Question
Hi Dr. Leatherman.  I have a question about a sternal injury I sustained snowboarding.  I took a jump and when I landed (poorly), I tucked myself in to avoid breaking anything.  Unfortunately, I ended up landing with the full force of my weight on a closed fist into my sternum and ribs.

I've been seeing a chiropractor regularly, but this has seemed to make the pain more prevalent.  It hurts most when I'm in traction, but generally doesn't ache too much throughout the day.  However, it is affecting my training at the gym.  I can no longer perform dips - the pain is too severe when doing the movement.

I'm 26, already take a good dose of EPA/DHA and Glucosamine/MSM/Chondroitin, stretch frequently and have pretty good posture.  I try to massage the area (at the advice of my DC) to break up any scar tissue looming around.  But the injury is going on 10 months and I'm wondering what else I can do to help heal and strengthen the area.

Thanks in advance!
-JT

Answer
Dear JT,

First of all, what kind of traction are you doing in the office, and for what diagnosis/problem?  Second of all, the EPA/DHA needs to be At least 4000mg daily, and the chondroitin/MSM/glucosamine needs to be a minimum of 2000mg daily, and you should take this in divided doses if possible.  **please see additional nutritional recommendations for bone/tendon/cartilage injury below**

Moving on, sternal and rib injuries can be very problematic because of the fact there is no known specific fix for the problem.  in addition micro-fracture is common with these injuries, but is not easily visualized on standard x-rays.  For confirmation, a bone scan is the imaging modality of choice.  It has been a few months, but if the area has been under constant stress, it is possible to have continued micro-fracture at that area. I would suggest you discuss this with your treating doctors.  If the traction you are doing is exacerbating the injury, then I would suggest that you stop for awhile at least a week or two.  Give the area more time to heal/scar and then re-approach the problem...again I am not sure what type of traction you are doing.  

Dips are likely problematic because of the stretch of the pectoralis musculature at the sternal attachment point while performing the exercise.  If you are doing dips for the triceps try doing them with smaller movements, and in between two flat benches instead of a dip rack...this will alleviate some of the stretch on the pecs...also your hands need to be closer to the body, not wide.  Keep in mind that all weight lifting the affects the pec minor, pec major, serratus anterior, and rectus abdominus will produce strain near the sternum which may complicate healing.  Use your best judgement.

Concerning the scar tissue mentioned by the DC, he is correct that you will have additional scar formation that needs to be remodeled with manual therapy such as deep tissue massage etc..., but this is not an overnight fix.  You will need to continue this for At least 6 months, 3 times weekly, and this can create quite a bit of additional soreness.  Realize that when the body forms scar tissue it also forms new nerve endings that are highly pain sensitive and this may actually increase the amount of pain transmission signals to the brain for interpretation.  Again manual type therapies have proven the best in reducing this problem.

Additional nutritional concerns:  
A well-balanced and healthy diet obtains vitamins and minerals from natural sources. You should always use food first and supplements second. However, in times of physiologic stress, such as injury, it can be hard to meet the body's increased needs through diet alone. It is also important to stress that nutritional supplements do not work immediately and must be taken consistently, even if effects are not immediately and directly noticed.  The underlying repair mechanisms of the body only work when they have the correct substrates and cofactors. Following are some notes on nutrients for bone and wound healing.

Glucosamine/Chondroitin/MSM:  Glucosamine is thought to promote the formation and repair of cartilage.  Glucosamine hydrocloride is the form that is best absorbed by the body, but glucosamine sulfate is utilized more appropriately for repair. Chondroitin sulfate promotes water retention and elasticity in cartilage and inhibits enzymes that break down cartilage. MSM is also important in cartilaginous repair.  You need to consume a minimum of 1500 mg of Chondroitin and Glucosamine, as well as 750mg of MSM per day after injury.  A minimum dosage period would be for two months.

