Acute Soft Tissue Injuries and How to Manage Them

Summary of article

• After a new soft tissue injury, take these steps to aid recovery (1)

  • Protect

  • Elevate

  • Avoid Anti-Inflammatory Modalities

  • Compress

  • Education

• 1-3 days after sustaining a new injury, implement the following steps to return to function (1)

  • Load

  • Optimism

  • Vascularisation

  • Exercise

Article

The concept of an acute soft tissue injury is one that would be familiar to everyone. Whether it was an ankle sprain from stepping in a pothole, a tendon tear from a landing heavily on a shoulder during a tackle, or a lumbar muscle strain from a completely innocuous movement on a slightly-to-cold morning, all people have or will experience injury. Despite injuries being so commonplace, recommendations on how they should be managed can vary widely.  

A Brief History of Injury Management Acronyms

Although it has widespread popular recognition Rest, Ice, Compression, Elevation (RICE) for acute injury management has been superseded multiple times by: 

• PRICE (the extra P standing for Protect) (2)

• POLICE (Protect, Optimal Loading, Ice, Compression, Elevation) (2)

• PEACE and LOVE (the current best-practice recommendation) (1)

PEACE and LOVE for acute injury management was published in the British Journal of Sports Medicine in 2020, and at this time represents the most up-to-date method of managing an acute tissue injury.

 “Immediately after injury, do no harm and let PEACE guide your approach” (1)

 P – Protection 

For the first 1-3 days after a new injury, limit exposure to potentially irritating movements and positions that could cause new tissue damage. For example, after an acute ankle sprain you should not be running, and, depending on the severity of the injury, bracing or walking with crutches may be warranted.  

Complete rest is not recommended during this time, however, as this can negatively impact tissue strength and quality (2).

E – Elevate 

Whenever possible, elevated the injured area higher than the heart in order to facilitate excess fluid to drain from the area. For example, after a new knee injury, lay with pillows underneath the thigh and shank to elevate the leg (1).

A – Avoid Anti-Inflammatory Modalities 

In the early phase of managing a new injury, inflammation is a normal response which facilitates repair of damaged tissue. Therefore, avoiding the use of anti-inflammatory medications (such as ibuprofen or diclofenac), particularly at high doses, is recommended (2).

Additionally, there is some evidence that cold or ice application can inhibit inflammation and impair tissue healing. While there is some evidence that it can be effective in reducing pain, this may come at the cost of longer-term healing (3).

C – Compress 

Mechanical pressure from taping or bandages to an injured area can reduce bleeding and fluid buildup. This can reduce swelling, and improve function (4).

E – Education 

Education from a qualified clinician on the diagnosis and management of the injury can guide appropriate treatment and ensure that expensive investigations (such as x-rays or MRIs), passive therapies (such as massage and manipulation), and invasive treatments (such as injection or surgery), are only used as necessary (2,5).

In the current clinical era, there are many treatments available if they are sought out. However, for a new tissue injury none represent a “magic cure”, and tissue healing times will ultimately dictate the large majority of recovery (1).

“After the first days have passed, soft tissues need LOVE” (1)

 L – Load 

Optimal mechanical loading of an injured area promotes tissue healing, and a faster return to pre-injury function (6). Some mild symptoms are to be expected when loading an injured area, however, pain should be well controlled and not progressively increase.  

For example, three days after a lateral ankle sprain it may be appropriate to walk with only one crutch, and place more weight through the injures area. However, if this increase in loading causes significant increases in pain, a more gradual approach would be recommended. 

O – Optimism 

Maintaining a positive and realistic outlook makes implementing appropriate management easier. People who have become overly fearful of movement, or are otherwise affected by depression or tendencies to catastrophize, find it more challenging to implement appropriate management (7). In these scenarios, seeking assistance from a qualified clinician for guidance would be recommended. 

V – Vascularization 

Comfortable cardiovascular activity improves blood flow to injured sites, and results in faster functional recovery and reduced need for pain relieving medications (8). The form of activity needs to be appropriate to the injured tissue, however.  

For example, cycling on a stationary bike after an ankle sprain may be pain-free. Conversely, an early return to running may represent a load that is too aggressive for the injured tissues to tolerate, and result in increased pain. 

E – Exercise 

Appropriately dosed exercise can increase the rate of recovery of mobility, strength, and proprioception after an injury (6). Additionally, for some injuries there is evidence that future injury risk can be reduced by completing a comprehensive rehabilitation program (2).

In Summary

The acronyms PEACE and LOVE represent the current best practice recommendations for managing new soft tissue injuries (1). These acronyms recognise that a combination of protection and appropriate loading of injured tissues is key to healing and return to function.

References

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. Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE?. British journal of sports medicine, 46(4), 220-221.

3. Singh, D. P., Barani Lonbani, Z., Woodruff, M. A., Parker, T. J., Steck, R., & Peake, J. M. (2017). Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in physiology, 8, 93.

4. Hansrani, V., Khanbhai, M., Bhandari, S., Pillai, A., & McCollum, C. N. (2015). The role of compression in the management of soft tissue ankle injuries: a systematic review. European Journal of Orthopaedic Surgery & Traumatology, 25(6), 987-995.

5. Graves, J. M., Fulton‐Kehoe, D., Jarvik, J. G., & Franklin, G. M. (2014). Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health services research, 49(2), 645-665.

6. Khan, K. M., & Scott, A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British journal of sports medicine, 43(4), 247-252.

7. Briet, J. P., Houwert, R. M., Hageman, M. G., Hietbrink, F., Ring, D. C., & Verleisdonk, E. J. J. (2016). Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury, 47(11), 2565-2569.

8. Sculco, A. D., Paup, D. C., Fernhall, B., & Sculco, M. J. (2001). Effects of aerobic exercise on low back pain patients in treatment. The Spine Journal, 1(2), 95-101.