Bulletproof Your Target Joints

Dr. Michael Zolotnitsky, PT, DPT

Originally published in PEN May 2020, ©LA Kelley Communications, Inc. All rights reserved.

Growing up with hemophilia, I endured frequent joint bleeds into my ankles and knees while playing basketball. I was told that those were my target joints because I continued to bleed into the same joints, and that ultimately, this would cause hemarthropathy. I was put in braces, and told to use crutches, ice, rest, and elevate. All good things, right?

Well, have you heard of Steph Curry, the all-pro basketball superstar? He continuously experiences ankle sprains that force him to miss games. In our community, we would say that Steph has an ankle target joint; but he doesn’t have a bleeding disorder. So why do some people with a bleeding disorder get target joints, and others who experience similar injuries do not?

If an athlete has a low-level ankle or knee sprain, it takes 4–6 weeks for a ligament injury to recover. Recovery includes exercise to strengthen the lengthened ligament and exercises to stabilize the joint. A more intense sprain or strain takes 8–12 weeks to heal, with additional stability training recommended. Someone with a bleeding disorder has different recommendations: usually rest, avoid weight bearing, and ice. If this is all we do, we develop scar tissue, lose range of motion, and lose muscle mass. This turns into a negative cascade of events, because now that particular joint has limited mobility, stability, and flexibility.

When a joint is in a weakened state, it’s more likely to be reinjured. After four to six injuries per year, we call this cascade a target joint. This is all preventable with the appropriate post-injury exercise regimen. We must “bulletproof” our target joints, but how?

Let’s look at different treatment stages following an injury. When the initial injury occurs, we feel pain, our joint swells, it feels warm and tingly, and we begin to limp. First, follow the treatment protocol that is recommended by your hematologist. After that, consider this four-step return-to-activity protocol that I recommend:

            Step 1: The initial focus is to reduce swelling, so apply kinesiology taping specifically for edema reduction by using the fan strip.1 (See “HemoDoc” videos on YouTube.)

            Step 2: Active range of motion of the joint can improve blood flow in a non-weight-bearing position. For the ankle specifically, you can trace the alphabet with your foot, make ankle circles, and do gentle towel curls.2 This will reduce scar tissue adhesion and reduce the loss of range of motion.

            Step 3: Now begin to strengthen the joints and ligaments by employing gentle resistance. It takes three days to lose strength, but six weeks to regain it, so for a low-level ligament sprain, I recommend performing these exercises three to four times per week, for six to eight weeks.

            Step 4: Gently and gradually return to activity.

In my first 13 years of life, I was continuously in and out of the hospital for insidious joint bleeds. I began to exercise and took control of my own life. This is what inspired me to become a physical therapist. And for the past 15 years, I have not experienced joint bleeds, and I can say that I don’t have target joints. My dedication and focus now are to help people affected by bleeding disorders.

We are just like normal people. We get hurt; our muscles and joints are weakened. If we don’t take the appropriate measures to rehabilitate them, then we’re more likely to reinjure them, just like NBA star Steph Curry. Joint injuries are preventable with appropriate workouts and mobility exercises. Allowing our muscles to regain their strength is possible, and will ensure improved overall joint health. Let’s all bulletproof those target joints!

Dr. Michael Zolotnitsky is director of neurological rehabilitation at New Jersey Spine and Wellness in Old Bridge, New Jersey. He also has severe hemophilia A. He can be reached at 732-952-2292 and

  1. A fan strip is a piece of tape that is cut in the shape of a fan. The head of the fan is placed above the area of the swelling, and four pieces are applied over the area without tension. This will allow a negative pressure gradient to occur to reduce swelling and improve circulation.
  2. Towel curls strengthen the inner foot. Place a towel flat on the floor and use your toes to grab the towel and curl it toward you. Then use your toes to push it away from you. Increase resistance by placing a weight on the towel.

Time to Rethink RICE? Part 2

By Paul Clement

RICE—rest, ice, compression and elevation—has been the most often recommended therapy for soft tissue injuries for more than forty years. However, the effectiveness and rationale for the “rest” and “ice” parts of RICE have increasingly been called into question. In part one of this two-part series, we looked at how using ice on a soft tissue injury not only slows the clotting process but may actually delay or prevent proper healing. Now we’ll look at why the “rest” part of RICE is also being questioned.

When you’re injured, the body responds with three sequential but overlapping phases of recovery:

1) inflammation [1 to 3 days];

2) repair [4-21 days]; and

3) remodeling [21 to 365 days or more].

Each phase must be successful, in order for the next phase to be successful. How does “rest” delay or prevent proper healing throughout these phases?

First, what does “rest” in the RICE protocol actually mean? Here, rest refers to immobilization (not moving) and non-weight bearing. So resting actually interferes with completion of both the inflammation phase and the repair phase of recovery!

