What is ligament damage?

For the first podcase I am using Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics

                Published in The Open Rehabilitation Journal 2013

                Hauser (MD neurologist), Dolan , Philiips, Newlin, Moore and Woldin.

-The article starts with discussing ligaments function.  Ligaments were once thought to be inactive structures, but they are in fact complex tissues- ligament mediated reflexive control- so important to understand the control ligaments have on muscles (more in future podcasts)

-How often are ligaments injured?  ligaments are the most frequent injured tissues within a joint “most common mechanism of injury is blunt trauma”. 

-Women are more ligament dominate than men & therefore women have more frequent ligament injuries. 

-Once ligaments are damaged what is the healing process?  “injured ligament, lead to inadequate healing and tissue formation that is inferior to the tissue it has replaced. The incomplete healing and lower integrity of the new ligament tissue results in ligament laxity, predisposing the joint to further injury. This cycle of ligament injury and subsequent laxity causes joint instability, which then leads to chronic pain, diminished function, and ultimately, to osteoarthritis (OA) of the affected joint”. 

- Where does OA come from?  Besides some autoimmune diseases it comes from too much movement, not enough movement or abnormal movement in a joint.  This is based upon Wolff’s law (which states bones will adapt to the changes and stress placed on them.  OA remains the long-term consequences of ligament injuries and OA is the most common joint disorder in the world. 

- The article discusses the composition of healthy ligaments.  Healthy ligaments are made of 75% collagen and 25% proteoglycans, elastin and glycoproteins.  Within the 75% of collagen 85% of the collagen is type 1 collagen which helps with the tremendous strength ligaments have.  Proteoglycans store water and contribute to the viscoelastic properties of the ligaments which allows the ligaments to lengthen under tension and return to their original shape.   

-5 stages of healthy ligament stretching:  1=relaxed. 2= beginning stretch (some fiber tight some loose). 3= full physiological stretch (all fibers tight and at the end range). 4= micro tearing. 5= full failure.  Ligament damage goes from micro tearing to full tears. 

-Once ligaments reach stage 4-5 how will they attempt to heal? 3 phases of (attempted healing).

                1- acute inflammatory phase (tissue remodeling phase)

                                Growth factors lead to stimulation of fibroblasts to synthesize ligament tissue

                2- Proliferative/repair phase.

                                Tissue is disorganized scar tissue with blood vessels, fat cells, fibroblasts and inflammatory cells.   Starting to synthesize collagen Type 3 (weaker, less stiff (10-20% viscoelastic properties) and leads to mechanical instability). 

                3- Remodeling phase

                                Maturation of collagen which is similar to scar tissue and remains functionally different from normal tissue.  The remodeled ligaments are different than normal ligaments and remain inferior and laxity results.  This ligament remodeling predisposes the joint to further damage. 

-What will this inferior healing do to the patients?  Traditionally, the cause of OA was thought to be due to aging and wear and tear on a joint, but more recent studies have shown that ligaments play a crucial role in the development of OA.  bones begin to track improperly and put pressure on different areas, resulting in the rubbing of bone on cartilage. This causes the breakdown of cartilage and ultimately leads to deterioration. 

-The article went on to show that ligament damage leads to increased OA and muscle weakness, joint laxity, joint instability and decreased function.  READ AGAIN

- How is ligament damage diagnosed?  In deposition I’ve been asked if there is serious ligament damage why is it not seen on the MRI.  “MRI is not always the best tool of the trade.”  “MRI is unable to detect when ligaments are lax or stretched”.  X-rays or motion x-rays are used to detect changes in joint structure and instability.  (AOMSI history and how to diagnose in a future podcast).  

-They compared management (not cure) of ligament damage to the search for the Holy Grail.  “Therapies can help alleviate the subjective symptoms of pain following a ligament injury, but do not all contribute to the actual healing of ligament tissues. 

-Immobilization and rest: Immobilizing a joint with a ligament injury can cause detrimental side effects.  “Despite this evidence RICE (rest, ice, compression, elevation) continue to be routinely prescribed as first-line treatment”. 

-NSAIDs: NSAIDs have an adverse effect on healing of ligaments by decreasing the inflammation.  Inflammation recruits cells to the area initiating the healing process.

