General pediatricians encounter patients suffering from soft-tissue injury (ie, sprains, strains, and contusions) sustained through athletics and physical activity on a regular basis. A recent survey conducted by the National Center for Health Statistics recorded more than 4.3 million sports and recreational injuries annually in the United States. Sports accounted for 36% of injuries from all causes.1
In the past, sports medicine often has been associated with team physicians, therapists and trainers. However, increasing numbers of youths participating in sports make every primary care medical provider accountable to know about the management of sports injuries. The physician who does not recognize the importance of sports and exercise, and who is not sympathetic to the interests of the injured athlete would be prudent to refer these type of patients to sports medicine specialists.2 This article briefly reviews the types and mechanisms of injury and focuses on the rationale for the "RICEM" method of acute treatment of these common injuries.
TYPES OF INJURIES
There are basically two different types of injuries encountered in sports: acute and overuse. Acute injuries usually result from a single impact force to a muscle, ligament, or tendon. Direct impact to a muscle leading to a contusion, a twisted knee or ankle causing a sprained ligament, or a sudden start/stop leading to a tendon rupture are all examples of an acute injury. Overuse injuries may be defined as those that occur from the repetitive application of submaximal stresses to otherwise normal tissues. Stress fractures, tendonitis, apophysitis, rotator cuff impingement, and patellofemoral stress syndrome are conditions resulting from overuse.
Some injuries are possibly the result of a combination of an acute injury superimposed on an underlying overuse condition. An example of this is a young thrower with chronic medial epicondylar elbow pain who continues to throw and subsequently experiences an acute avulsion injury of the medial epicondylar apophysis. Therefore, when evaluating an apparent acute injury, the physician must consider predisposing overuse microtrauma.
A blunt injury to the soft tissues or muscle results in damage and disruption of the soft tissue and muscle fibers. Capillary disruption and bleeding lead to intramuscular hematoma formation and subsequent inflammation. Contact sports commonly cause quadriceps and tibialis anterior contusions. Myositis ossificane is caused by calcification within the site of bleeding and is a complication of the muscle contusion. Persistent pain and stiffness is the common presentation of this condition. Plain radiographs show a calcific density in the injured muscle that may be mistaken for a tumor by an inexperienced clinician.
A sprain is the result of injury to a ligament or joint capsule. Ligaments are designed to resist forces in several directions and therefore can be damaged by more than one mechanism. For example, the medial collateral ligament is designed to resist separation of the medial surfaces of the femur and tibia when valgus force is applied and resist rotation of the joint when torsion is applied. Injury to the ligament results from stretching beyond the physiologic limit to recover, which causes various amounts of tearing of the ligament fibers in the direction of the stress, with later bleeding and inflammation.4
Sprains are graded depending on the degree of injury. A mild or grade 1 sprain is characterized by mild joint swelling, mild pain and tenderness, and no joint laxity. Although the ligament may be stretched with this injury, few fibers are actually torn. A grade 2 sprain is the result of significant tearing of ligamentous fibers and is characterized by increased joint laxity with some remaining and distinguishable strength. More swelling, pain, and functional impairment is evident. Grade 3 sprains are seen with complete tearing of the ligament and the loss of the ligament to sustain a load under stress. Severe pain, swelling, and loss of motion are noted with this injury. Surgical treatment may be necessary for some grade 3 injuries.
A strain is an indirect injury to a tendon or muscle. The majority of strain injuries are thought to occur at musculotendinous junctions. This injury may be the result of excessive use (chronic strain) or excessive force (acute strain). Muscles that cross two joints and contain a high percentage of type II muscle fibers (fast-twitch, glycolytic metabolism) are particularly susceptible to injury. The gastrocnemius and hamstring muscles are examples of this type of muscle. Other factors that may predispose muscle injury include fatigue, previous injury, inadequate warm-up, and environmental conditions.
Similar to sprains, strains are graded based on the loss of integrity of the musculotendinous unit. However, grading muscle strain injuries and identifying the exact muscle that is injured prove to be formidable tasks even for the most astute clinician. Mild strains occur with minimal disruption to the musculotendinous unit. Mild pain without loss of strength, motion, or function are the hallmarks of a mild injury. A moderate strain is the result of some tearing and actual damage to the musculotendinous complex. Some loss of motion and strength are evident with this type of injury. Rupture of any portion of the musculotendinous unit defines a severe strain. A palpable defect with loss of motion, strength, and function are the hallmarks of a severe injury. Significant bleeding and swelling may make it difficult to grade the severity of injury and to pinpoint the exact muscle affected in many cases.
