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Acute Management Injury/Pain.

The following section is evidenced based information and advice which patients may find helpful in the self management of acute injuries or pain. This information has been produced by the Physiotherapy Staff at Southend Hospital.

Acute (Immediate) Soft Tissue Healing Times.

If you have had an acute onset of pain it is possible that there may have been minor soft tissue injury that has occurred and is contributing to the onset of the pain.

Once soft tissue damage has occurred there is a well-recognised healing process. This is summarised in the graph below:

 

Tissue Healing

 This applies to musculoskeletal tissue including muscle, ligament and joint tissue such as joint capsule or disc.

Soft tissue healing can take up to 6-12 weeks. This means that your pain can take this length of time to improve. In 60-90% of patients their pain will fully resolve within 12 weeks.

 

Management of Acute Injuries or Pain.

Latest guidance from the British Journal of Sports Medicine (2020) (1) suggest the PEACE & LOVE method  as this encompasses the rehabilitation continuum from  immediate (PEACE)  to subsequent managment (LOVE).  Previous RICE/PRICE/POLICE methods only focused on the immediate management.

P&L

PEACE:

PROTECT:

The purpose of protection is to avoid further injury to the area by protecting the injured structures. The type of protection used varies depending on the injured area but may include a bandage, splint, sling, protective tape, or over-the-counter brace.

 

ELEVATION:

What it could do?

The theory for using elevation after injury is to try to restore the pressure gradients within the affected tissue.  Elevating an acutely injured joint could decrease the gravitational force exerted on the column of blood between the heart and limb. With the possible result being decreased hydrostatic pressure within the vasculature, minimising swelling and the resistance to venous and lymphatic flow around the injured tissue.

How to Elevate.

Despite clear rationale, the optimal duration or angle of elevation remains contentious.  However if you choose to elevate your limb try to complete this as long as can be tolerated. 

It is also important to know that some research suggests that after elevation the limb volumes return to their original measurements after 5 minutes, on return to a gravity dependent position e.g. Ankle - sitting with foot on the floor.  Clinically, a graduated return to standing after elevation is perhaps most likely to minimise rebound swelling and discomfort.  

So why Elevate? 

Well during the period of elevation is perhaps an opportunity for you to gently move the injured/painful tissues more easily which if repeated frequently could reduce localised stiffness.

 

AVOID ANTI-INFLAMMATORIES:

The various phases of inflammation help repair damaged soft tissues. Thus, inhibiting inflammation using medications may Negatively affect long-term tissue healing, especially when higher dosages are used (2).

 

 COMPRESSION:

The rationale for using compression pressure is to minimise initial tissue haemorrhage after injury however the research remains conflicting.

If you are to apply compression to your injured area attempt to complete this immediately after injury, with continuous use over the first 72 hours. 

How to Apply?

When applying compression you should aim for uniform pressure, from the highest point of the limb/injury to the lowest point.  Compression can be applied through the use of elastic compression bandages.

 

EDUCATION:

TAKE AN ACTIVE APPROACH.  Passive treatments like electrotherapy, manual therapy, acupuncture etc... have repeatedly been shown to have  insignifcant effects on pain and function compared with an active approach (2) (3).

Is there evidence for functional treatment or immobilization?

This question can be answered by the meta-analysis published by Kerkhoffs et al (2002). Based on the analysis of 21 trials involving 2,184 participants these authors concluded that functional treatment appears to be the favourable strategy for treating acute injuires when compared with long-term immobilization (4-6 weeks).

 

LOVE (after the first days have passed soft tissue needs love):

 

LOADING:

Why 'optimal loading' and not 'rest'?

Rest may be useful in the immediate short term (<48 hours), however continued rest could cause deconditioning of the tissues, joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance).

Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing.

The right amount of activity can help manage swelling. 

 

OPTIMISM:

Remaining optimistic and having realistic goals/expectations can be associated with better patient outcomes. Psychological factors such as depression and fear can represent barriers to recovery. Beliefs and emotions are thought to explain more of the variation in symptoms following an injury rather than previously stated stages of healing (5).  This can be related to any injury and any joint.  

 

VASCULARISATION:

Cardiovascular activity (any exercise that raises your heart rate) represents a cornerstone in the management of musculoskeletal injuries. Research is still needed on dosage however as a guide pain- free aerobic exercise should be started a few days after injury to boost motivation and increase blood flow to the injured structures.  This has been shown to improve physical function, suppor a return to work and reduce the need for pain medication in individuals with musculoskeletal conditions (1).

 

EXERCISE:

As previously mentioned above exercise to key to any treatment plan and is condsidered one of if not the most important element when recovering from an injury.  It helps to restore mobility, strength and proprioception (sense of self-movement & body position e.g. balance), reduce swelling and pain, improve mood, confidence amongst other things.  Sometimes we can get confused with which is the 'right exercise'.  Firstly as a generalisation all exercise is right as long as you enjoy it.  If ou would like further guidance regarding exercise and specific conditions please view either our own physiotherapy leaflets or Arthritis Research Council's leaflets.  Alternatively please speak to your GP for a referral to our service.

