Acute Management of Soft Tissue Injuries: Should We Still Be Resting, Icing, Compressing and Elevating?

Daniel Reeves (Physiotherapist – Burnie)

It is common that if you injure a muscle or ligament you should follow the acronym R.I.C.E (Rest, Ice, Compression, and Elevation).

Over time the recommendation moved from R.I.C.E. to P.R.I.C.E (Protection, Rest, Ice, Compression, and Elevation). It then moved to P.O.L.I.C.E (Protection, Optimal loading, Ice, Compression, Elevation) as rest should be of limited duration. These recommendations have been made despite limited evidence supporting these elements.

Most recently there has been some discussion of whether P.O.L.I.C.E is still relevant and if we should consider a different approach to soft tissue injuries.

This has come about in part due to research showing that icing an acute injury may potentially have a negative impact on the early healing capacity of injuries. The main effect of ice is pain relief via reducing nerve conduction velocity, which reduces pain from surface tissues. Ice can also reduce inflammation. However, some inflammation is part of the natural healing process and is a good thing so inhibiting it can hinder the healing process. You can think of inflammation like a soup that contains important nutrients the body needs for healing to take place. On the flip side, chronic inflammation is not so helpful.

Dr. Gabe Mirkin, the physician who came up with the acronym R.I.C.E in the 70’s has since changed his opinion, stating that due to current evidence it appears that ice and complete rest can delay healing, instead of helping it. His advice is to use ice soon after an injury for pain reduction. Ice for up to 10minutes, remove for 20min, repeat 10min application a few times and do not ice more than 6 hours after the injury has occurred. The best way to apply crushed ice in a plastic bag directly to the skin as this can achieve desired skin temperature after 5minutes. Achieving desired skin temperature can take longer depending on the amount of subcutaneous fat tissue present.

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The new acronyms that have been suggested are P.E.A.C.E (Protect, Elevate, Avoid anti-inflammatories, Compress and Educate) and L.O.V.E (Load, Optimism, Vascularisation, and Exercise). They incorporate acute management to longer term management.

“Immediately after a soft tissue injury, do no harm and let PEACE guide your approach”

Protect: unload or restrict movement for 1-3 days. Rest should be short as prolonged rest can compromise tissue strength and quality.

Elevate: Elevate higher than the heart to encourage flow of fluid out of the tissue.

Avoid anti-inflammatory modalities including ice: Inflammation contributes to optimal soft tissue regeneration, inhibiting this important process using medication may impair tissue healing. Avoiding ice may have a positive effect. There is also no high quality evidence for the usefulness of ice therapy in treating soft tissue injuries. Ice may potentially reduce aspects of the inflammatory and healing processes which can have negative consequences on tissue regeneration.

Compression: Taping or bandaging can help to reduce swelling in the early stages following a soft tissue injury.

Educate: See your physiotherapist for correct education and advice about your injury, rehab and recovery.

After the first days have passed, soft tissues need LOVE

Load: Having an active approach to rehab with movement and exercise is highly beneficial for most people with injuries. Return to normal activities once symptoms allow. Optimal loading without worsening pain promotes tissue healing, remodeling and increases tissue tolerance/capacity.

Optimism: Having a positive mindset helps improve recovery.

Vascularisation: Pain free cardiovascular exercise helps to increase blood flow to the injured area and can reduce the need for pain relief medications. This can be started a few days after injury. Examples include swimming, walking, riding.

Exercise: Exercise helps restore mobility, strength and proprioception. Range of motion, strength, power and balance exercises can all help reduce risk of further injury.

So there you have it, maybe soft tissue injuries just need P.E.A.C.E and L.O.V.E. If you have a soft tissue injury such as a muscle strain or ligament sprain the Physiotherapists and Exercise Physiologists at Coastal Physiotherapy can advise you on how to get back to full function.

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References

1 Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police? Br J Sports Med 2012; 46: 220-1.

2 https://blogs.bmj.com/bjsm/2019/04/26/soft-tissue-injuries-simply-need-peace-love/

3 https://www.drmirkin.com/fitness/why-ice-delays-recovery.html