Bone-Healing:  rates may be enhanced by following some of the recommendations for preventing and reversing age-associated bone loss, such as supplementing with the nutrients calcium, magnesium, boron, and vitamin K. It should also be noted that you must have sufficient vitamin D (D3) to facilitate the absorption of calcium and magnesium.  The preferred forms of calcium and magnesium are the citrate forms. Do not use calcium carbonate. You can obtain enough vitamin D from 20-30 minutes of sun exposure daily.  In addition you must eliminate the intake of carbonated beverages and sodas.  These products will inhibit the repair mechanism of the bone and leach calcium from the bone structure.

Copper: supplementation is important in fracture healing and in the early formation of collagen in a wound. Eight milligrams of copper daily provides adequate supplementation and should be taken for six weeks for a fracture of a non-weight-bearing bone such as ribs or the upper extremities. It should be taken for 2-3 months for a major weight-bearing bone such as the femur or pelvis. Because copper is also a pro-oxidant, supplementation should be stopped after this period of time.  In addition you will need to have an increased intake of antioxidants such as vitamins a, c , e, selenium, bioflavanoids, quercetin, pycnogenol, co-enzyme q-10, and ginko biloba  to combat the excess oxidant actions of copper.

Zinc:  has been recommended at a dose of 90 mg daily (as recommended for early healing of wounds). Zinc's enhancement of fracture healing may be related to its effects on increasing IGF-1 and TGF-beta.

Vitamin-C: and additional anti-oxidants have also been shown to speed the healing process.  Whole food complexes of vitamin c are preferred over synthetic forms.  Ascorbic acid is a poor form. Vitamin C is a major constituent concerning collagen repair.

Omega-3 Fatty Acids:  act as anti-inflammatory agents, making them beneficial for patients with any inflammatory condition. There are three major types of omega 3 fatty acids that are ingested in foods and used by the body: alpha-linolenic acid (ALA)-18 carbons, eicosapentaenoic acid (EPA)-20 carbons, and docosahexaenoic acid (DHA)-22 carbons. Once eaten, the body converts ALA to EPA and DHA, the two types of omega-3 fatty acids more readily used by the body. Extensive research indicates that omega-3 fatty acids reduce inflammation and help prevent certain chronic diseases such as heart disease and arthritis.  Typical dosage after injury is 4000 to 6000 mg daily for 3 months.  Then reduce to a maintenance dose of 3000 to 4000 mg daily.  In addition the supplement should be molecularly distilled, pharmaceutical grade, and free of toxins.

Flaxseed-Oil:  One or two tablespoons of flaxseed oil daily is considered optimal for a healthy individual. Capsule doses are 3,000 mg per day for disease prevention and 6,000 mg per day for treatment to reduce inflammation.  Flaxseed is not utilized as well by the body as omega III fatty acids, but it is still important in eicosanoid management.

Linolenic-Acid:  A diet that gets 1-2 percent of its calories from Alpha-linolenic acid has been shown to give maximum tissue levels of DHA, avoiding any apparent deficiency symptoms.  ALA does have to be converted in the body through an enzymatic process using delta-5-desturase, before it can enter the cell membrane.  

Precautions:  The ratio of omega-3 fatty acids to other essential fatty acids is important, but some caution is warranted. Take omega-3 oils cautiously if you bruise easily, have a bleeding disorder, or take blood-thinning medication. Excessive amounts of omega-3 fatty acids may increase the amount of time that it takes for the blood to clot following a cut or other injury.

Possible-Interactions:  Omega-3 fatty acids may increase the blood-thinning effects of aspirin. While this combination may be helpful in the treatment of some diseases, you should only take omega-3 fatty acids under the guidance and supervision of your healthcare provider if you are on aspirin therapy. That being said, it is not advisable to take aspirin or NSAIDS like ibuprofen and Tylenol for pain after injury, due to research showing that it interferes with the normal inflammatory process, and will hinder optimal healing of bone and cartilaginous structures.  Healing times are actually increased when aspirin and NSAIDS are consumed.

Hope this helps your understanding JT, I would love to be able to outline a treatment approach for you, but the injured area is kind of an enigma.  Print this information off and discuss it with your treating chiropractor...he should be able to blend this information with his treatment plan for the best efficacy as he has had the opportunity to actually examine the area of complaint.  Let me know how things work out.

Respectfully,
Dr. J. Shawn Leatherman