Recovering from an injury can be a nuanced process - there are some symptoms that you should listen to and others that aren’t so important, poor information abounds during searches on Dr. Google, there are friendly recommendations to try certain products, drugs or stretches, and just when you think it is okay to resume your normal activities pain may re-surge. It can be confusing…
That being said, if you focus your attention on the overarching principles of an effective rehab, recovery doesn’t have to be complicated!
Here are few key areas that anyone can assess and will help to simply your return to wellness:
A) If you’ve sustained an injury, rehab will take time. Determining its severity can help you plan your rehab timeline. If it’s a small injury (micro-tearing or grade 1 sprain/strain), allow three days of relative rest for the injured area and slowly start to return to your sport. If it was a moderate or severe injury (grade 2-3 sprain / strain, fracture), you will need more time to allow the injury’s wound margins to heal back together. Due to the magnitude of a more severe injury you will likely benefit from a support (see below) and clever ways of modifying activity/programming.
B) If you are not seeing many signs of improvement from your injury within a week, consulting a health care provider (Physio/Doctor) is a good idea. Diagnosing the injury and its severity will be important for your rehab strategy and long-term success.
A) Make sure that you perform exercises specific for your injury/dysfunction. Your exercises should address all three of the following:
A) Your recovery from an injury may be uncomfortable but it needn’t be exquisitely painful. Utilizing walking aids (crutches/cane/walking poles), braces, taping techniques, medication (oral, topical or injections) or certain types of shoes/orthotics may help to alleviate some of your pain. These supports are not be relied on for very long, but can help reduce the harmful effects of feeling too much pain during your recovery.
4. Activity level
A). Many of my clients see me because they have slow progress or are seeing no progress. This is often because #2 is not being addressed and clients are often doing too much or too little activity in their day to day life. Determining the appropriate amount of activity requires:
Creating a good rehab program is an art. Of course there are other items to consider whilst recovering from an injury, but if you can dial in these four key areas it should help with setting realistic expectations and executing a planned recovery.
As always, if you have any questions feel free to send me an email or leave a comment!
I was in Washington over the weekend cheering on a friend who was running the Orcas Island 50K - what a well run event! http://www.rainshadowrunning.com/orcas-island-50k.html
After the race was finished, one of the runners discussed fear regarding pain on the outside of his knee. Paraphrasing, he said “I have IT band pain that started up around 20km and is quite sore now. It popped up in my last 50 mile race as well.” Despite finishing top 10, his next race will be his first 100 miler and has 3 times more elevation gain than the 50km race.
His greatest fear was that his leg may have some bony protuberance that may cause persistent pain for the rest of his running career. This would be a legitimate concern if this were the case, but the truth is that this athlete jumped to these conclusions and hadn’t tried any strengthening exercises, mobility exercises or formal rehabilitation yet. It boggles my mind how a top 10 finisher can be so amazing at their sport yet but so blind to gaps in their training or rehab. Perhaps it is my cognitive bias, but I digress… haha
Lateral Knee Pain Origin
Common Triggers in Developing Lateral Knee Pain
Lateral knee pain due to the IT band or lateral quadriceps can arise for a number of reasons. Here are a few to consider:
1) Valgus (inward collapse of the knee)
This may be caused by:
- Reduced lateral hip muscle strength (often glute medius)
- Compromised control of the hip muscles (how well the various hip muscles time contraction, intensity of contraction in response to various positions of the leg and in response to fatigue)
- Structural or functional foot pronation… or shoes/orthotics that do not adequately support a neutral foot position
2) One leg that is shorter than the other
Some people are born with or develop (usually through injury) a shorter leg.
- The longer leg has to exert more effort to extend the knee in an effort to propulse the body forward
- The shorter leg could be the victim as it must absorb more force with each landing step as the body will “drop” further down onto this leg with each step.
3) Running on a cambered surface
- Always running on the left side of the road leads to running on a left leaning surface. It has the same impact as running on one leg that is shorter than the other.
4) Strength or mobility/flexibility imbalance
- There is almost always a reason for side to side imbalances. It could be something you were born with or an old injury has led to a one-sided imbalance
5) Your tissues are not “load tolerant” enough to withstand all of the volume you ask of them
- An increase of running volume too quickly in your program may not be tolerated
- An increase of running intensity too quickly in your program may not be tolerated
- Not enough load tolerance has been developed via strength training. Heavy squats, deadlifts, lunges, step ups and lateral hip strengthening exercises are a necessity.
