Dr. Alan Hetherington
If you have played a sport long enough, you will experience aches and pains from a collision, sprained ankle, or strained muscle. Everyone is familiar with a long held guide to manage these injuries called the RICE protocol. For the injury in question, you are told to Rest, Ice, Compress, and Elevate the body part. This method was developed in 1978 by Dr. Gabe Mirkin to improve recovery and reduce inflammation for soft tissue injuries.
However, since its adoption, there is now an abundance of research supporting the idea that ice and rest can delay recovery while the evidence of benefits for compression and elevation remain inconclusive. As a result of subsequent research into the protocol, Dr. Mirkin retracted his original position on the RICE protocol in 2015, “subsequent research shows rest and ice actually delays recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune response that starts and hastens recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today RICE is not the preferred treatment for an acute athletic injury.”
A more comprehensive acronym to guide soft tissue injuries was suggested in 2020 by Blaise Dubois, PT and Jean-Francois Esculier, PT, PhD of The Running Clinic, that takes into consideration the immediate response (PEACE) and continual management (LOVE) of injuries. The following is how they suggest to use PEACE and LOVE.
P for Protect: Protect the injured area by avoiding movements that increase pain for 1-3 days. Absolute rest should be kept to a minimum. It is important to maintain movements that do not cause further aggravation to the injury in order to maintain overall tissue strength and quality while taking time to recover.
E for Elevate: Elevate the limb above the heart to promote interstitial fluid flow out of the tissue and away from the injury. Although there is weak evidence for the benefits of elevation, it has a low risk to benefit ratio.
A for Avoid anti-inflammatory modalities: Acute inflammation helps repair damaged soft tissue. Using medication to inhibit inflammation after an injury may negatively impact the long-term healing of tissue. Despite the appeal, anti-inflammatory medication should not be used for immediate care. Use of ice following injury is not recommended either. Despite widespread use, there is no high quality evidence for it improving recovery of soft tissue injuries. It can decrease pain with application but may interrupt inflammation and the cellular healing process for tissue repair.
C for Compress: External pressure with the use of tape or bandage helps limit intra-articular edema and tissue hemorrhage. Despite inconclusive evidence, compression after an injury like an ankle sprain may reduce swelling and improve comfort in the acute setting follow injury. Highly compressive sleeves and braces that reduce range of motion should be avoided.
E for Educate: Patients need to be educated on the benefits of an active recovery. Passive modalities, electrotherapy, manual therapy, acupuncture have insignificant effects compared to active therapy. Promoting an external locus of control or broken athlete will lead to therapy dependant behaviours. Although there are intriguing hi-tech options for treatment, patients need realistic expectations for recovery, understanding the condition and how to manage returning to sport.
After immediate care, Soft tissue injuries need LOVE
L for Load: An active recovery with movement and exercise benefits most patients with soft tissue injuries. Physical load and normal activities should begin as early as symptoms allow. Appropriate loading of tissue without aggravating pain, promotes repair and builds tolerance of muscle, ligaments, tendons for future stresses.
O for Optimism: Optimistic expectations are associated with better outcomes for patients. Catastrophization and depression can produce barriers to recovery. Beliefs have a substantial influence on how you perform in sports as well as recovery. Maintaining a positive mindset can make a significant impact.
V for Vasculature: Cardiovascular activity can help injured athletes remain active while they recover from soft tissue injuries. Pain free aerobic exercise a few days after an injury can improve motivation and stimulate blood flow. Not to mention, being sidelined for an extended period can lead to de-training. Maintaining aerobic fitness will make it more likely that your return to competition will be seamless.
E for Exercise: There is a strong level of evidence supporting exercise for treatment of ankle sprains to reduce injury recurrence. Injuries will alter the composition and function of soft tissue. These alterations can be reinforced with time lost from training. If proper mobility, strength, and perception are not restored with targeted exercise, you are returning to play in a compromised state. This can lead to a series of aggravations if the initial injury is not properly addressed.
If soft tissue injuries are managed with a patch up job to get out of pain and back on the field, then the athlete with a sprained ankle repeatedly returns to play with compromised function of important body regions until it becomes an injury that cannot be played through. Dubois and Esculier’s guide for soft tissue injuries provides important updates from the traditional RICE protocol. Protecting injuries from aggravating movements in the first few days is important but after relative rest, it is necessary to begin loading tissues for appropriate repair. Learning about your injury from a knowledgeable health professional and remaining focused on recovery will quicken your return to sport. A major factor that is frequently overlooked is maintaining your level of fitness. If you are not training due to injury, the gains you have made can fall off precipitously. The time it takes you to loose your fitness from not training is much shorter than the time it takes you to regain your original level of fitness pre-injury. If you maintain your cardiovascular fitness, strength, and mobility away from the site of your injury, you will likely not face as much struggles when you return to sports training. For athletes unsure of how to manage sports injuries, a health professional with sports experience can help guide them on how to give their soft tissue injuries the PEACE and LOVE they need.
References
- Scialoia D, Swartzendruber AJ. The R.I.C.E. Protocol is a Myth: A Review and Recommendations. The Sport Journal. 2020 Oct 30.
- Reinl G. Iced! The Illusionary Treatment Option 2nd ed. 2013. USA: G. Reinl.
- Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020 Jan;54(2):72-73. doi: 10.1136/bjsports-2019-101253. Epub 2019 Aug 3. PMID: 31377722.