In order to understand the principles of soft tissue management one must first have some basic understanding of the tissues involved and the body’s response to an acute soft tissue injury. Soft tissues injuries that are most commonly involved are listed below:
Bones and periosteum:
Bones form the rigid framework of the body. Periosteum is the sensitive covering layer of the bone to which the tendons, capsules, and ligaments are attached.
Joints, Capsules, and Ligaments:
Joints are the meeting places of two or more bones where movement takes place. A tough capsule encases all joints. Strap like bands called ligaments reinforce capsules.Capsules and ligaments have little give and are common sites of injury.
Muscles and Tendons:
Muscles are fleshy tissues, richly supplied with blood vessels. They contract and relax both voluntarily and involuntarily. Tendons are strong cable like structures, which connect the muscle to their bony attachments. The muscle-Tendon unit is responsible for producing movement at the joints. Compared to muscles, tendons have much less blood supply, therefore often take longer to heal.
Bursa are fluid filled sacs, strategically placed to reduce friction between layers of
tissues: for example, between tendons and bone.
Nerves are the electrical lines between the brain and the tissues of the body. They send messages to muscles directing them to move parts of the body. They also provide the skin and all other tissues sensation such as the sense of pain, sense of temperature, and sense of touch.
Blood vessels supply nutrition to the tissues of the body, as well as remove waste
products from the tissues of the body.
Your body’s response to injury can be divided into 3 phases:
1. Soft tissue damage
Soft tissue damage occurs when excessive force or repetitive minor forces are applied to soft tissues excessively enough to cause soft tissue damage. This results in pain and may lead to a certain amount of internal bleeding and swelling. If blood vessels have been damaged bruising may appear.
Inflammation is the initial response of the body to soft tissue damage and is achieved by the increased movement of plasma and white blood cells from the blood into the injured tissues. The purpose of inflammation is to eliminate the initial cause of cell injury, clear out necrotic cells and tissues damaged from the original insult.
The signs of inflammation are:
• Loss of movement
The inflammatory process may be present for as little as 3 and as much as 21 days depending on the severity of tissue damage, and the individual’s response to injury.
If the initial injury is not treated effectively the inflammatory response could persist for an extended period of time. This often may delay repair, lead to excessive scar tissue formation, cause loss of flexibility, strength, function, and cause the tissues to become overly sensitive to normal stimuli (severe pain with the lightest of touch or pressure to the injured tissues).
The repair phase begins within 2 days following injury, while the inflammatory process is still present. The repair process begins with the formation of new blood vessels around the edge of the injury site. After a further three to five days a new tissue is formed. The repair process may continue for several weeks. The new tissue that is formed is commonly known as scar tissue. Scar tissue does not have the same properties as the original tissue. As the scar tissues matures it shrinks, leading to inflexibility and pain/stiffness when the scar is stretched, compressed, or contracted.
So how does PRICE help?
Protection and rest immediately following a recent injury is a no brainer. When you feel pain following a recent injury, you should stop whatever you are doing. Take a few minutes to assess the damage and let the pain settle. To prevent further damage it is necessary to rest the injured part. To achieve this you may need to immobilize the injured part with a brace and/or use a crutch to reduce weight to the injured area if it is a leg or a sling if it is an arm. When applying the principle of rest following an injury, it is not necessary to completely stop all activity for extended periods. In fact even short periods of rest have been shown to be deleterious to the healing process producing adverse changes in tissue morphology, biomechanical properties, and tensile strength. Usually a few days of rest is adequate. The injured part should only be rested to the extent that all painful activities are avoided. This is called relative rest. For example if following a lateral ankle sprain walking does not cause any pain, continue to walk short distances as pain allows. New research suggests early movement or “optimal loading” may accelerate the repair process (more on this later).
Ice and cold therapy:
Both ice and cold therapy are very effective in reducing pain when the skin temperature is cooled to less than 15˚C for periods of 10-20 minutes. Ice and cold therapies effect on the inflammatory process has recently been questioned. Studies on ice performed on animals have shown positive results in reduction of cell metabolism and white blood cell activity. However, the studies of ice performed on humans have not been supportive. Researchers hypothesize that the ability to reach adequate cellular cooling to reduce cellular metabolism and white blood cell activity in humans is hindered by the depth of the injured tissue, excessive layers of adipose, and the placement of ice over bandages/dressings.
Ideally ice or cold therapy should be applied immediately following injury, as this assists to decrease pain, and possibly inflammation. Ice therapy involves the use of ice to obtain cooling of the injured area.
The following methods of applying ice are recommended:
- Place crushed ice with a little water in a plastic bag. Then place the bag containing the ice inside another bag and mold this over the injured area.
- Mold a packet of frozen vegetables over the injured area.
- Place a commercial therapeutic ice pack on the injured area following the manufactures instructions
Cold therapy provides less cooling of the injured area than ice therapy. It is therefore more suitable to apply cold therapy to children, elderly, and persons with thin, fragile, or sensitive skin.
