Ankle injury

[LBVT]

Doc, I sprained my ankle really badly in September, resulting in a torn ligament (I believe it was either the anterior talofibular or calcaneofibular ligament) and my achilles tendon.

There is a lot of clicking going on back where my tendon is (typically where the peronae longus tendon is, I think), and I had this problem before my injury, but it's become a lot more pronounced. I was told by my MCAT biology teacher that the clicking is a result of build-up of scar tissue, and that every morning, the reason it hurts is because of the reduced blood flow to my foot throughout the night and when I wake up, I start to break down the scar tissue, thus not hurting as much. He said that if I want to reduce the healing time, to take three divided doses of 200-400mg of NSAIDs per day for 3 months, and it should help drastically.

Now, I assume this is healthy because I know he wouldn't tell me false information considering he's my teacher, and I'm really cool with him. But are there any other supplements you can recommend I take along with the NSAIDs to help decrease the scar tissue build-up and possibly the inflammation that is involved with breaking it down.

And I know you can't diagnose me without looking at my ankle, only my orthopaedist can, but why do you think it's taking so long for my ligament and tendon to heal? My orthopaedist said even 6 months from now, it won't be 100%. I know tendons and ligaments aren't very vascular, so they have much less blood flow to help them heal compared to muscles, but it's been almost 4 months since the injury. It's just annoying, because I can't do so many things I was able to do, such as running, basketball, tennis, etc.

Thanks.

[dinoiii]

Originally Posted by LBVT

Doc, I sprained my ankle really badly in September, resulting in a torn ligament (I believe it was either the anterior talofibular or calcaneofibular ligament) and my achilles tendon.

I am sorry to hear about your misfortune.



[quote]There is a lot of clicking going on back where my tendon is (typically where the peronae longus tendon is, I think), and I had this problem before my injury, but it's become a lot more pronounced. I was told by my MCAT biology teacher that the clicking is a result of build-up of scar tissue, and that every morning, the reason it hurts is because of the reduced blood flow to my foot throughout the night and when I wake up, I start to break down the scar tissue, thus not hurting as much. He said that if I want to reduce the healing time, to take three divided doses of 200-400mg of NSAIDs per day for 3 months, and it should help drastically.[quote]

The wonders of the MCAT. HA!

Well, NSAIDs will likely reduce inflammation, though I am uncertain I would suggest a "reduction in healing time." I am trying to come up with a mechanism in my head as to why your teacher would suggest this and I am essentially stumped to be honest.

But - again as I usually offer - there are two goals of therapy:

[1] Analgesia (which would be accomplished by the NSAIDs)

and

[2] Repair


But I usually like to reference them in the opposite order.

With recent suggestion of decreasing protein synthesis with NSAID usage, I am not overtly optimistic that NSAIDs would accomplish that second task. Still, I usually don't go the NSAID route myself personally (I will re-post something at the conclusion of this post that will give some alternative ideas of how to best attain these two goals of treatment in my opinion).

[dinoiii]

Now, I assume this is healthy because I know he wouldn't tell me false information considering he's my teacher, and I'm really cool with him. But are there any other supplements you can recommend I take along with the NSAIDs to help decrease the scar tissue build-up and possibly the inflammation that is involved with breaking it down.

Again, uncertain I follow the recommendation on NSAIDs, but here is a post I did some time ago which might give you some other ideas:

Treatments

2 GENERAL GOALS:

A. REPAIR
B. ANALGESIA (Pain Relief / Inflammation Reduction)

We will look at both in turn...

----------------------------------------



THE REPAIR AGENTS


1. Glucosamine/Chondroiton:

Rationale for Use: Likely the most popular, both are natural building blocks used to repair connective tissue such as cartilage, tendons and ligaments. Because your body is slow to make glucosamine, taking it as a supplement speeds joint and tendon healing.

Chondroitin is an advanced molecule, created when many glucosamine molecules stick together. It is closer to being cartilage than glucosamine is, but isn't as well-absorbed (only 10 percent to 15 percent is absorbed, compared to 90 percent to 98 percent for glucosamine). Chondroitin is also a bit more expensive at about $1 per gram, whereas glucosamine goes for about one-third less. As a result, chondroitin is sometimes not marketed as aggressively, but evidence suggests it's as good or better at supporting connective-tissue renewal as glucosamine.

