There you are, treating a recent motor vehicle collision (MVC) patient, probably from a rear impact, and you are doing a marvelous job of documentation of your findings, treatment and outcomes.
Your patient goes to the IME. Your notes document significant injury and that although there has been progress in recovery, in your opinion (and that of the objective evidence) the patient is not yet back to their pre-accident status.
A few weeks later, the response letter from the insurance company arrives, with a few snippets from the report basically stating: "In the opinion of our examining physician, your patient does not need continued care past six weeks after the date of the accident." And with that your case comes to a quick and abrupt end.
You get a copy of the report, start to read it and find that the examining doctor's conclusions were based on six weeks of treatment for ankle sprains. You grab your book on sports medicine and sure enough, it recommends six weeks of recovery for ankle sprains. And according to this doctor, a sprain is a sprain, no matter where it is.
Ankle Sprains: Healing Times
How do you rebut this argument? Your first argument could be that a neck sprain is somehow different than an ankle sprain. You might be able to pull that off in front of a jury. (You and I both know this to be true). But could there be anything in the ankle sprain literature that could support our already strong understanding of healing tissues relative to whiplash? Could there be literature that shows ankle sprains take longer than six weeks to heal? It turns out there is.
In a 2008 article by Hubbard & Hicks-Little1 titled "Ankle Ligament Healing After an Acute Ankle Sprain: An Evidence-Based Approach," the authors found that "it took at least 6 weeks to 3 months before ligament healing occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had objective mechanical laxity and subjective ankle instability." At a minimum, six weeks after injury healing was just beginning, lasting up to three months, with "objective mechanical laxity" at one year.
How many whiplash patients could you say the exact same thing about? This is one great article to put down the long, old argument that whiplash injuries heal in six weeks (or eight, or 12) compared to an ankle sprain.
In a more recent German article by Suhr, et al. (2012),2 titled "Therapy of Acute Ankle Sprain: One-Year Results of Primary Conservative Treatment," the authors noted that "about 15-20% of the patients still suffer from persistent pain, swelling or instability" after one year.
Furthermore, whiplash injuries from MVC are often perceived to be trivial, with the perception that all patients recover without any disabilities. If we use the ankle sprain literature again, a 2013 article from Wikstrom, et al.,3 tells us "it is imperative to remember that an ankle sprain is not simply a local joint injury; it can result in a constrained sensorimotor system that leads to a continuum of disability and life-long consequences such as high injury recurrence and decreased quality of life if not managed properly." Again, this statement could easily be transposed to refer to a chronic whiplash patient, well after the acute phase is over.
Phases of Healing
Does any of this literature on ankle sprains fit with the model and literature on tissue healing time? As it turns out, it does. In 1988, the American Academy of Orthopedic Surgeons (AAOS) published a position paper that stated how long it took ligaments to heal.4 According to the paper, it could take up to two years to heal completely. However, since it is the damage to the facets (joint capsules – ligaments), it takes much longer than six, eight or 12 weeks to heal. Here are the stages of healing, per the AAOS:
- Phase I: acute inflammation (0-72 hours)
- Phase II: repair (3 days to eight weeks)
- Phase III: remodeling (2-12 months; up to 24 months)
The acute inflammatory phase response causes pain, swelling, redness and warmth around the injured area due to tearing of the tissue and blood vessels. The area gets warmer because blood is being pooled in the area, which actually causes the swelling. This is your body's way of protecting itself. The swelling causes stabilization in the area, just like when you can't move your neck after a car accident.
The repair phase is when the inflammation has gone down and your body begins to repair the injured area. Repair includes three main features: regeneration of myofibers, production of connective-tissue scar, and capillary ingrowth into the injured area. During the repair phase, your body will begin to lay down collagen to replace the damaged tissue structure. The structure of the collagen is unorganized at this point.
The remodeling phase is designed to accomplish three main functions: maturation of the regenerated myofibers, contraction and reorganization of the scar tissue, and recovery of the functional capacity of the muscle. This phase is largely one of an improvement in the quality, orientation and tensile strength of the collagen. Once the collagen has been regenerated in the second phase of healing, it is not in an alignment that will be very capable of withstanding any stresses placed on it. The collagen is similar to sticky glue at first. It needs to be molded in certain alignments in order to be able to perform the functional capabilities of the tissue it is replacing (Davis' Law). This phase last from three weeks to 12 months (some research suggests up to two years).
Making the Connection
I have discussed only three research articles of many that demonstrate the following relative to the management of ankle sprains and their parallel to whiplash management:
- Ankle sprains take a minimum of six weeks to three months to begin healing.
- One year after injury, objective mechanical instability is still present.
- Fifteen percent to 20 percent of patients still suffer from pain and instability one year after injury.
- Ankle sprains can have lifelong consequences and decrease patients' quality of life.
You could take each one of these points and transpose them directly into any whiplash management case. So, the next time you have an IME state something silly like six weeks of care (or eight, or 12) was all that was needed, whether the examiner mentions ankle sprains or not, just lay this on them and see what happens.
- Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train, 2008 Sep-Oct;43(5):523-9.
- Suhr A, Mückley T, Hofmann GO, Spahn G. Therapy of acute ankle sprain: one-year results of primary conservative treatment. Sportverletz Sportschaden, 2012 Mar;26(1):39-44.
- Wikstrom EA, Hubbard-Turner T, McKeon PO. Understanding and treating lateral ankle sprains and their consequences: a constraints-based approach. Sports Med, 2013 Jun;43(6):385-93.
- Woo SLY, Buckwalter JA. Injury and Repair of Musculoskeletal Soft Tissues. American Academy of Orthopedic Surgeons, December 1988; p. 106.
Dr. Garreth MacDonald practices in Eugene, Ore., with an emphasis on conservative management of patients with whiplash, spinal trauma and other injuries attributable to motor vehicle accidents.