After you’re injured, fluid and waste products produced by white blood cells accumulate around the damaged site. To remove this fluid, the body relies on lymphatic vessels (part of the lymphatic system). The lymphatic system has no heart, like the circulatory system, to pump fluid—it’s a passive, one-way mode of transportation that relies on the contraction of muscles, which in turn squeeze the lymph vessels, . If you rest a long time, you greatly reduce the movement of lymph fluid, which then allows an accumulation of waste products and excess swelling. Your damaged tissues will not recover well.

Resting (along with swelling and icing) also delays the repair phase. Resting decreases blood flow to the injured site. This delays the formation of new blood vessels that help rebuild tissues, which occurs in the remodeling phase. Stresses to the injury site which occur during movement also help collagen fibers  align themselves correctly, so proper healing can occur. Resting also starves cartilage cells in joints of nutrients, because the synovial fluid in the joint which lubricates and nourishes the cartilage, requires movement of the joint to flow.

No one is advocating you walk on a sprained ankle. Rest is important, but in moderation. (Of course, in addition to “factoring up,” all serious injuries should be evaluated by your hematologist!) The key is early mobilization, to regain or maintain range of motion, prevent muscle atrophy, and stimulate the movement of lymphatic fluid. Even simple motions such as wiggling your toes (in the case of an ankle soft-tissue injury) or light stretching are beneficial. Your hemophilia treatment center physical therapist can help you establish an appropriate balance between rest, early mobilization, and weight-bearing. This will help prevent delayed healing and unwanted complications associated with immobilization, while simultaneously minimizing the risk of rebleeding.

And the good news is that elevation (above the heart, for lower extremity injuries) and light compression can both help in healing: elevation by using gravity to assist in the movement of lymph fluid and compression in preventing excessive swelling. So keep these parts of RICE in your treatment plan!

Time to Rethink RICE? Part1

by Paul Clement

If you’ve ever sprained or strained an ankle or knee, or suffered from a muscle or joint bleed, you’ve probably heard that a couple of days of rest, ice, compression and elevation—RICE—is the surest route to recovery. But this simple at-home treatment has increasingly been called into question, especially the “rest” and “ice” parts. Many physicians and researchers now believe that rest and ice may actually delay or prevent proper healing.

RICE guidelines have been recommended by coaches and healthcare providers for over four decades—ever since the term was coined by Dr. Gabe Mirkin in his 1978 publication Sports Medicine Book. The intent of RICE was to speed the recovery process by reducing inflammation, swelling and pain. However, subsequent research demonstrated that icing actually prolongs the healing process. Dr. Mirkin recanted his original position in 2015, and today, he advises against icing an injury.

How can icing delay or prevent proper healing? When you’re injured, the body responds with three phases of recovery: 1) inflammation, 2) repair, and 3) remodeling. Each phase must successfully occur in order for the next phase to proceed and be successfully completed. That means inflammation must occur before the repair process can begin. If you reduce inflammation, then you delay the healing process.

Why is inflammation good? Immediately after an injury, blood vessels in the damaged tissue constrict (called vasoconstriction) to reduce blood flow; simultaneously, the blood clotting process (called hemostasis) occurs to reduce blood loss. Immediately after vasoconstriction, a type of immune cell in the damaged tissue, called mast cells, release inflammatory chemicals, such as histamines, which cause the blood vessels to expand (vasodilation) and become more permeable. This initiates the inflammatory process and allows other immune cells, called neutrophils, which are attracted to the site of the injury, to leave the blood vessels and enter the space between the cells, where they destroy damaged cells and mediate the inflammatory process. This sets the stage for another type of immune cell—macrophages—to come in and remove dead cells and release growth factors which are necessary for healing. When this process is complete, the neutrophils self-destruct, ending the inflammatory phase of the healing process.

The inflammatory process is extremely complex and researchers are still learning about it at the molecular level. We  know that the inflammatory process is not always good: in some auto-immune diseases such as rheumatoid arthritis, neutrophils that enter a joint during inflammation do not self-destruct, ending inflammation, but hang around and attack the cartilage lining the joints, destroying the joints.

Icing an injury delays healing by slowing inflammation. It slows the activity of clotting factors, slowing the formation of a clot. It prevents vasodilation, which slows the movement of immune cells into the damaged tissue, and the movement of waste out of the damaged tissue. It prevents the release of growth factors necessary for healing. And it increases the permeability of the lymphatic system, allowing fluids to flow in the wrong direction: from the lymph vessels into the injured area, increasing the amount of local swelling.

Icing can help reduce pain, but many physicians now recommend using acetaminophen (Tylenol) to reduce pain, and not ice. Finally, do not use anti-inflammatory drugs, such as ibuprofen (Motrin), to reduce pain: these drugs also reduce inflammation and slow healing—in addition to interfering with the clotting process, which may prolong bleeding.

Next week: Why movement helps in the healing process.

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