These days it seems that many more people are having their fracture stabilised with surgical insertion of plates and screws (which generally stay in forever) and are being given a sling or protective boot, rather than the plaster-cast of old. The reasons for keeping away from the plaster-cast are often to maintain Range of Movement, but are not meant for you to keep doing your sport in the same way!

So what happens if you try to exercise with a broken bone?

Let’s go back to our friends the (new) Numskulls that I introduced at the start of this blog.

In those early days Mr(s) Preparation is out there working her socks off trying to clean everything up ready for Mr(s) Repair to get going. But if the area keeps getting moved, vibrated or jogged more bit of stuff keep falling off and Mr(s) Preparation keeps getting called back and getting in the way of Mr(s) Repair.

Likewise, Mr(s) Repair is trying to build out a new structure into the gap. This job takes weeks (like most building jobs!) and happens once the worst of the swelling and inflammation has passed. But if the area keeps getting moved, vibrated or jogged the bits fall off – meaning the work has to be done over and Mr(s) Preparation has to keep coming back and cleaning up again, rather than sitting down and having a cup of tea!

So activities like running and strong movement of the area lead to delay and having to repeat the healing

But there are a number of things that you can do to really help the healing:

  1. Good nutrition: the body needs a lot of nutrients to heal the bone, so ensuring that you have a good balanced diet with enough protein, and key vitamins (C and D) and minerals (Calcium, Iron, Magnesium and Phosphorus)
  2. Sleep well at night: a lot of healing happens in the deep sleep phases, so ensuring that you are getting your head down for a good uninterrupted 8 hours of sleep (or more if your body feels that it needs it) will be a big help.
  3. Avoid aspirin and ibuprofen, if you can: there can be a lot of pain, especially in the early inflammation stages, but the problem is that aspirin and ibuprofen delay the body’s natural healing process and therefore delay progress. So the sooner that you can stop taking them, the better. (There are some other medications that have impact – so worth checking with your Doctor, if you are taking any medication)
  4. Avoid smoking and limit alcohol intake
  5. Don’t feel tempted to test your broken bone whilst it is healing! Do keep it immobilised and work out how to take away risks in your day-to-day activities that could lead to a knock to the area. If you have been told that you must not be weight-bearing, then respect that and get shower chairs, scooting devices, crutches etc that enable you to do this all of the time (cycling gloves are brilliant for protecting your hands If you are on crutches).

So no sport at all?

You should review this with your medical team and coach. Depending on the fracture and the treatment, there may be some things that you can safely do that keep your strength and give you a cardiovascular workout whilst keeping the fracture immobilised. I have seen some really clever ideas that are safe and keep things going.

But if that is not possible? This is 6-8 weeks of your life. Add up how many weeks you have been alive (52 weeks per year!) – and this 6-8 weeks will be a very small percentage. Be kind to your body: let those Numskulls go their job without having to keep going back and repeating it, because you knocked down their hard work!

Good luck and keep smiling!

How do musculoskeletal injuries heal?

Following my blog on how the body heals from invasive surgery (http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/) , I thought that it would be useful to do the same for musculoskeletal issues, since these are common injuries for athletes. This is a really huge topic, and I have struggled to get down the most relevant parts into something that I think may be useful for injured athletes and coaches to understand what questions they will ask of the medical team treating them. I have not covered musculoskeletal diseases such as osteoarthritis, carpal tunnel syndrome, tendonitis etc (many of which qualify as a disability under Social Security, if the symptoms reach a certain level of severity), as these are much more complex and long-lasting.

The challenge of most of musculoskeletal injuries is that they generally involve tendons (which connect bones to muscles), ligaments (which connect bone to bone) and/or cartilage (the soft, gel-like tissue that provides cushioning and enables movement in joints). The white colour of these tissue types give a clue to the fact that they do not have their own blood supply. This means that they heal much more slowly than damaged skin or muscles (which have their own blood supply). The surgical view is that they do not regenerate and this is why often surgery is offered – mending torn tendons and ligaments and replacing ruptured ones.

You need to play an active role in healing musculoskeletal injuries

Whilst the fundamental phases of healing are the same as a cut or muscle tear, there are a couple of key differences that you need to act on:

  1. the pain signals through the healing phases are very different and you need to actively manage your way through this – at times managing the pain to protect the healing of the correct Range of Movement for your body. It seems counter-intuitive not to listen to the pain in your body, but this is the reason.
  2. you do need to actively rehabilitate the area through each of the 3 stages, as it is unlikely to heal correctly without your active focus and support: initially using the ‘POLICE’ protocol (see below) and then with range of movement for that joint and then specific strengthening of that area. When you are in a lot of pain, the constant health professional exhortations of ‘keep moving’ may not seem to be very helpful, but this is the reason why.
  3. this is a long-term game, and you can expect to need to focus on this for a period of 12 to 24 months. But for those who stay the course and do the right things, the results do come.

Stage 1 of musculoskeletal healing – Inflammation.

The swelling and redness may be hidden inside the joint, but the symptoms will be such that no time day or night is pain-free and you may be able to detect the heat coming from the joint, as well as the tenderness, pain and loss of range of movement. If rest or a change of position gives relief, then the healing has progressed to the repair stage. The inflammation stage generally lasts 3-5 days, but can last a lot longer and if you re-injure or re-inflame the same area, then you go back into this stage.