The first steps in finding a resolution requires an introspective analysis and physical assessment of the above items. If pathology exists at the tendon and a few weeks of local and regional treatment does not start to improve your pain then further evaluation may be helpful.
In my experience, when you are in pain it is always best to focus on movement quality and quantity. That is, are you doing the optimal amount and type of strengthening exercises and how is the quality of your movement? Are you doing the correct amount/type of running volume, and how is the quality of your running gait? Are you doing the optimal amount of mobility/flexibility work and is it actually helping to improve any of your limitations.
Stay curious, fight to find answers and work hard!
Impaired Tendon Stiffness
Tendon stiffness is built up over months and years to match the loads we impose on our bodies. In the athletic realm, tendon stiffness increases via general strengthening and sport-specific training programs that either matches or is greater than the needs of our athletic pursuits.
So you have tendon pain? We know that tendons with chronic pathology usually have changes in structure including thickening, increased extracellular fluid (also called ground substance) and degeneration of the collagen matrix. We also know that tendons with chronic pathology have reduced stiffness, which impairs the tendon’s ability to store and release energy as a healthy tendon would (1).
So what factors can assist health care practitioners to determine who is more likely to develop tendon pathology? Also what strategies seem to work the best in improving tendon pain? I’ve extrapolated this blog post from a summary statement I wrote for Family Physicians in the Bow Valley. Read on and let me know if you have any questions or comments!
Pathophysiology - Why do we develop tendon pain?
Genetic Predisposition – Collagen diseases (Benign Hypermobility Syndrome, Ehler’s Danlos, Scleroderma) (2).
Comorbidities that may predispose you to a greater risk of tendon pathology – Diabetes, thyroid, menstrual disorders, kidney disease, gallstones, gout (2,3).
Environmental Overload – Change in activity, duration, intensity, footwear, sporting equipment, activity surface (2).
Asymmetries –Biomechanical disadvantage secondary to stiff muscles, joints, poor strength, poor movement patterns/control (2).
Solutions - Reducing pain and helping patients plan for long-term success.
Step #1: Control Pre-Existing Medical Issues (from above).
Step #2: Educate
A) “You need to improve the strength of your tendon”. The best treatment outcomes occur from loading the tendon, improving movement patterns, building a proper training schedule, and reducing fears (4-7).
B) “This may take a while”. Resolving irritable tendon pain can take months. Although it is a generalization, for every one month that your patient has had tendon pain, they can expect one month of strength and rehab work (4).
C) “Some pain is acceptable during and after you exercise”. Ideally pain does not exceed 3/10 on a visual analogue scale, and symptoms should resolve quickly after exercise. Patients should perform a self-assessment 1 hour after exercise AND 24 hours later. If they experience increased levels of discomfort, they have loaded the tendon too much and must reassess their exercise form, and reduce the exercise volume or intensity (5).
D) "Every tendon rehab is different". Each area of the body requires a different set of priorities and exercises to properly manage the tendon pathology. Your day-to-day activities, or athletic pursuits affect how you will heal and what is included in your rehab program. It is best to get a plan that is tailored for you.
Step #3: UNLOAD The Tendon
A) Physiotherapy: Reduce asymmetries in body.
B) Reduce irritable activities but continue exercise.
C) Tendon-specific unloading devices, if required.
Step #4: Start To RELOAD The Tendon. Improve the tendon's ability to tolerate loads.
A) Isometrics exercises involving the tendon, 2x/day. Perform 3 repetitions of 30 seconds hold and 30 seconds rest. Start with low intensity and increase as tolerated. Isometrics have been shown to reduce pain fairly quickly and is the necessary first step of loading the tendon before you can progress the patient to dynamic strengthening exercises (4,8-10).
B) Dynamic strengthening exercises, 3x/week. 3-5 sets of 8 reps. Heavy and very slow (4,8-10).
C) Activity/Sport Specific – Graduated return (4,8-10).
Step #5: Consider Modalities And Injections.
A) Extracorporeal Shockwave Therapy is a non-evasive technique that has a large and expanding amount of research to support its use in treating chronic tendinopathies (4,11).
B) Injection therapies: If the aforementioned steps do not help to improve function consider referring the patient to a Sports Medicine Physician to determine any underlying pathology and possible cortisone injection, plasma-rich-protein injection, prolotherapy injection, or barbotage.