I am NOT, however, fond of supplemental response supplied by the oral ingestion of the aformentined said agents (this is glucosamine included), I DO think that research supports the use of such items in topical preparations with improved efficacy, if true efficacy can be claimed in the first place.

Both supplements have been used successfully to reduce osteoarthritis symptoms and to speed healing of joints. However, chondroitin has the unique ability to distract enzymes bent on destroying cartilage, causing them to target chondroitin instead. The chondroitin that gets chewed up is then converted to ordinary glucosamine and used to heal joints and tendons.


2. Vitamin C / Hydroxyproline / Hydroxylysine:

Rationale for Use: Each of the aforementioned 3 agents are actually quite imperative in any kind of tissue (namely as collagen is concerned) growth/repair. The amounts of vitamin C required for human health are far from established; the picture gets even trickier when considering wound/tissue growth/repair. Linus Pauling's suggestion that human needs for this vitamin probably have been underestimated by a factor of 10 or more has frequently been ignored or refuted by rhetoric rather than by sound experimentation. The thinking was still enough to gain Pauling the Nobel Prize and I am convinced as a water-soluble concern for true overdose is limited, so my own orthomolecular dosing parameters will be established for this trial.

There is also some suggestion that the use of the said agents can aid in analgesia. The presentation of cartilage auto-antigen (types II, IX, and XI collagen, aggrecan, and link protein), in conjunctionwith a major histocompatibility class II receptor by theantigen-presenting cell, is believed to initiate the inflammatory cascade. Offering up the repair agents sometimes thwarts this in adequate cross-linking of the collagen strands in repair. I am still using this as a repair agent. Hopes that it may offer analgesic response would simply be added benefit.

These particular agents will all be taken through oral route as I like the essential oral bioavailability in contrast to the aformentioned gluc/chond agents.


3. Hyaluronic Acid:

Rationale for Use: Hyaluronans are large polysaccharide molecules found naturally in the synovial fluid, which help to create a viscous environment cushioning joints and preserving normal function. Hyaluronans are used extensively in the management ofosteoarthritis of the knee and clinical trial results have documented their effectiveness for this indication. One of the nice things is that the growing body of evidence also supports use of the hyaluronic acid stucture in treatment of chronic pain versus the acute inflammatory variety.

Usually the growing body of research centers on the use of said agents through injection, a route I am trying to essentially avoid. That said, oral bioavailability has been shown as less than stellar. Again, this leaves us with few options to increase the efficacy of the said agent - that of which I am going to try also centers on transdermal.




THE ANALGESIC AGENTS


1. Methylsufonylmethane (MSM):

Rationale for Use: I think this agent has great potential as a organic sulfur donor which is the kind that the body can absorb and use and this in turn can reduce inflammation. The best thing about it, all acute, intemediate, and long-term studies indicate that MSM exhibits very low (virtually nil) toxicity NO MATTER HOW IT IS ADMINISTERED. How low? Some authors describe it as similar to that of water (but even water can be abused).

One of the most significant applications of MSM is that of pain reliever, due to a demonstrated ability to alleviate pain associated with systemic inflammatory disorders. People with arthritis report substantial and long-lasting relief while taking daily doses ranging from 100-5000 mg.

The beneficial effect here is due in part to the ability of MSM to sustain cell flow-through, allowing harmful subbstances such as lactic acid to flow out while permitting nutrients to flow in, thereby preventing the pressure buildup in the cells that causes joint inflammation in joints and elsewhere. [please note: Some of the substances in Clout and Body Octane, which I will also be using along side this trial also accomplish this in part!]

The nerves that sense pain are located primarily in the soft tissues of the body, such as the muscles. Many types of pain can be attributed to a pressure differential involving the cells that make up these tissues. When the outside pressure drops, the cells become swollen and inflammed. The nerves register the inflammation, and pain is experienced. Often, contributing to the pain are rigid fibrous tissue cells, which lack flexibility and permeability - kind of like that in the supraspinatus tendon. MSM has been shown restore flexibility to the protein layer of the cell walls, allowing fluids to pass through more easily. This softens the tissue and helps equalize pressure, treats the cause of inflammation, UNLIKE ASPIRIN, which treats the symptom by shutting off the nerve.


