Sports Injuries, Tendinitis, and Bursitis
• Tendinitis:
Acute or chronic pain localized in a tendon
Limited range of motion
• Bursitis
Severe pain in the affected joint, particularly on movement
Limited range of motion
This chapter deals with sports injuries (e.g., sprains, strains, and bruises), tendinitis, and bursitis. Tendinitis is an inflammatory condition of a tendon—the tissue that connects muscles to bones. Tendinitis usually results from a strain. Although acute tendinitis usually heals within a few days to two weeks, it may become chronic, in which case calcium salts will typically deposit along the tendon fibers. The tendons most commonly affected are the Achilles tendon (back of ankle), the biceps (front of shoulder), the pollicis brevis and longus (thumb), the upper patellar tendon (knee), the posterior tibial tendon (inside of foot), and the rotator cuff (shoulder).
Bursitis is inflammation of the bursa, the sac-like membrane that contains fluid which lubricates the joints. Bursitis may result from trauma, strain, infection, or arthritic conditions. The most common locations are shoulder, elbow, hip, and lower knee. Occasionally the bursa can develop calcified deposits and become a chronic problem.
Causes
The most common cause of sports injury is sudden excessive tension on a tendon or bursa, producing a strain or sprain. Repeated muscle contraction, leading to exhaustion of the muscle, can result in similar injury. Sometimes tendinitis develops when the grooves in which the tendons move develop bone spurs or other mechanical abnormalities. Proper stretching and warm-up before exercise are important preventive measures.
Therapeutic Considerations
After an injury or sprain, immediate first aid is very important. The acronym RICE summarizes the approach:
• Rest the injured part as soon as it is hurt, to avoid further injury.
• Ice the area of pain to decrease swelling and bleeding.
• Compress the area with an elastic bandage to limit swelling and bleeding.
• Elevate the injured part above the level of the heart to increase drainage of fluids out of the injured area.
Proper application of these procedures is important for optimal results. When icing, first cover the injured area with a towel, then place an ice pack on it. It is important not to wrap the injured part so tightly that circulation is impaired. The ice and compress should be applied for 30 minutes, followed by 15 minutes without the ice to allow recirculation. You want to get the affected area cold, but not so cold that it freezes or damages the tissues.
Of course, for any serious injury, a physician should be consulted immediately. Conditions that indicate the need to see a physician include severe pain, injury to a joint, loss of function, and bruising around or below or pain that persists for more than two weeks.
After the acute inflammatory stage (24 to 48 hours), gradually increase range-of-motion and stretching exercises, to maintain and improve mobility and prevent adhesions (abnormal scar formation). Alternating hot and cold packs are also useful to improve circulation, thus bringing in nutrients and more rapidly clearing the debris from the injured tissues.
Several nutrients are important for the promotion of healing. For example, vitamin C supplementation is important, since vitamin C plays a major role in the prevention and repair of injuries. Deficiency of vitamin C is associated with defective formation and maintenance of tendon and bursal tissues. In addition to vitamin C, vitamin A, zinc, vitamin E, and selenium are important not only for their wound-healing properties but also for their antioxidant effects.
Flavonoids
Flavonoids, a group of plant pigments responsible for the colors of many fruits and flowers, are extremely effective in reducing inflammation and strengthening collagen structures. Collagen is the major protein in tendons and other connective tissues. Flavonoids help maintain a healthy collagen structure by (1) decreasing blood vessel permeability, thereby decreasing the influx of inflammatory mediators into areas of damage; (2) preventing free radical damage by means of their potent antioxidant properties; (3) inhibiting damage to collagen tissue caused by enzymes that break down collagen; (4) inhibiting the release of inflammatory chemicals; and (5) reinforcing the natural cross-linking of collagen fibers to make them stronger.
Double-blind, placebo-controlled studies have shown that supplemental citrus flavonoids cut in half the time needed to recover from sports injuries.1,2 But, given the greater biological activity of the procyanidolic oligomers found in pine bark or grape seed extract, we prefer these sources over citrus flavonoids.
Bromelain and Other Proteolytic Enzymes
Bromelain (the protein-digesting enzyme complex of pineapple) was introduced as a medicinal agent in 1957, and since that time more than 400 scientific papers on its therapeutic applications have appeared in medical literature. In these studies, bromelain has been reported to exert a wide variety of beneficial effects, including reducing inflammation in cases of sports injury or trauma and preventing swelling after trauma or surgery.3
One of the most interesting studies that used bromelain to treat sports-related injuries involved 146 boxers.4 Seventy-four received bromelain; in 58, all signs of bruising cleared completely within 4 days. In the remainder, complete clearance took 8 to 10 days. Among the 72 boxers who did not take bromelain, at the end of 4 days only 10 had completely cleared bruises; the remainder took 7 to 14 days. These results indicate that bromelain goes a long way in reducing bruising, inflammation, and swelling due to trauma.
