Advice on treating acute injuries – the R.I.C.E protocol

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Injuries, like a sprained muscle, strained tendon, torn or damaged ligaments need immediate first aid treatment to help increase speed of recovery and reduce the risk of potential complications.

R.I.C.E. is an acronym for Rest, Ice, Compression and Elevation.

Injuries are frequently accompanied by pain, bruising, swelling, bleeding and inflammation. These are all natural responses of the body as a result of injury and are part of the healing process. By applying the four elements of the RICE protocol you can help to reduce pain or swelling and help to speed up recovery by aiding the healing process.

REST: stop the activity which caused the injury, and anything else that may further increase pain or exacerbate the injury. You may need to see a doctor or other medical professional – it is important to follow their guidelines as to when you may be able to resume activities.

ICE: applying ice to the injury site and immediate surrounding area has the benefit of reducing bleeding, swelling and pain. It is important to apply ice as soon as possible after the injury has happened.

How is Ice applied?

As a guide use cold packs indirectly (wrapped in a clean dry cloth to prevent skin burning) for 20 minutes every 2 hours, for the first 1 to 3 days. Crushed ice in a plastic bag (or a bag of frozen vegetables) works best as you can mould the bag around the injury site. 

 

Do not apply ice directly to the skin as it can cause ‘ice burns’. If your skin is sensitive to ice or you have circulation problems you may need to adjust the duration/frequency of ice application. Please use your own judgement as you know your body best. It is better to apply ice for a shorter duration and more often if you find the cold excessively painful. Remember though, it is ice, so it will be cold!

You may have heard that heat should be applied to an injury but this is not the case in acute injuries, which is usually during the first 1-3 days following injury. Heat can increase the level of bleeding and therefore cause an increase in swelling and pain. Heat is best applied once the injury is sub-acute (3-21 days after injury, depending on the severity).

COMPRESSION: is used to prevent and reduce any additional swelling by wearing an elastic compression bandage around the swollen area. The aim is to reduce swelling as much as possible as it can slow down the healing process. Some people may also experience pain relief from applying compression. If a throbbing sensation or feeling of tightness is experienced it means the compression is too tight and should be loosened off immediately.

ELEVATION: the final step in helping to reduce swelling and speed up your recovery. The injured area needs to be higher than your heart – this is because you want the excess fluids to drain towards your heart, and clearly gravity will help this immensely. For example, if your ankle is sprained you need to put your leg up higher than your heart; a good way is to lay on the floor with your leg on the sofa or bed – and ensure that the foot propped up on pillows higher than your knee.

Cramp

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What is it? Excruciating. That's what. Out running last week and my left calf decided to cramp. I knew I needed to stop...not much choice really...and stretch out the muscles. But why it was happening is another thing, which I'll come to later.

Back to the what. Well, it is an intensely painful sensation caused by a sudden onset of involuntary muscle contractions or severe muscle shortening. What essentially is happening is an acute muscle spasm. This forces the blood out of the muscle: this is bad, it means oxygen and nutrients aren't getting to where they should be. Lack of oxygen and the muscle contraction stimulate pain receptors and hey presto – you're bent over in agony. Cramp is most common in the calves, quadriceps (thighs) and arches of the feet.

So why do muscles cramp? Although the exact cause (or causes) are not known; there are many theories: fatigue, low sodium and/or potassium in the blood, dehydration, low carbohydrates, and overexertion. More recent research could point to there being disturbances in the central and peripheral nervous systems, connected to neural excitability, but this is still a hypothesis and hasn't yet been proved. I'll be on the look out for more on this theory.

What to do about it? In a pre-emptive sense, the main thing you can do is to ensure your body is in a healthy state. You may be physically fit, you may not be, however, if your electrolyte balance isn't optimal then as you dehydrate, the balance of sodium/potassium/carbs in your blood and thereforei n your muscles is going to be off. Generally you should avoid dramatically increasing your mileage, duration or intensity of activity, or undertaking any strenuous activity to which you're unaccustomed. Gradual increases are the way to go. I suspect that my run last week and the ensuing cramp was a combination of overexertion (I had just climbed about 150m in 0.4km after 4km of already uphill running), electrolyte imbalance and some residual tightness in the calf muscles (gastrocnemius and soleus – which merge into the achilles tendon). I'm now having regular massage on my calves to decrease the change of this reoccurring.

