Soft tissue injuries - do you RICE, RICER, MICE, PRICE or just do nothing?

 

If you’ve done a first aid course, you will be familiar with the acronym R.I.C.E or R.I.C.E.R for soft tissue injuries such as strains and sprains. As you may already know it stands for Rest, Ice, Compression, Elevation and Referral.

More recently M.I.C.E and P.R.I.C.E have also been added to the mix with the M standing for Movement and P for Protection.

So, which do you use? Well to make things more confusing there is limited scientific evidence to support the various components of all these acronyms despite their wide use (Bleakley, McDonough, MacAuley, 2004; Schaser, Disch, Stover, Lauffer, Bail, Mittlemier, 2007; van den Bekerom, Struijs, Blankevoort, Welling, van Dijk, & Kerkhoffs, 2012).

So, what should you do?

What we do know so far is that early functional movement is better than complete rest (Bleakley, Glasgow, Phillips, Hanna, Callaghan, Davison, Hopkins, Delahunt, 2011; Kannus, 2000).  Moving utilises the principals of mechanotherapy whereby the mechanical loading prompts cellular responses that promotes tissue structural change – strengthening the healing tissue and minimise loss of condition (Khan & Scott, 2009).

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See when we tear a muscle there is damage to the muscle’s cells. Within moments following the injury inflammatory cells such as macrophages and neutrophils flood the area to seal off the area and clean away dead tissue (Toumi, & Best, 2003). This paves the way for the fibroblast cells to start laying down scar tissue to mend the muscle. The thing about muscle though, is the fibres are always orientated in a parallel fashion - the direction of force or pull, scar tissue however is very disorganised and if it doesn’t align in a parallel fashion it can become a structurally weak point (Khan & Scott, 2009). Stressing the tissue can help organise the scar tissue so it is orientated in the same direction for maximal tensile strength and make it less likely to re-tear (Hurme, Kalimo, Lehto & Jarvinen, 1991; Khan & Scott, 2009).

So early movement appears to be good, but the challenge is finding a balance. If the tissue is stressed too aggressively after injury, the mechanical insult may cause re-bleeding or further damage. Therefore, a balance is key were activity is progressed slowly as pain allows.

As for Ice, compression and elevation the benefits are still an undetermined (van den Bekerom et al., 2012). There use is recommended as a way of controlling or minimising swelling but also for pain relief and support or reassurance if using a brace/guard.

See swelling is essential to healing but you can have too much of a good thing and excessive swelling can lead to more cell death and more injury (longer recovery). During the initial inflammation stage there is an influx of neutrophils which release oxygen free radicals that break down the cell’s structural protein and with it there is some ‘collateral damage’ to the uninjured surrounding tissue (Toumi, & Best, 2003).

So, it is recommended that limiting but not abolishing the inflammatory response is the best approach at present to improve muscle healing. If using these treatments be mindful of the patients’ needs and expectations.  For example, some people will feel ‘safer’ or more ‘supported’ with a compression bandage or tubigrip and if it means they are mobilising sooner, then they will probably have a better outcome. As for dosage the jury is still out but there are guidelines produced by the Association of Chartered Physiotherapists in Sports Medicine and Exercises – see link - https://www.physiosinsport.org/media/wysiwyg/ACPSM_Physio_Price_A4.pdf

Finally, Referral. When it comes to soft tissue injuries your body is pretty good at starting the healing process but unfortunately re-tears are a frequent occurrence, so it’s a good idea to see your Physiotherapist for a structured strength and conditioning program that is tailored to your needs and helps you return to whatever it is you want to do.

Samuel Dunn,

Principal Physiotherapist, MSportsPhysio, BPhysio, SPA

If you would like to read more on this, you might enjoy reading these articles.

References:

Bleakley, C., McDonough, S., & Macauley, D. (2004). The use of ice in the treatment of acute soft-tissue injury: A Systematic review of randomized controlled trials. American journal of sports medicine32(1), 251-261.

Bleakley, C. M., Glasgow, P. D., Phillips, N., Hanna, L., Callaghan, M. J., Davison, G. W. Hopkins, T. J., Delahunt, E. (2011). Management of acute soft tissue injury using protection rest ice compression and elevation: recommendations from the Association of Chartered Physiotherapists in sports and exercise medicine (ACPSM)[executive summary]. Association of Chartered Physiotherapists in Sports and Exercise Medicine, 1-24.

Hurme, T., Kalimo, H., Lehto, M., & Jarvinen, M. (1991). Healing of skeletal muscle injury: an ultrastructural and immunohistochemical study. Medicine and Science in Sports and Exercise, 23(7), 801-810

Kannus, P. (2000). Immobilization or early mobilization after an acute soft-tissue injury?. The physician and sportsmedicine28(3), 55-63.

Khan, K. M., & Scott, A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British journal of sports medicine43(4), 247-252.

Toumi, H., & Best, T. M. (2003). The inflammatory response: friend or enemy for muscle injury? British Journal of Sports Medicine, 37(4), 284-286.

Schaser, K. D., Disch, A. C., Stover, J. F., Lauffer, A., Bail, H. J., & Mittlmeier, T. (2007). Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats. The American journal of sports medicine35(1), 93-102.

van den Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. Journal of athletic training47(4), 435-43.