There is almost always a way to escape tendon pain. Resolve to finding a health care team that understands tendon rehab, your sport, and fights as hard as you do to find answers.
1) Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the Achilles tendon. Journal of applied physiology. 2009 Nov 5;108(3):670-5.
2) Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology. 2006 Feb 20;45(5):508-21.
3) Ejnisman B, Andreoli CV, Monteiro GC, de Castro Pocchini A, Cohen C, Tortato S, Franklin MM, Machado AB, Cohen M. Calcifying tendinopathy: a local or a systemic condition?. Revista Brasileira de Ortopedia (English Edition). 2012 Jul 1;47(4):479-82.
3) Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
4) Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, Selfe J, Logan P. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017 Dec 1;51(23):1679-87.
5) Kubo K, Ikebukuro T, Maki A, Yata H, Tsunoda N. Time course of changes in the human Achilles tendon properties and metabolism during training and detraining in vivo. Eur J Appl Physiol. 2012;112:2679–91.
6) Kubo K, Ikebukuro T, Yata H, Tsunoda N, Kanehisa H. Time course of changes in muscle and tendon properties during strength training and detraining. J Strength Cond Res. 2010;24:322–31.
7) de Boer MD, Maganaris CN, Seynnes OR, Rennie MJ, Narici MV. Time course of muscular, neural and tendinous adaptations to 23 day unilateral lower-limb suspension in young men. J Physiol. 2007;583:1079–91
8) Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research. 2008. 1;466(7):1539-54.
9) Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016 Feb 1;50(4):209-15.
10) Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. The American journal of sports medicine. 2015 Mar;43(3):752-61.
Tennis Elbow / Lateral Epicondylitis
The outside of your forearm hurts and you do a quick Google search. You discover that the most likely cause of your pain is called Tennis Elbow. How could this be? You haven’t played tennis in years!
Tennis elbow, or lateral epicondylitis, is the most common problem of the forearm/elbow. While it is treatable, not all tennis elbows are the same, and they have to be assessed and treated differently in order to ensure success. In this article I will outline some of the typical factors that lead to tennis elbow and how to ensure you have an appropriate treatment plan.
Overuse Syndromes of the Elbow
Sixteen muscles cross the elbow joint. Nine of those muscles help to control our wrist and hand, and are used almost constantly throughout the day. These muscles also tend to get tight, be under-strengthened, and over-used. It’s a wonder why more of us don't develop forearm pain!
The second most common reason for elbow pain is golfer's elbow (medial epicondylitis), which affects the inside of the elbow. here are many other tendon problems that can occur near the elbow: Some of the more common ones include an inflamed tendon of the biceps, brachialis, brachioradialis or the triceps muscles. Before going any further, check out this article on tendon dysfunction to learn more about how tendons work and why they become injured: www.jacobcarterphysiotherapy.com/articles/tendon-function-and-dysfunction
Tennis elbow can present as pain/discomfort/stiffness on the outside of the elbow at rest or when gripping objects, moving the wrist or fingers, rotating the forearm, or bending/straightening your elbow. Often there will be pain when palpating/touching near the lateral epicondyle.
With chronic or very painful cases of tennis elbow, tears of the common extensor tendon may occur. This location is where most of the tendons that help to extend the wrist and fingers meet.
Acute tennis elbow can often be solved in a matter of weeks, however pain that persists (often because of inadequate treatment of the condition) may take 6-24 months to fully resolve. The most important step required to initiate healing is to develop a plan that addresses all of the contributing factors.
Factors that Contribute to Tennis Elbow
Here are a few common factors that contribute Tennis Elbow, and possible treatment options:
1. Repetitive Movement and Excessive Load
When tendons are required to withstand more volume or load than their structural integrity permits, the tendon will develop microscopic tears. The result is inflammation (which is actually important in the first stage of healing) and pain (due to the inflammation that activates local pain receptors). If you could simply allow the body to rest for 2-3 days, then start with some strengthening exercises, it is likely that your rehab would be much shorter.
Most individuals that develop tennis elbow spend a large amount of time doing a single task such as repetitive administrative work (e.g. typing on a computer), repetitive manual labour (e.g. using a hammer or screwdriver), mountain biking, rock climbing, etc. The key step here is to ensure variety in physical tasks so that there is an equal growth of the supporting forearm musculature.