2. FISH OIL:

Rationale for Use: A standout among joint supplements is fish-oil extract, more specifically, the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. Both EPA and DHA fight joint-damaging enzymes called collagenases and reduce inflammation, factors believed to play a role in joint aches and pains, including arthritis. As a result, fish oil is a great supplement for the active guy who wishes to reduce joint and tendon pain and prevent any damage.

In fact, a number of top-notch clinical trials, including one published in Journal of Rheumatology, have found that about six grams of fish-oil extract per day reduces symptoms of rheumatoid arthritis (which is essentially joint inflammation raging out of control). To get the equivalent amount of omega-3s from your diet, eat fish twice a week (see table for best choices). For instance, two nine-ounce salmon steaks a week provide about 42 grams of fish oil.

[Please Note: Part of my Omega-3 requirement will come in the form of BIG FISH from MAN Vaporize, of course, but I will get to the doses I will be using below.]


3. S-adenosylmethionine (SAMe)

Rationale for Use: For those familiar with my writing, you know I am A HUGE FAN of SAMe use for many ailments, and joint pain is one. Although many will likely critique that the dose needed to achieve joint releif based on very early clinical trials and the essential high cost of this support supplement will not warrant it's use in many people, I am going to use it DESPITE COST at a trial mimicking dose for true efficacy as this joint pain has gone on far too long as discussed above.


4. Celadrin (The registered proprietary blend of various cetylated, esterified fatty acids (cetyl myristoleate, cetyl myristate, cetyl palmitoleate, cetyl laurate, cetyl palmitate, cetyl oleate)

Rationale for Use: It is actually suggested to be superior to ALL of the aforementioned agents and has a couple of clinical trials to boot in the Journal of Rheumatology (although no head-to-heads so I am still employing the other agents). The great part is that both trials were double-blinds unfortunately one was an oral preparation and the other a topical. To further this, there were two trials in the Journal fo Strength and Conditioning also showing efficacy in replicated fashion to the topical, however, I will already be using a topical preparation for this trial so I am going to be trying it as an oral and based on structure alone - theory would likely dictate the oral bioavilablity to be sufficient as well as the first trial.

All of this suggested, I am going to ingest a dose that mimics the clinical trial in the Journal of Rheumatology to offer up aid.



PLEASE NOTE:
The thing with the Fish Oil and the oral Celadrin is that they MUST be adjusted into my caloric intake for the duration of the trial - which will likely sit at 68 days. Why 68 days? This mimics the upper-limit of some study protocols as listed within the information above...While some study info is based on shorter time protocols, I am emeshing the longest trial with the basis of an adequate exercise protocol/treatment plan.

[dinoiii]

-----------------------------------------

DEJA REVIEW

I have reviewed everything as best I can. Some may say - why aren't you using cissus Dana? Well, as I have said in other pieces, I feel cissus harbors a low toxicity and if I were recovering from a fracture...I might actually include it. There has been hypothesized suggestion of an estorgenic component that leaves me a little unsure about some of the current ketosteroid preps available.

All of that said, I would like to review what my entire supplemental protocol will be for the duration of this trial (one that is unmatched IMO) on the review end:

(1) VPX Glucosacream: I have had success with this product in the past and absolutely swear by it! I have turned many of my clients on to it as well for years. It is a topical preparation of Glucosamine HCl, MSM, Chondrotion Sulfate, Hyaluronic Acid as the listed actives. There are some inactive cetylated molecules including fatty acids that may contribute to efficacy. MY DOSE: 2 generous applications of the cream, morning and night.

(2) Fish Oil: I will employ the aid of 2 red gels of MAN Vaporize x 3 doses evenly spaced throughout the day. Because this will supply me at about 1/2 the fish oil I want, I will add in 3 grams from an alternative source as I don't want additional Sesamin on top of this.

(3) SAMe: Because of my money going to a rather high dose here, I am going to support an independently-tested product (consumerlabs.com) and use Vitamin Shoppe SAMe which has passed with its 1,4 butanedisulfonate, disulfate [sic] tosylate formula @ 400mg x 3 doses per day.

