The methods of acute injury management are generally well known in the community, but I feel an overview of these will never go astray. This became even more relevant to me recently when a patient was referred with quite a high grade calf tear. Despite going to casualty, seeing 2 GP’s and one orthopaedic surgeon, no one advised him to ice or compress the injury! The casualty doctor even told him that there was ‘no need to bother with that’!
To understand why we treat acute soft tissue injury the way we do, it is first important to understand what happens in the body when injury occurs. When a muscle or joint is sprained, strained or bruised, we get bleeding of the injured tissue. The more blood vessels that there are in the tissue (like muscle), the more bleeding that will occur. Bleeding will cause soft tissue swelling, and the swelling itself causes further damage to the soft tissues. The aim of acute management is to limit the initial bleeding and swelling, and thereby limit the secondary soft tissue damage. This will then make the process of tissue repair faster as there is less overall damage to heal, resulting in a faster return to normal activity.
The pneumonic RICE is well known to most people. It stands for:
Rest, Ice, Compression and Elevation
Out of this equation ice and compression are the 2 most important elements. Both ice and compression limit the amount of initial bleeding by constricting and closing off the injured blood vessels. Both of these measures are important for the first 48-72 hours (2-3 days) post injury. The most important period is initially and over the first day. Ideally icing should be performed as often as possible, but care needs to be given not to damage the skin, so some rest periods are important. A scheme of 20mins on, 20 mins off is reasonable. Icing is best delivered to the skin directly with the use of a compressive bandage in the interim periods. The bandage should be elasticized to improve the compressive ability. The more cold and compression that can be applied in the first day, the faster the injury will recover.
Elevation of an affected limb will help to keep the swelling accumulating due to the effects of gravity. Rest simply stops motion of the injured tissue, which will decrease further bleeding and swelling. Again rest and elevation are most important in the first 2-3 days post injury.
Once the first 2-3 days has passed then the body’s healing responses are well under way. As such the risk of enhanced swelling and secondary tissue damage are reduced. This is the time where protected motion of the joint becomes important. If a joint or soft tissue is immobilized for too long then there are secondary effects that may include excessive scar tissue formation, muscle wasting, joint stiffness and even bone and articular cartilage weakness. The best way to avoid this is with protected early motion of the joint or soft tissue, that avoids further aggravation of the initial injury. For example, an acute lateral ligament injury to the ankle may benefit from being placed in a stirrup brace to protect the affected ligament whilst allowing movement in the joint.
A last point should be made between the relationship of alcohol to soft tissue swelling. There is no doubt that alcohol will cause significantly worse swelling in any soft tissue injury. As important as ‘RICE’ then should be ‘no alcohol’!