We know that tendons respond best to slow increases in volume or load. An example of this would be a runner with ambitions of running a marathon: They will require at least a few months of slow progression in their training program to build strength of the connective tissue.
2. Forearm Muscular Imbalance
Functionally, the forearm extensor group is most often engaged to keep the wrist in a neutral position as you use the forearm flexor group to grasp and manipulate various items with your hand/fingers. Without the forearm extensors, the wrist would simply flex forward as seen here:
Therefore, if any of the other muscles that cause wrist or forearm movement (most significantly the wrist flexors) are tight, it often requires the wrist extensors to work excessively. If this increased load on the extensor tendon lasts long enough, tendinitis can occur.
As mentioned earlier, the muscles that extend the wrist and fingers attach to the elbow via the common extensor tendon. There is always a fine balance of muscle strength to flexibility required for optimal function. If muscles are weak, excess strain is placed upon the tendon to absorb the forces applied during movement. If muscles are tight, there is a resulting increased strain placed on the tendons at baseline, as the muscles constantly pull on the tendon.
3. Shoulder Tightness
As we expand our view to include the concept of regional interdependence, we must consider the shoulder, neck, and perhaps a focus on the thoracic spine, lumbar spine and pelvis. I would say that in my experience, it is possible to return an individual to their normal activities and sports by addressing the forearm alone in approximately 30% of cases. The other 70% of cases require an expanded view of the body. My reasoning for the success of addressing other areas of the body, in addition to the forearm, is as follows:
1. If we lack flexibility or strength at one joint, the neighbouring muscles and joints tend to make up for it.
2. If we have increased muscle tension in certain muscles, they may cause compression on the nerves that travel underneath of them and innervate the forearm muscles (e.g. the infraspinatus may compress the radial nerve at the shoulder, causing changes to the forearm muscles that are innervated by this nerve).
3. Compression of nerves at the neck, typically the lower cervical spine, can cause weakness to the muscles of the forearm and therefore be the cause of the forearm dysfunction… OR the nerve compression can refer pain to the elbow that mimics tennis elbow, causes pain when palpating the elbow and causes reduced strength to the muscles of the forearm.
4. Body Movement and Posture
The body develops pain for a reason. Often that reason has, at least part, to do with how you move - There is probably a movement pattern to blame.
To ensure full recovery, it’s important to use strategies and control-based exercises to address the poor movement patterns directly. This requires a skilled eye, knowledge of the sport, and ideally your Physiotherapist should watch how you move in your sport or at work. It is usually time consuming (and therefore, expensive) to have a Physiotherapist watch their clients perform their sport in person or go to their job site, but some video footage or photos can certainly help!
A few strategies to improve work-related causes of tennis elbow may include adjusting (A) Computer seat height, (B) Keyboard position, (C) Size of grip on various tools required at work, (D) Amount of vibration you are required to control with tools at work, (E) Number of rest breaks.
The initial stages of treatment for nearly any tendinopathy requires reducing muscle tension (via manual therapy and intramuscular stimulation (IMS)), addressing compensation patterns within the body, reducing the strain on the tendon by altering body mechanics, decreasing workload (rest), and possibly using braces/strapping.
If the tennis elbow is acute (having started within the last 3-6 weeks), then focus should be placed on rest and ice for a few days to reduce the level of pain to a 3/10. If needed, you may consider taking analgesics (e.g. acetaminophen), however you may want to restrict the use of anti-inflammatory medications (e.g. ibuprofen) as recent evidence suggests that restricting the initial inflammatory process may impair healing. As the acute level of pain settles, it is now time to start with strength and flexibility exercises that are tailored to your unique presentation, and gradual re-introduction of the activity that initially caused pain.
If the dysfunction is chronic (over 6 weeks worth of pain), the focus should be placed on increasing blood flow to the area, increasing the load tolerance of the affected tendons (via certain types of exercises) and Extracorporeal Shockwave Therapy (ESWT). Shockwave therapy has proven very effective in cases of thickened tendons (due to collagen/scar tissue accumulation) and calcification build up. These treatment techniques are used at specific intervals of time, and allow the body to resume its natural healing process.
In cases of tennis elbow that prove resistant to conservative treatment options, it may be helpful to consider other options: To rule out underlying pathology your Physiotherapist or Physician may refer you for diagnostic imaging, which may include an x-ray, ultrasound or MRI. Based off of these findings, a Sports Medicine Physician may consider an injection to reduce inflammation or encourage healing. The most popular injection options include corticosteroid (cortisone), prolotherapy, or platelet-rich protein (PRP).