The point of this stage for the body is protecting the area with swelling whilst it lays the foundations for the healing – clearing out the damaged cells and starting to spin webs of protective tissue that bind the wound together and stop the flow of liquids through the area.

This is the stage that you really need to apply the ‘POLICE’ protocol. This has replaced the old ‘RICE’ protocol (see the table below). So that in the past, the recommendation was Rest, get an Ice pack on the area, use Compression and Elevate the limb. All of these are designed to reduce the inflammation and allow the body to get through this first stage. Interestingly, anti-inflammatory medications do reduce the inflammation, but interfere with the body’s natural management of inflammation – so as soon as you are out of the immediate pain it is best to stop taking these in order to encourage the cellular-level healing process to begin.

The new ‘POLICE’ protocol reflects the fact that the latest medical studies suggest that some movement is good, even at these early stages. So ‘Protect ‘the joint from the bad motion that has caused the injury (eg twisting), with support, splinting or bracing as needed. Then work to get ‘Optimum Loading’ – moving the joint through the range of movement in every-day activities, but not causing additional pain. This is why we see increasing numbers of people in protective boots and slings, instead of full plaster-casts. The view on ‘Icing’ has also developed – and the guidance is that you should not apply it for longer than 10 minutes and more than 3 times per day (as too much icing can also damage the tissues).

P = Protect
OL = Optimum Loading
R = Rest
I = Ice I = Ice
C = Compression C = Compression
E = Elevation E = Elevation

Stage 2 of musculoskeletal healing – Repair or Proliferation.

During this stage the body develops the new tissue, initially haphazardly and then starting to align these cells correctly. This stage usually starts from a week after the injury and lasts 6-12 weeks or longer. Pain usually comes and goes, according to the position or movement of the body. If pain or fear of pain inhibits movement in this stage, then the pattern with which the scar tissue is laid down can inhibit movement significantly and reduce your body’s ability to function. Failure to stretch and move at this time will lead to weak, but tight muscles that are intermittently painful and vulnerable to re-injury. Therefore you really need to consistently (and gently) put the body through a normal range of movement and the unhelpful cross-fibres will be broken and the useful fibres that support the usual range of movement will be strengthened.  If this repair stage does not lead to correct healing, the danger is that the body will start to develop workarounds and compensating movements, which can lead to aches and injuries elsewhere as the body moves into the third stage of healing with the wrong fundamental structure in the injury area.

Stage 3 of musculoskeletal healing – Remodelling or Maturation.

In this stage the tissues build their flexibility and strength, and this lasts at least 6 months and can be two years or more. Even now, you may get some pain with certain movements (especially when you take the movement to the end-zones of the Range of Movement – which you do need to do), or you may be pain-free. This is why usually from around 4-12 weeks after injury (depending on the injury: follow your surgeon’s or physio’s advice), you should be adding in some strength-based training – starting very gently and slowly building up to 3 sets of 10 repetitions (working to failure), with a day or two of rest between sessions for the body to recover and rebuild (in line with the progressive overload model of development) and obviously backing off if the level of pain increases.

If you do not keep rehabbing the area, there is a very strong probability of significantly reinjuring it because it is so far below strength. This is very challenging, as it is usually just one or two exercises that you need to do over and over again, gently progressing them. And before you have done this, it may well be too premature to go back to a repetitive loading activity like running, or even cycling. Many people do not have the patience to do this progressive strengthening over the period of 12-24 months that it takes, and this is one of the reasons why re-injury is common. Even with the correct rehab, the area often stays 20% weaker than before the injury.  Hence you will need to keep looking at your form to check that there are not compensation behaviours that will cause other injuries, and look at your activities to check that you are giving it the protection that it needs.

Why pain makes this all so much harder

The challenge for many people in chronic pain* is that the correct level of managing the inflammation, mobilising the joint to get the range of movement and strength building across the 3 phases is hard to do. The pain makes them avoid exercise and stretching required for correct healing. At times the level of incorrect healing in stage 2 can need significant manipulation (even under general anaesthetic) to break up the adhesion and re-stimulate inflammation. You then effectively start back at phase 1 of healing, and need to ensure that stretching (for Range of Movement) and exercise (to stimulate the limited blood supply to the area) then begin the process of rehabilitation.

As well as medications, guided corticosteroid injections into the area are common and can bring very significant short-term relief. You need to make the decision on these with your Orthopaedic Consultant. The only anecdote that I would pass on is one where an athlete had a number of injections into the tendon over a 2-year period, and the tendon did rupture. One of the questions was whether the perforations from the multiple injections had played a role.

* The definition of chronic pain varies, but it is long-term pain and most seem to define it as having lasted for over 3 months or over 6 months. I think that the key definition is having been in pain for that length of time, you get to the stage where you adapt your physical, mental and emotional approaches to life (whether consciously or unconsciously) as a consequence of the pain. As well as these external impacts on your life, the internal impacts of your body swimming in the chemicals associated with inflammation and the nerve pain patterns can also have significant impacts on your healing.