-Cortisone injections: “They inhibit the histological, biochemical, and biomechanical properties of ligament healing”. 

-Diet and nutrition: A diet of low saturated fat and high in micronutrients may help decrease the progress of OA, but no benefit seen with ligament damage. 

-Surgery: “even after ligaments have been surgically repaired or reconstructed, they remain weaker than the original ligaments and are unable to hold the same tensile load”.  No surgical repair for spinal ligament damage besides fusion which doesn’t fix the ligaments. 

-Prolotherapy (regenerative injections and platelet rich plasma):  Has shown an increase in the inflammatory healing response.  Still left with inferior ligament remodeling. 

-Mobilization and exercise: Functional treatment involving motion of the affected joint was a statically significant strategy for healing the injured ligament”.  Patients with mobilization and exercise were able to return to work quicker and resume activities sooner.  They showed a decrease in pain, swelling, stiffness and were able to preserve more ROM.  Showed a decrease in stability on motion x-rays.   Still just a management and not a cure of ligament damage. 

-even with management of ligament damage, the ligaments will remain structurally inferior, lose the ligament mediated muscular reflexive control (more about that in a future podcast), regain 10-20% of the viscoelastic properties, lead to OA and joint instability, muscle weakness and decreased function. 

Real world

This knowledge and article have been really helpful with almost all of my patients with ligament damage.  One that comes to mind is a young single mother.  She was not in a high-speed or high damage MVC.  She worked, went to school and raised a family and did not have a lot of time to come in for care.  She was seen 10 times following the MVC and 2 times the following year.  She had lots of gaps in care.  The PIP threshold in Utah had not been met and this was a difficult client for the attorney.  The patient remained in a lot of pain and dysfunction and would literally cry to the attorney about needing more time to take care of her injuries, but couldn’t find it. 

Motion x-rays were done that showed she had AOMSI (we will discuss this in a future podcast).  The x-rays showed she did have serious and complete ligament damage in her cervical spine.  This article helped with her final report in a couple significant ways.  It showed that Ligaments are the most frequent injured tissues within a joint, with the most common mechanism of injury being blunt trauma and more often injured in women. 

-X-rays showed she has the ligament damage.

-this article supports that blunt trauma as seen in her MVC if it caused cervical pain is most likely her ligaments since they are the most frequent injured tissues and this type of injury is more often seen in women.

- The article showed that following this type of injury the “injured ligament, will lead to inadequate healing and tissue formation that is inferior to the tissue it has replaced. The incomplete healing and lower integrity of the new ligament tissue results in ligament laxity, predisposing the joint to further injury. This cycle of ligament injury and subsequent laxity causes joint instability, which then leads to chronic pain, diminished function, and ultimately, to osteoarthritis (OA) of the affected joint”.

- her x-rays showed no OA indicating that this ligament damage seen on x-ray is not an old injury. 

- this article helps show ligament damage is often micro tearing or complete tearing. This correlated with the motion x-rays showing the significant ligament damage. 

- The article showed that her ligament damage will lead to increased OA and muscle weakness, joint laxity, joint instability and decreased function.

- This article went on to show that healing Tissue is disorganized scar tissue with blood vessels, fat cells, fibroblasts and inflammatory cells.   Starting to synthesize collagen Type 3 (weaker, less stiff (10-20% viscoelastic properties) and leads to mechanical instability). 

- This article showed that there is no healing of this type of injury for my patient but only ongoing management.  In collaboration with a neurosurgeon I work with we came up with a future care plan for her.  As seen in this article increasing movement of the affected joint is the only treatment shown to help manage the injury.  The treatment plan consisted of monthly chiropractic treatment and a home care exercise program.  The future treatment plan from the neurosurgeon reported that she is not a surgical candidate at this time, but her ligament damage is a degenerative type of injury that will lead to OA over the years.  It is likely that in the next 15-20 years her cervical spine may deteriorate to the point she will have nerve involvement and may need surgery at this time.  This future surgery will be directly related to the ligament damage seen in her spine following her MVC. 

-She was given an impairment rating for her ligament damage which was shown to be permanent injury and she was able to overcome the PIP threshold in Utah.  The attorney was able to settle her case for policy limits of $50,000.