No two cases of tennis elbow are exactly alike. It is important to understand the contributing factors that led to the dysfunction, and understand which stage of healing the injury is in. In more complicated cases that fail initial Physiotherapy management, diagnostic imaging may be warranted. Once all of this information is gathered, a skilled Physiotherapist or Sports Medicine Physician can then create a comprehensive plan that will maximize your success.
As written for www.one-wellness.ca
We try to improve the body’s natural response to injury in many different ways. Health professionals around the world offer products and techniques that promise the greatest reduction in inflammation and swelling, believing that their product can rise above the competition… But why?
Is it helpful to alter these responses, and is it even possible that we can alter these responses? For the most pragmatic answers, we can rely only on research…
Understanding the differences in medical terminology allows us to better understand what processes are happening in our body. With this higher level of understanding, both practitioners and patients can better communicate what is happening in the body to achieve optimal outcomes.
Swelling and inflammation of are often thought of as synonymous terms, however they have distinct definitions and applications.
Inflammation: Inflammation is “a local response to cellular injury that is marked by capillary dilatation, leukocytic infiltration, redness, heat, and pain and that serves as a mechanism initiating the elimination of noxious agents and of damaged tissue” (1).
Swelling: From Greek, the word ‘oídēma’ translates to ‘swelling’ (2).
‘Edema’ suggests “an abnormal infiltration and excess accumulation of serous fluid in connective tissue or in a serous cavity” (3).
To briefly summarize, inflammation is a cellular response to tissue injury and may result in swelling, however swelling can actually occur within the body without the process of inflammation.
A few common examples of swelling occurring within the body, in the absence of inflammation include: Lymphedema (failure of lymphatic drainage system to circulate blood plasma, and immune system regulators), cerebral edema (accumulation of extracellular fluid in the brain), pulmonary edema (accumulation of extracellular fluid in the lung).
A few common examples of swelling that occurs within the body with inflammation as the causation includes: Acute tissue injury (fractures, sprains, strains), dermatitis (inflammation of the dermis layer of the skin), thrombophlebitis (inflammation of vein due to a blood clot).
Is it possible to alter the inflammatory response? Is it helpful to alter the inflammatory response?
Over the last few decades there has been a culture of reducing inflammation immediately following acute injuries. However recent research has been changing the way clinicians should treat acute injuries:
Anti-inflammatory medication can decrease the inflammatory response, but they may impair healing:
In addition to their potential side effects (affecting GI tract, kidneys and cardiovascular systems), using NSAIDs (Non-steroidal anti-inflammatory drugs) may result in:
a) Impaired bone healing after a fracture (4-9).
b) Impaired tendon healing after an acute injury (10-11).
c) No improvements in chronic tendinopathies, as there is no active inflammatory process (12).
d) No improvement or possible small improvements in functional recovery In acute ligament injuries (13-18). Although one study found that using NSAIDs resulted in decreased pain and improved functional status, they also found a greater risk of adverse affects compared to using only analgesics.
Also, one review of the literature found that acetaminophen is as effective as NSAIDs for pain reduction after musculoskeletal injury (19).
These new results teach a few lessons:
1) The inflammatory mediators (e.g. prostaglandins, and cytokines) in inflammation help to initiate the subsequent stages of healing.
2) Removal of inflammation from an acute injury may harm the subsequent stages of healing.
3) In many cases, acetaminophen (e.g. Tylenol) will help to reduce pain as much as the use of anti-inflammatory medications, and will not impair healing.
The overall justification for the use of the RICE principle (Rest, Ice, Compression Elevation) is very practical and helps minimize bleeding into the injury site. However, there has not been a single randomized, clinical trial to validate the effectiveness of the entire principle. 50 There is some support for each item, including immediate rest, and elevation to help in managing the accumulation of interstitial fluid (20).
Summary: As much as possible restrict the usage of NSAIDs, employ the RICE principle, and if pain requires additional control then consider the use of other analgesic medications (e.g. acetaminophen, opiods, etc). It is a counterproductive goal to attempt to resolve all inflammation around the acute injury site.
Is it possible to alter swelling caused by acute injuries? Is it helpful to alter the swelling?