The inflammatory reaction following injury to soft tissue is essentially the same for contusions, sprains, and strains (Figure). Bleeding into the tissue from damaged capillaries is the initial response. A brief vasoconstriction response is seen followed by a marked increase in vascular permeability. Vascular permeability is increased secondary to the exposed vascular endothelium contacting factor XII, which activates the intrinsic clotting cascade, the complement system, and the kinin system.6
Complement activation releases chemotactic factors, which cause recruitment of neutrophils, monocytes, and lymphocytes. Inflammatory cells and injured tissue later generate significant amounts of arachidonic acid, which can be released from cell membrane phospholipids.7 Damaged cells and leukocytes spill lysosomal enzymes such as proteases, causing degradation of tissue and liquefaction. The resultant increased vasodilation and leaky capillaries causes edema. Damaged nerve endings are sensitive to increased pressure from edema and the noxious chemical inflammatory stimuli. Pain causes acitivation of a reflex arc mediated via spinal pathways, resulting in muscle spasm.
Figure. Tissue damage as a result of initial trauma.
Following the acute inflammatory response, repair of soft tissue occurs via scar formation. Soft tissue has minimal capacity to regenerate. Within 2 to 3 days, macrophage proliferation, fibroblast activation, and granulation tissue formation are all evident within most soft-tissue injuries.
Exercise has been shown to modify the healing response of tendons, ligaments, and muscles. Exercise has been found to increase fiber size, tendon strength, and stiffness whereas immobilization has die opposite effect. Exercise increases strength and stiffness at the ligament-bone junction and within the substance of the ligament. Increased numbers of myofibrils and muscular hypertrophy also can be seen with an exercise program.8
Treatment of soft-tissue injuries is aimed at reducing pain and swelling, limiting bleeding and inflammation, and restoring function to the injured area so that athletes can return to their sports in a safe and reasonable manner. "RICEM" is the acronym used to guide the practitioner in the treatment of soft-tissue injuries in the acute setting. The acronym, which stands for Test, ice, compression, elevation, and motion, will allow the athlete to rapidly progress through the acute phase of rehabilitation.
For the initial 24 hours following an injury, the athlete should be resigned to doing whatever possible to minimize further injury; complete rest will allow this. Continued movement, loading, or trauma to an injured soft tissue may cause persistent bleeding, edema formation, and connective tissue injury. Immobilization and unloading prevent excitation of muscle spindles, which reduces spasm, and prevents excitation of nerve endings, which reduces pain.4
Immobilization with various types of makeshift or customized slings, splints, braces, or immobilizes can be achieved when covering a game or practice situation. Unloading weightbearing lower extremities with crutches until the patient is able to bear weight with minimal limp may be necessary to protect the injured area from further damage.
The duration of rest varies depending on the severity of the injury, the injured body part, and practice variations among practitioners. Prolonged immobilization can unnecessarily lengthen rehabilitation and delay return to sport. Most injuries require 24 to 48 hours until early motion should be started so that mobility returns in a timely manner.
Ice has been the universal treatment of acute softtissue injuries for the past four decades. Despite this, little research has been done on the topic. Physiologic effects attributed to cryotherapy include decreased temperature, inflammation, metabolic rate, circulation, and metabolism. Indirectly, cold has the ability to limit hypoxic injury by slowing cellular metabolism. It is this effect, more than stopping bleeding, that may be more important in the acute treatment of most soft-tissue injuries. During the rehabilitation phase, ice aids with analgesia and allows pain-free early motion, which may assist in stimulating healing.
In general, most sports medicine experts recommend the generous use of ice in the acute phase of treatment (48 to 72 hours). Ice in the form of cubes or chips is placed in a plastic bag with the bag then being directly placed on the skin and fastened with an ace or plastic wrap. Ice massage is an alternative technique used commonly for small areas of injury such as tendonitis or focal ligament sprains. Treatment duration should be no longer than 20 minutes during any one sitting because of the increased risk of nerve injury due to prolonged cryotherapy.9
Through direct pressure, compression has the ability to limit the amount of swelling. Theoretically, compression should increase hemostasis and interstitial pressure resulting in decreased swelling. Initially, compression may be used in conjunction with cryotherapy and continued after the initial 20 minutes of icing. Ice generally is reapplied every 1 to 4 hours, and compression is continued for the first 24 hours. At all times, distal perfusion and venous return of the affected extremity must be monitored to prevent compression hypoperfusion or venous congestion, which could result in further damage to an already injured area.
