I’m sure you know how it feels to roll your ankle or twist your knee. The immediate reaction for most of us is to follow the PRICE (Protection, rest, ice, compression, elevation) protocol but why do we do it?
Today we are going to bring you a “message in a bottle” that we have moved on from PRICE to POLICE (Protection, optimal loading, ice, compression and elevation) and what the evidence is to back up each point.
You can’t turn a pun opportunity like this down so here is a link to message in a bottle by the POLICE
So why change from rest to optimal loading and what are the benefits behind the other stages?
While rest may be helpful in the very short term, continued rest may lead to deconditioning of the tissues – joint stiffness, muscle weakness or 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. For example in the ankle, contraction of the calf muscles (muscle pump) helps to move swelling up the body against gravity. Complete rest would the prevent this.
In some cases optimal loading may be no loading. Unstable fractures, complete tendon ruptures etc are unlikely to benefit from loading and may require casting, bracing or surgical repair. If there is bony tenderness and difficulty weightbearing then further investigations may be required. An example of this would be in the ankle where health professionals use a tool called the Ottawa guidelines to assess who should be referred for an X-Ray. Here is a link to the tool in question http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf The role of ice:
Let’s start with the don’ts – they are common sense but here we go anyway
- Apply ice over an open wound or an area that is numb. An open wound represents an infection risk and if the skin is numb you won’t know if you are suffering an ice burn
- Apply ice directly onto the skin – wrap it in a tea towel and don’t leave in situ longer than 20mins
How does ice work:
Ice is primarily used for its pain killing effects. The rationale behind this is due to a basic scientific principle called Van’t Hoof’s law. This states that for every 10degrees Celsius reduction in tissue temperature the rate of chemical reaction will decrease 2-3 fold. This means that the demands placed on the injured area will be decreased and therefore blood flow to the area will be reduced. If we think back to the last blog on pain and nociception it means there will be a decrease in the signal speed going to the brain.
The only slight snag is that there are very few human studies to back all this up. The studies that have done the research show that it is very difficult to lower the body part to the required temperature. This is particularly difficult in a hamstring where there is a lot of muscle overlying the injured part.
However, if we aim to put a bag of cruched ice on the injured area for 10-20mins 2-3 times per day for 5-7 days we will be in good shape. Note I said crushed ice rather than an ice pack as this will extract heat energy from the skin and will stay close to 0 degrees Celsius.
Much like ice the evidence behind compression is poor. The rationale is sound that if we limit the amount of swelling which is caused by the leakage of the inflammatory soup from the damaged structures then we can reduce the amount of scar production (decreased amount of a protein called fibrin). If this is achieved then natural balance within the muscle, joint or ligament will be restored. The best option for compression is tubigrip doubled over. This needs to feel snug but ensure there is good circulation below the tubigrip.
This helps to lower the pressure in the local blood vessels and therefore helps limit bleeding. It also helps with draining the inflammatory fluid through the lymph vessels which in the leg are behind the knee and at the hip. This is part of the reason that swelling seems better in the morning but increases with loading. It’s just a case of perseverance over the first 48-72 hours.
So what should you do post injury…
- Protect the injured area for 24-48 hours post injury by using pain as your guide when moving and walking.
- Ice – using crushed ice wrapped in a damp tea towel for 20mins every 2 hours if possible
- Compression – using a bandage or compression sleeve for a minimum of 72 hours post injury
- Elevation – as often as possible for minimum 72 hours post injury
We hope this helps the next time you experience an injury. Come and see us at Capital Sports so we can return you to 100% prior to returning to sports or just day to activities.
- Bleakley CM, Glasgow PD, Philips P, et al.; for the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). Guidelines on the Management of Acute Soft Tissue Injury Using Protection Rest Ice Compression and Elevation. London : ACPSM , 2011
- Kerr KM, Daley L, Booth L, Stark J. PRICE guidelines: guidelines for the management of soft tissue (musculoskeletal) injury with protection, rest, ice, compression, elevation (PRICE) during the first 72 hours (ACPSM). ACPOM. 1998;6:10–11. http://www.csp.org.uk/ publications/price-guidelines-guidelines-management-soft-tissuemusculoskeletal- injury-protection-re
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