It is important to recognize that while bromelain has been shown to effectively reduce pain, this probably is the result of a reduction in tissue inflammation and swelling, rather than a direct analgesic effect.
A couple of studies have used a commercial preparation (Phlogenzym) containing bromelain (90 mg), trypsin (48 mg), and rutin (100 mg per tablet). In a study of ankle sprain, Phlogenzym was not found to be effective.5 However, in another study, conducted at the Canadian College of Naturopathic Medicine, postal workers with shoulder (rotator cuff) tendinitis for a duration of more than 6 weeks were randomly assigned to receive naturopathic care or standardized physical exercises over 12 weeks. Participants in the naturopathic care group received dietary counseling, acupuncture, and Phlogenzym (two tablets three times a day). The physical exercise group received passive, active-assisted, and active range-of-motion exercises and a matched placebo. Final total shoulder pain and disability scores decreased by 54.5% in the naturopathic care group and by 18% in the physical exercise group.6
Curcumin
Curcumin—the yellow pigment of turmeric, Curcuma longa—exerts excellent anti-inflammatory and antioxidant effects. Curcumin is as effective as cortisone or the potent anti-inflammatory drug phenylbutazone in animal studies. However, while phenylbutazone and cortisone are associated with significant toxicity, curcumin is without side effects. In human studies, curcumin has also demonstrated beneficial effects comparable to those of standard drugs.7
QUICK REVIEW
• Proper stretching and warm-up before exercise are important preventive measures.
• After an injury or sprain, immediate first aid to the injured area (RICE: rest, ice, compression, and elevation) is very important.
• Deficiency of vitamin C is associated with defective formation and maintenance of tendon and bursal tissues.
• Vitamin A, zinc, vitamin E, and selenium, as well as vitamin C, are important not only for their wound-healing properties but also for their antioxidant effects.
• Bromelain has been reported in scientific studies to exert a wide variety of beneficial effects, including reducing inflammation in cases of sports injury or trauma.
• Curcumin exerts excellent anti-inflammatory and antioxidant effects.
• Physical therapy can aid in pain relief and recovery from injury.
One concern regarding curcumin has been absorption, but there now exist a number of methods and products that enhance the absorption of curcumin. One of those methods is complexing the curcumin with soy phospholipids to produce a product called Meriva. Absorption studies in animals indicate that peak plasma levels of curcumin after administration of Meriva were five times higher than those after administration of regular curcumin.8 Studies with another advanced form of curcumin, Theracurmin, shows even greater absorption (e.g., 27 times greater than regular curcumin).9
There are a number of physical therapy techniques that can be quite helpful in speeding recovery and relieving pain. Perhaps the two most popular techniques are transcutaneous electrical nerve stimulation (TENS) and ultrasound. TENS involves the use of electricity to stimulate muscular contractions. The use of TENS to control pain has been well documented. Individuals with tendinitis have been found to respond well to TENS. TENS therapy may be applied by a physical therapist or physician. In addition, home units are now available.
Ultrasound is a form of high-frequency sound vibration used to heat an area and increase its blood supply and lymphatic drainage. While it is useful during the acute stage (the first 24 to 48 hours) of an injury, it offers the greatest benefit in the recovery phase. It is particularly useful when the bursitis or tendinitis forms calcium deposits, or when adhesions (scar tissue) have formed inappropriately, thus limiting function and increasing the risk of future injury.
TREATMENT SUMMARY
Treatment of the muscle, joint, tendon, or bursal damage caused by acute and chronic injuries involves two phases: inflammation inhibition and protection of the injured tissues, followed by promotion of healing after the acute phase has resolved. For any serious injury (involving severe pain, injuries to the joints, loss of function, or pain that persists for more than two weeks), consult a physician immediately. Utilize RICE therapy for 24 to 48 hours, after which increasing range-of-motion and stretching exercises should be used to maintain and improve mobility and prevent abnormal scar formation.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin C: 500 to 1,000 mg one to three times per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 3,000 mg EPA + DHA per day until symptoms resolve, then 1,000 mg EPA + DHA per day thereafter
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, “super greens formula,” or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• Bromelain (1,800 to 2,000 MCU): 250 to 750 mg three times per day between meals
• One of the following:
Meriva: 500 to 1,000 mg twice daily
BCM95 Complex: 750 to 1,500 mg twice daily
Theracurmin: 300 mg one to three times daily
• TENS if needed for pain control
• Ultrasound: three times per week during the recovery phase and if adhesions or contractures develop