When cramp does strike, you need to stop the activity and stretch out the muscles, gentle massage can help too. What you're aiming to do is to relax out the muscles and increase blood flow to the area, thereby improving circulation and delivering fresh oxygen and nutrients to the muscle fibres. There is often pain or stiffness felt in the affected muscles for a few days afterwards. This is because the effects of cramp is the same as a muscle strain. Fibres can be damaged because of the lack of oxygen and the severe muscle contractions. Treatment following any occurrence of cramp should follow the RICE protocol (Rest, Ice, Compression, Elevation), just as though you had suffered a strain, because it possible you have without realising it. We don't tend to think of cramp as the cause of injury, but it can be. Added to that, I've read that incorporating plyometrics and eccentric muscle strengthening can help, as well as regular massage and elimination of trigger points (these can be the source of already taut bands of muscle).

Healing muscle strains - Treatment

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As mentioned in a post earlier this month (Processes involved in healing a muscle strain) what treatment aims to do initially in a muscle strain is to reduce pain, swelling, bleeding and secondary tissue damage by utilising PRICE (protection, rest, ice, compression and elevation).

At the acute stage treatment is, as mentioned, to follow the PRICE protocol. You should immediately stop the activity which caused or aggravated the injury. Protect the area, limit movement either with bandages or splints and keep it away from danger. From the perspective of a massage therapist you may think that there is little that can be done. But, regular (perhaps daily) lymphatic drainage massage is very helpful in keeping the good fluids moving into the area and the toxins flowing away – this will promote healing and a quicker recovery. Sessions may only need to last 10-15 minutes, maybe shorter, depending on the size and site of injury. It can also be a good idea to start gentle, passive movement in the midrange; this will encourage any scar tissue that is beginning to form to form in a functionally efficient way. At no point should there be any stretching of fibres which are damaged – this will only serve to compromise the delicate matrix of scar tissue which is in the early stages of forming. A good therapist will be looking for any evidence of compensation patterns and will start to address these – don't be surprised if treatment is on parts of you well away from where you are injured, this is perfectly normal! The application of ice immediately following injury slows blood flow to the area thereby limiting swelling. And don't forget elevation – if you've sprained your ankle you need to get your foot above your heart. It's no use just putting it on a chair because the aim is to use gravity to help the flow of fluids away from the injury.

The next stage of healing is the sub-acute stage, which can last anywhere from 3 to 21 days from the time of injury. This is the repair stage, with treatment varying according to how healing is progressing. We can now carry out controlled movement of the injured area both passively and actively – but still keeping to midrange movements to protect the delicate healing tissues. The aim is to encourage a mobile and functional scar. When I say scar, I don't necessarily mean surface scar which is visible after a cut to the skin. Scar tissues can form within muscles, on the fascia that wrap muscles and in all soft tissues within the body. This is one reason we can have muscular imbalances yet be uncertain where they stem.

One thing that happens following injury is muscle guarding; this is when muscles are in a state of readiness – i.e. partially contracted, and therefore not relaxed. They do this around the site of an injury to protect that area. In some ways this is good, but if the muscles remain contracted (partially or otherwise) for prolonged periods of time then they can become fatigued and inefficient. They can become part of the problem, perhaps adding to developing compensation patterns or causing muscle imbalances which can lead to other injuries later on. The good news is that as therapists we know to look out for these issues and help to prevent them. This is all part of managing compensation patterns in the sub-acute stage of healing a strained muscle.