Elevation controls swelling by increasing venous return and lymphatic drainage centripetally, away from the injured part.4 Increased pressure in the peripheral circulation through elevation of an injured extremity will augment venous and lymphatic drainage toward the central circulation.
Early motion following most soft-tissue injuries will help the athlete in making a more rapid recovery. Complete immobilization in a knee immobuizer, walking ankle cast, or upper extremity sling may relieve pain in the acute phase of treatment. However, prolonged immobilization delays progression to functional rehabilitation and return to sports. The patient or athlete must work harder to overcome the loss of motion caused by prolonged immobilization. Therefore, early mobilization provides the best results in most cases by providing a faster recovery rate.10 Early motion aids in diminishing edema, résorption of the hematoma, and prevents spasm and scar contracture.
The judicious use of RICEM often will provide adequate pain relief and fairly rapid recovery of motion. Despite the fact that nonsteroidal antiinflammatory drugs (NSAIDs) are used routinely by patients, their use has remained controversial in terms of whether they actually are beneficial in the acute and rehabilitation phase of treatment.
The anti-inflammatory effects of NSAIDs should give them a theoretical benefit over pure analgesics when treating soft-tissue injuries. A recent medical literature review concluded that NSAIDs shorten the time period to recovery and were associated with less pain.10 However, the poor study design and the variable nature of sports injuries makes it difficult to draw definitive conclusions on the use of these medications for soft tissue injury management. Nonsteroidal antiinflammatory drugs are effective analgesics without potential for dependence from chronic use, which is seen with opiates. In addition, several NSAIDs require less frequent dosing intervals than aspirin, acetaminophen, or narcotics and are therefore advantageous for an adolescent athletic population who routinely have difficulty with compliance.
The toxicity of NSAIDs is related to their ability to inhibit prostaglandin synthesis. Potential side effects include inhibition of platelet function, impaired renal function, gastritis, and hypersensitivity reactions. The other main disadvantage of most NSAIDs over aspirin or acetaminophen is cost.
Overall, most soft-tissue injuries can be managed without NSAIDs. Stressing the use of RICEM, insisting on compliance, and having the patient follow-up with a therapist or trainer are the most important elements in the treatment of most soft-tissue injuries.
Following the acute phase, the main goals of physical therapy are to restore range of motion and regain strength, balance, functional agility, and coordination. The rehabilitation program should be supervised by a physical therapist or certified athletic trainer.
Range of motion should be started in the first 24 to 72 hours as pain allows. Passive motion with little resistance or with the help of buoyancy in a swimming pool can assist the patient in making a rapid recovery.
After regaining range of motion, the athlete must regain strength. Strength is important in overcoming any weakness and atrophy secondary to inactivity as well as in preventing reinjury. Once again, a therapist or trainer can design a practical and simple program using the resources the athlete has available. The availability of a pool also can assist an earty start to the strengthening phase of the program. Initial strengthening exercises should be performed in a protected range of motion with progression to a more functional and provocative program later in the rehabilitation program.
Maintaining cardiovascular fitness through some type of cross training is important in allowing a more rapid return to sport than would be possible if the athlete were deconditioned because of a prolonged rehabilitation solely concentrating on the injured area. The use of exercise bicycles, swimming pools, stairclimbing machines, rowing machines, etc allows athletes to maintain or improve their cardiovascular fitness while rehabilitating their injuries.
Proprioceptive exercises and sport-specific drills are the last phase of rehabilitation and allows the athlete to regain balance, agility, and confidence prior to return to sport. When athletes have regained painfree, full range of motion, and full strength and passed through a functional rehabilitation program, they can be allowed to return to sport.
Most primary care physicians will encounter soft tissue injuries in their office. The acute treatment of these injuries using the acronym RICEM is the most important part of treatment so that the athlete may progress to a more functional phase of rehabilitation in order to allow for a rapid recovery and safe return to sport.
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