It is possible to alter swelling that has been caused by acute injuries. In the following photos you can see that with appropriate rehabilitation, swelling improves.
Unlike inflammation, it is in your best interest to reduce the amount of swelling at the local injury site. Depending on the amount of swelling, it can result in nerve compression, and restricted joint mobility making it painful and difficult to move the affected area (21). There is no benefit of allowing this swelling to stagnate as it will increase the level of irritability of the injury site and cause further deconditioning.
While there are numerous modalities that purport to increase blood flow (e.g. interferential current, acupuncture, laser, ultrasound, etc., they majority lack substantial research and are unnecessary to resolve 99% of cases. In addition to the RICE principle mentioned previously, there are two supported methods to reduce swelling at the injury site:
Movement - Regular movement of the affected joint, or at least the joints above and below should help pump the excess fluid back toward your heart using the lymphatic system. In addition, when able, start to perform cycling, swimming, rowing or perform upper body exercises.
Massage - Stroking the affected area toward your heart using firm pressure may help move the excess fluid out of that area. There are many physiotherapists and massage therapists that have extra training in lymphatic drainage techniques that may be able to guide you, if you have been experiencing poor outcomes.
1. Merriam-Webster Dictionary [Internet]. 2018. Inflammation; 2018-07-28. Available from: https://www.merriam-webster.com/dictionary/inflammation
2. Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus
3. Merriam-Webster Dictionary [Internet]. 2018. Edema; 2018-07-28. Available from: https://www.merriam-webster.com/dictionary/edema
4. Matsumoto MA, De Oliveira A, Ribeiro Junior PD, et al. Short-term administration of non-selective and selective COX-2 NSAIDs do not interfere with bone repair in rats. J Mol Histol. 2008;39:381-387.
5. Endo K, Sairyo K, Komatsubara S, et al. Cyclooxygenase-2 inhibitor delays fracture healing in rats. Acta Orthop. 2005;76:470-474.
6. O’Connor JP, Capo JT, Tan V, et al. A comparison of the effects of ibuprofen and rofecoxib on rabbit fibula osteotomy healing. Acta Orthop. 2009;80:597-605.
7. Bergenstock M, Min W, Simon AM, et al. A comparison between the effects of acetaminophen and celecoxib on bone fracture healing in rats. J Orthop Trauma. 2005;19:717-723.
8. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of femoral diaphysis: the influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg. 2000;82B:655-658.
9. Bhattacharyya T, Levin R, Vrahas MS, Solomon DH. Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fracture. Arthritis Rheum. 2005;53:364-367.
10. Elder CL, Dahners LE, Weinhold PS. A cyclooxygenase-2 inhibitor impairs ligament healing in the rat. Am J Sports Med. 2001;29:801-805.
11. Ferry ST, Dahners LE, Afshari HM, Weinhold PS. The effects of common anti-inflammatory drugs on the healing rat patellar tendon. Am J Sports Med. 2007;35:1326-1333.
12. Aström M, Westlin N. No effect of piroxicam on achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand. 1992;63:631-634.
13. Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg Br. 2001;26:258-260.
14. Dahners LE, Gilbert JA, Lester GE, et al. The effect of nonsteroidal antiinflammatory drug on the healing of ligaments. Am J Sports Med. 1988;16:641-646.
15. Moorman CT 3rd, Kukreti U, Fenton DC, Belkoff SM. The early effect of ibuprofen on the mechanical properties of healing medial collateral ligament. Am J Sports Med. 1999;27:738-741.
16. Ekman EF, Fiechtner JJ, Levy S, Fort JG. Efficacy of celecoxib versus ibuprofen in the treatment of acute pain: a multicenter, double-blind, randomized controlled trial in acute ankle sprain. Am J Orthop (Belle Mead NJ). 2002;31:445-451.
17. Ekman EF, Ruoff G, Kuehl K, et al. The COX-2 specific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med. 2006;34:945-955.
18. Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits. The kapooka ankle sprain study. Am J Sports Med. 1997;25:544-553.
19. Feucht CL, Patel DR. Analgesics and anti-inflammatory medications in sports: use and abuse. Pediatr Clin North Am. 2010;57:751-774.
20. van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. J Athlet Train. 2012 Jul;47(4):435-43.
21. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison’s Principles of internal medicine. New York: McGraw-Hill Companies. 18th ed; 2011.
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Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.