The following methods of applying cold therapy are recommended:
- Place a cold, damp flannel over the injured area. The flannel can be cooled by dipping it in ice water. When the flannel warms up replace it with a cold one.
- Place the injured area in a bucket containing water and ice. This is useful if the injury is to the hand or foot.
- Place the injured area under cold running water. This is useful for minor injuries or when other options are not available.
Guidelines for the application of ice and cold therapy:
- Ice can burn if the skin surface temperature reaches 0̊ C. To avoid this, protect your skin with a layer of insulation before applying ice. Use a covering of oil, or a damp cloth. Check your skin after a few minutes. If your skin has become white stop the ice and try cold instead.
- Both ice and cold may give some initial discomfort. This should wear off in a few minutes. If, with the use if ice or cold therapy, your skin is becoming numb or increasingly painful, stop the ice or cold therapy and seek advice from a therapist.
- Apply ice or cold for no longer than about 20 minutes. Prolonged application will be of no further benefit. To obtain the maximum benefit after a recent injury, apply ice or cold therapy every 3 hours.
Edema is one of the cardinal signs of acute inflammation after a soft tissue injury. Although some components of inflammation are essential for the healing process, prolonged edema is an unwanted as it leads to increased tissue pressures causing pain, movement restrictions and muscle inhibition. Edema forms when fluids accumulate within the interstitial space; this is really the aggregate effect of leaky capillaries, higher hydro-static pressures within the vasculature and an altered osmotic gradient after injury. If we can restore the pressure gradients at the capillary bed, we can prevent or limit the extent of edema. Most practitioners try to achieve this using at least one of these approaches: compression and elevation. There is some suggestion that elevation and compression should not be used simultaneously. In fact, a few studies have reported that when used together, they actually increase tissue girth after injury.
Compression is the application of pressure over the injured area by bandaging. This is an invaluable and often overlooked first aid measure. It is the most effective way of reducing internal bleeding and swelling, particularly if applied within the first few minutes following injury.
Guidelines for the application of compression:
- Use a bandage that will mold around the injured area, providing a firm and even pressure. Elastic bandages are preferable to other types of bandages.
- Bandage a good distance below and above the injured area.
- Apply the bandage firmly and comfortably. If too tight it may cause numbness, if too loose it will be ineffective.
- A 15-30 mmhg compression garment may be substituted for elastic bandage wraps for some lower leg injuries.
- Remove the bandage before ice or cold therapy, and during elevation re apply immediately afterwards. Re wrap in the mornings or whenever the bandage has loosened.
- For minor edema the use of kinesio text taping (or similar products) applied appropriately to the injured soft tissues may be of benefit and allow more mobility during use of the injured body part.
Immediately following the injury, elevate the injured limb above the level of your heart to limit the development of swelling. Elevate your injured limb at every opportunity for as long as swelling continues. Raising the injured limb above your heart level may be impractical at work and in other situations, but remember that some elevation is better than none at all. For example, resting your injured ankle on a chair will still provide effective elevation. Gentle pain free muscle contractions while elevating your injured limb may enhance venous outflow and lymphatic drainage and should be performed when movement is tolerated (i.e. pumping of ankle while elevating your leg).
As excessive rest following a soft tissue injury may be harmful and inhibit recovery, the secret is to find the” optimal loading” to enhance tissue repair without prolonging or intensifying the inflammatory process. Optimal loading means replacing rest with a balanced and incremental rehabilitation program where early activity encourages early recovery. Injuries vary so there is no single one size fits all strategy or dosage. The optimal load is dependent on the predominant phase of healing (i.e. inflammatory or repair), the type of soft tissue involved (muscle, tendon, ligament, etc.), and the severity of the injury. The optimal loading strategy is guided by the behavior of pain with controlled movements/activities. In general the controlled movements that are optimal to enhance recovery should slightly increase or produce familiar pain at the injury site, but should gradually reduce in intensity with repetition or at least subside immediately upon rest from the controlled movement/activity. As the injury progresses though the phases of healing the optimal loading of the injured tissues are progressed via more intense or rigorous activity. The aim of this strategy is to normalize newly forming scar tissue. The frequent adoption and progression of appropriate and controlled movements/activities in this manner have been shown to create a more elastic and stronger scar that is less likely to become re injured with normal use of the injured body part.
If you have suffered a recent soft tissue injury and are unsure of the extent of injury or what optimal loading strategy is right for your injury, seek advice from a physical therapist with advance knowledge in mechanical therapy and orthopedics.
American Heart Association. (2005). Circulation. Retrieved January 25, 2015, from http://circ.ahajournals.org/content/112/22_suppl/III-115.full
Bleakley, C. (2013, October). Acute soft tissue management update. SportEx medicine(58), 16-19.
Bleakley, C., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating,should we call the POLICE? British Journal of Sports Medicine, 46(4), 220-221.
Lindsay, R., Watson, G., Hickmott, D., Broadfoot, A., & Bruynel, L. (1994). Treat your own strains, sprains, and bruises. Waikanae: Spinal Publications LTD.