 

HANG ON WHAT ABOUT ICE?????  SHOULD I USE HEAT????

  ICE:

 What does ice do?

From a pain perspective numerous studies have concluded that a person's Nerve Conduction Velocity (NVC) is significantly and progressively reduced concomitantly with skin temperature.  Associated with the changes in NCV, are increases in Pain Threshold and Pain Tolerance.  So in a nut-shell in acute pain states, application of ice will help to reduce your pain.

Previous other suggestions for the application of ice have been the role of controlling inflammation.  However current research is undecided at present with some suggesting that its use can delay the muscle regeneration process (6) and like the use of anti-inflammatories others are questioning if we should be interferring with bodies natural recovery process in the first place.

RECOMMENDATIONS:

Therefore at the present time consider ICE if your pain is not manageable but bare in mind that it could possibly delay your recovery.

How to Apply Ice:

Current research advocates the use of crushed ice only as this adequately cools the temperature of the area to between 10-13C (therapeutic ranges).  Length of time to reach this therapeutic range is typically 15 minutes, however suggested icing application is for 20 minutes as this limits the increase in temperature. This can be repeated every 2 hours if required.

Make an Ice Pack:

Place crushed ice into a small plastic bag and then tied off at the top. By using a small amount of ice, squeezing out all of the air from the bag, and tying the knot at the very top, you can produce an ice bag that can be flattened out and wrapped around an injury, completely covering the injured area.

WARNING:

Ice left on an area for too long (+60 minutes) can burn.

Contraindications to use of  Ice:

  • Active Deep Vein Thrombosis (DVT) or Thrombophlebitis.
  • Areas near a chronic wound.
  • Cold hypersensitivity e.g. Raynaud's, cryoglobulinema, hemoglobulinemia.
  • Cold urticaria (cold allergy or hypersensitivity).
  • Impaired circulation.
  • Over regenerating nerves.
  • Tissues affected by tuberculosis.
  • Haemorrhaging tissue.
  • Untreated haemorrhagic disorder.
  • Areas with impaired circulation.
  • Research has suggested that compression should not be combined with elevation.

Precautions to use of Ice:

  • People with cardiac failure.
  • People with hypertension.
  • Areas of impaired sensation that prevent people from giving accurate and timely feedback.
  • Infected tissues.
  • Damaged or at-risk skin.

 

 

HEAT:

What does heat do?

Similar to ice, heat influences the your bodies localised receptors which may modulate antinociceptive desecending neural pathways resulting in pain reduction (7). Other reported physiological effects of heat therapy are increased blood flow and metabolism, and increased elasticity of connective tissue. Again as with ice, research is unclear if this does actually promote healing.

RECOMMENDATIONS:

Therefore at the present time consider heat if your pain is not manageable but bare in mind that it could possibly delay your recovery.

 How to apply heat:

Hot packs, wax baths, towels, sunlight, saunas, heat wraps, steam baths/rooms, hydrotherapy.

 WARNING:

The 2006 Cochrane Database review, listed adverse events reported in trials of superficial heat as minor and mainly consisted of "skin pinkness".

Heat may cause disease progression, burns, skin ulceration, and increased inflammation. Skin should be protected when using heat therapy in heat-sensitive or high-risk patients, especially over regions with decreased sensory function (7).
 

Contraindications to use of Heat:

  • Dermatitis
  • Deep vein thrombosis
  • Peripheral vascular disease
  • Open wound
  • Skin sensation impairment (e.g. some diabetic patients)
  • Severe cognitive impairment (e.g. dementia patients)

Precautions to use of Heat:

  • Patients with multiple sclerosis. 
  • Poor circulation.
  • Spinal cord injuries.
  • Diabetes mellitus.
  • Rheumatoid arthritis.

 

 

 

 

  

 1) Dubois B & Esculier J-F (2020) Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine. 54(2) 72-73.

2) Vuurberg G, Hoorntje A, Wink LM et al (2018) Diagnosis, treatment and prevention of ankle sprains: update of evidence-based clinical guideline. British Journal of Sports Medicine. 52:956.

3) Murtezani A, Sllamniku, Osmani-vllasolli T (2011) A comparison of high intensity aerobic exercise and passive modalities for the treatment of workers with chronic low back pain: A randomized, controlled trial. European Jounral of Physical and Rehabilitation Medicine. 47: 359-366. 

4) Kerkhoffs GMMJ, Rowe BH, Assendelft AJJ, Kelly K, Struis PAA, van Dijk CN (2002) Immobilisation and functional treatment for acute lateral ligament injuries in adults (Review) Cochrane Database Syst Rev Issue 3 [PubMed]

5) O'Sullivan P (2011) It's time for change with the management of non-specific chronic low back pain. British Journal Sports Medicine 46(4): 224-227.

6) Takagi R. et al (2011) Influence of icing on muscle regeneration after crush injury to skeletal muscles in rats. Journal of Applied Physiology. 110: 382-388. [PubMed] [Google Scholar].

7) Malanga G. A et al (2015) Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine. 127(1):1-9. [ PubMed]

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