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Patients often come to my office a week or two after an injury complaining that the problem is not getting
better. The body part, an ankle, for example, is swollen, stiff and still hurts. When I ask about self
treatment, the patient tells me about using hot soaks or heating pads. Sometimes, the treatment program has
included ice for 24 or 48 hours before starting heat. This approach is still written into many first aid
books and medical texts. Unfortunately, it doesn't work very well. Improper initial treatment of trauma and
overuse injuries is so common that I am addressing it in this issue.
The acronym PRICES is a convenient memory device. For a long time in sports medicine, there has been a tradition of using the word ICE to remind us about ice, compression and elevation. Someone added an R to make RICE, indicating that rest is part of the program. My partner, a sports physical therapist and certified athletic trainer, uses the granddaddy of them all-PRICES-to outline a program of protection, rest, ice, compression, elevation and support. I would like to explain the PRICES program so that you know how to care for acute sports injuries.
PROTECTION means protecting the injured area from further injury. It involves using crutches, slings and splints. I tend to be very aggressive about using crutches for lower limb injuries because a few days of crutch walking may reduce overall recovery time. If walking causes any pain, swelling or limping, I prescribe crutches. I usually tell the athlete to bear some weight on the injured leg as long as there is no pain. When he can walk normally without any pain or limp, he may set the crutches aside. Certainly, there are some more severe injuries in which I don't allow weight bearing. As a general rule of thumb, if an injury is severe enough to require crutches, medical evaluation is necessary.
Splints, slings and specially designed immobilizers for parts of the arm or leg are excellent support devices for sprains, suspected fractures and dislocations. They help the athlete avoid moving the limb into a position which could extend or reinjure the affected area.
In the severely injured athlete, stretchers, backboards and neck immobilizers are important forms of protection.
REST prevents further injury. Rest can be absolute or relative, generalized or limited to a single body part. Some serious injuries warrant absolute rest, but the athlete pays a price for this severe strategy. The price is deconditioning. Since the highest rate of injury in athletics comes during a reconditioning phase, it makes a lot of sense to limit the amount of deconditioning that takes place.
The approach I like is called "relative rest." In minor injuries, relative rest may simply mean reducing the workout to 50 or 60 percent of the pre-injury level, then slowly building back up. In more severe injuries, it may mean cutting back to rehabilitation exercises for the injured part and using other conditioning programs for the rest of the body.
Whenever possible, it is important to maintain the athlete's general fitness level. For example, in our practice if someone sustains a lower extremity or back injury, we have specialized equipment to maintain conditioning. One piece is an underwater treadmill which allows exercise without impact because the buoyant water supports the athlete's body. Another is an upper-body ergometer. Here, the athlete cycles with his hands, rotating the crank much as the feet usually do on a bicycle. This allows upper body aerobic conditioning while the lower body is healing. Deconditioning may be prevented by converting to bicycling and swimming, for example, in overuse running injuries such as shin splints and stress fractures. Localized rest may also be relative. Perhaps a joint or a fracture is immobilized, but the athlete can still do isometric exercise to maintain strength in the adjacent muscles.
ICE causes the small blood vessels in the involved area to constrict and reduce flow. Reduced blood flow limits the acute swelling which may slow the healing process. Additionally, cooling reduces the tissue damage from the injury itself. Another benefit is that ice anesthetizes the nerve receptors which cause pain and often trigger muscle spasm.
The best readily available cooling devices are plastic bags filled with crushed ice or ice cubes, or reusable frozen gel packs, which can be purchased at most any pharmacy. Ice massage with a small block of ice, often frozen in a paper or Styrofoam cup, is useful over a small area. Ice treatment varies with the intensity of the cold and the patient's tolerance. I usually recommend 20 minutes three times a day. In severe acute injuries, 20 minutes out of every one to two hours is often warranted. I shorten the time of ice application to 10 minutes for finger and toe injuries. In any case, ice should not be applied for more than a maximum of 30 minutes, followed by at least a 30 minute break, unless there is close medical supervision. Although I used to use a lot of heat, I rarely use it in traumatic or overuse injuries anymore. I'm beginning to believe "Ice ever, heat never."
COMPRESSION is used in conjunction with ice to limit swelling. Compression provides a physical limit to the amount of tissue space that body fluid may occupy. It prevents or reduces swelling. Generally, elastic ("Ace") bandages are used. These bandages are as narrow as two inches for wrist and hand injuries to as wide as six inches for the knee and upper leg. Wrap the elastic bandage so that half the width of the bandage overlaps the preceding layer. When wrapping below the knee or below the elbow it is extremely important to start the wrap at the fingers or toes, then work back toward the body. This prevents the tissue fluid from accumulating in the parts of the limb beyond the injury.
Apply the elastic bandage with even and consistent pressure to reduce the swelling in the area. Do not wrap it so tightly that the returning venous blood flow is halted. Usually using only one quarter to one third of the available stretch in the bandage is enough. If you are wrapping an ankle injury, you can provide even better compression by cutting a U-shaped piece of felt or foam rubber to go on each side of the ankle around the bony prominences.
ELEVATION reduces swelling by using gravity to move the tissue fluid out of the limb and back toward the body. Raise the injured body part above the level of the patient's heart. This can often be done by supporting an arm or leg with pillows. The combination of elevation with ice and compression works much better than any one or two of these techniques alone.
The final part of the approach isSUPPORT. It is truly a form of protection, but support is protection that can be used while the athlete is actually practicing or competing. In the case of acute injuries, support may be appropriate for minor problems when the athlete is going to return to play immediately. Obviously, support devices are also used with more significant injuries after rehabilitation. Examples of support would be ankle taping or bracing after an ankle sprain, and knee braces after postoperative rehabilitation.
PRICES will not cure major athletic injuries. They need evaluation, treatment and rehabilitation. The system will, however, work extremely well to protect the athlete from making a major injury worse. It will also help the body's own healing processes deal with minor injuries.