So in the acute stage you were applying ice to the area, well now you can now use hot and cold therapy to help aid the healing process – applying ice (not directly on the skin) and heat with a hot water bottle or heat pack. Cold constricts blood vessels, preventing further inflammation and heat encourages fresh blood to flow to the area bringing oxygen and promoting healing. Both should only be applied for short periods of time to avoid further damage to soft tissues. Alternating the heat and cold helps to reduce pain and speed up recovery.

Proprioception (the ability to tell where your body is in space) can be disturbed following injury, meaning you are more likely to have a recurring injury at the same site if you don't do strengthening and balance exercises. The disturbance to your proprioception may not be noticeable to you but it is caused by the transmission of sensory information being disrupted when nerve endings and sensory receptors are damaged. This means the brain doesn't receive the correct information about where your body is positioned and, for example, in the case of an ankle sprain, can mean that if you start to go over on it again your brain won't get the right signals to prevent that from happening – the result being a re-injury.

The final stage of healing is called the remodelling stage because it is all about the tissues in the area maturing over a period of 3 weeks up to 2 years depending on the severity of injury. The tissues need to become fully functional through stretching and strengthening to ensure that the collagen fibres are aligning correctly. If they aren't then massage therapy using a variety of techniques can manage and reduce adhesions and encourage appropriate scar tissue development. Stretching can now be within the full range of the joint providing the healing process if going well. Tissue pliability can be restored and any remaining compensation patterns eliminated. The aim is to make tissues functional in response to their natural movement patterns. Taping the area can help at this stage to encourage correct alignment and functional use, and to assist in development of good proprioception.

Processes involved in healing a muscle strain

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The first aim of treatment in healing a muscle strain is to reduce pain, swelling, bleeding and secondary tissue damage by utilising PRICE (protection, rest, ice, compression and elevation). Encouraging circulation, after the acute stage, through gentle massage lymphatic drainage can help recovery. There are three stages to healing a muscle strain: inflammatory, proliferative and remodelling.

Inflammatory: this is the body’s reaction to the injury and preparation for the repair phases.

The inflammation stage is when the immune system increases circulation to the injury site, with the aim of producing edema (swelling). Pain will be felt at the site, which indicates that the immune response to injury is working as it should. In response to inflammation the body produces chemicals which eliminate dead muscle fibres and begin repairing the fibres. Inflammation also causes heat and redness to occur in the area because of the dilation of small blood vessels. Once the blood in the area clots the macrophages can start to remove dead tissue and digest any cell and bacteria particles. This ‘cleans’ the area ready for the next stage and blood vessels can begin to re-grow in the area and restore oxygen flow. Massage can help to speed up this process by flushing out the toxins and dead cells from the area, increasing circulation to bring oxygen and fresh nutrients to the area.

Proliferative: this is the stage when cells produce the materials to repair the injury. Fibroblasts begin to multiply and produce small fibres of collagen which is laid down, increasing the strength of the fibres. When a tear of the connective tissue in a muscle occurs it is fibroblasts which lay down collagen. The collagen fibres which make up the scar tissue mature and become aligned along lines of external stress and are able to withstand more force. This is how the area becomes functional again. In significant tears the adhesion could form in connective tissue layers. Adhesions in the fascia result because of abnormal cross-links forming in the collagen. The formation of scar tissue is where a matrix is formed in the damaged area. This is the result of bleeding which forms a scaffold to join the two sides of the scar together. In a typical injury the muscle will become shortened and can lose extensibility. Satellite cells help myoblasts develop into muscle fibre and regeneration is generally achieved within 3 weeks. At this stage massage will help align fibres correctly and keep scar tissue formation to a minimum.

Remodelling: this is where the body tries to restructure the injury site back to the pre-injury state. It consists of the new replacement tissue settling down to its ultimate structure. With maturation of the scar the site becomes shortened. This can be prevented by use of the muscle, thus maintaining the length of the fibres which are needed for normal function. Once the fibres are being used normally the scar will steadily mature until it resembles the tissue that was present before it became injured. Massage continues to play an important role in this phase, enabling the body to adapt in a functional way.