(4) Celadrin: I am going to dose this at 3 caps, 2 times per day - yielding 2100mg of proprietary cetylated fatty acids.

(5) Vitamin C/Hydroxyproline/Hydroxylysine: I will use orthomolecular dosing parameters as described by Linus Pauling to dictate much here, but these will all be rather cheap consumerlabs.com tested generic variety.

And I know you can't diagnose me without looking at my ankle, only my orthopaedist can, but why do you think it's taking so long for my ligament and tendon to heal? My orthopaedist said even 6 months from now, it won't be 100%. I know tendons and ligaments aren't very vascular, so they have much less blood flow to help them heal compared to muscles, but it's been almost 4 months since the injury. It's just annoying, because I can't do so many things I was able to do, such as running, basketball, tennis, etc.

Thanks.

There are a lot of intraosseous anastamoses that may aid healing, but I don't know is though I completely blame it on the lack of vascularity.

Has anyone ever suggested PT of any sort to you?


D_

[LBVT]

Hey doc, thanks for the help! So I guess I should go with the glucosacream you recommended? Can it be picked up at any GNC or VS, or does one need to order it online?

As for fish oil, I currently take that as a supplement, about 10 grams per day. I'll continue to use it.

I did go through PT for 5 weeks, typically once or twice a week. It helped, but after PT, I didn't keep up with my exercises. I should have, but got lazy and annoyed.

Thanks for the advice, and if you think of anything else, feel free to chime in! I'm trying to follow in the footsteps of many people I know, which is why I'm currently studying for the MCAT. It sucks because all of this stuff I learned while in undergrad, but didn't retain a lot of it, so it's like I'm learning the details all over again.

Why oh why do they have to include Physucks on the MCAT, it's the bane of my existence!

[LBVT]

Hey doc, just wondering, if you had to choose one product for my situation, would it be VPX Glucosacream?

Also, the bioavailability of glucosamine and chondroitin aren't well-established, correct?

[dinoiii]

Originally Posted by LBVT

Hey doc, thanks for the help! So I guess I should go with the glucosacream you recommended? Can it be picked up at any GNC or VS, or does one need to order it online?

On-line, but it retails for like $17-21 dependent upon where you get it, which isn't bad at all.

As for fish oil, I currently take that as a supplement, about 10 grams per day. I'll continue to use it.

Total fish oil (in grams) is not as pertinent as how much combined EPA/DHA you are getting. In the "Articles" section of this subforum, you will find a fatty acid recommendations sticky of mine - I have dose-adjusted recommendations for everyone on EPA/DHA tallies each day.

I did go through PT for 5 weeks, typically once or twice a week. It helped, but after PT, I didn't keep up with my exercises. I should have, but got lazy and annoyed.

Thanks for the advice, and if you think of anything else, feel free to chime in! I'm trying to follow in the footsteps of many people I know, which is why I'm currently studying for the MCAT. It sucks because all of this stuff I learned while in undergrad, but didn't retain a lot of it, so it's like I'm learning the details all over again.

Why oh why do they have to include Physucks on the MCAT, it's the bane of my existence!

Wish I could help with that. Physics, while the bane of my existence as an undergrad, I do actually sometimes wish I was going through the continued torture of hours upon hours of study of this nonsensical subject you will NEVER need again. I am slightly sadistic, I know.

The reality is - no one really ever "knows" physics - not those interested in health care. If you did, health care likely wouldn't be your desired pursuit...I assure you.

Originally Posted by LBVT

Hey doc, just wondering, if you had to choose one product for my situation, would it be VPX Glucosacream?

Well, if I had to choose something indefinitely (and I only had one choice), it'd be SAMe due to the versatility of the agent - even in your case. Glucosamine/Chondroiton have mixed results when not talking arthritis ailments.

Also, the bioavailability of glucosamine and chondroitin aren't well-established, correct?

I would suggest the contrary actually. The oral bioavailability of oral glucosamine is known to be 26%, indicating a significant first-pass metabolism of glucosamine by the liver when comparing it to intramuscular administration (96%)!

We do by-pass some of this first pass effect with transdermal delivery which is probably why there is still a noted superiority to transdermal blends in this regard.



D_