Acute Injuries and their Management

Acute injuries can involve various structures around the knee, however the immediate treatment principles will apply to most situations. Obviously if a fracture (broken bone) is suspected then you must go straight to casualty for investigation.

Damage to the ‘soft tissues’ (ligaments, muscles, tendons, joint capsule etc) will cause inflammation, which is your body’s natural response to injury and provides the necessary environment for healing. The healing process can be divided into three phases:

The principles of (P)RICE should be followed from the time of injury.

• The repair phase will begin on about day 3 and continues for approximately three weeks. This phase rebuilds the damaged structure – new blood vessels form around the periphery of the site and fibres of connective tissue develop across the area. It is important to begin graded movement at this stage, early on this will encourage the correct alignment of new fibres and will prevent the formation of unwanted adhesions within the new tissue. Scar tissue has a tendency to shrink and shorten over time, therefore it is vital that full movement and flexibility are gradually restored.
• The remodelling phase continues from day 21 onwards. Connective tissue repairs through a process of scar tissue formation which then attempts to mimic the structure and function of the original tissue. The eventual strength of the tissue is dependant on the orientation and stable linkage of the new fibres – this is influenced by mechanical tension applied through the structure, reinforcing the need to restore normal functional range of movement as soon as safely possible.

P R I C E

• P protection
• R rest
• I ice
• C compression
• E elevation

Protection

Protection prevents further injury which would increase the inflammatory response and delay healing.

Following injury, the muscles surrounding the area often go into ‘protective muscle spasm’, this can increase pain thus resulting in a vicious cycle – the increased pain causes an increase in spasm!Protection of the area will allow the muscles to relax thus breaking the pain / spasm cycle.  

Protection may take the form of simply removing the risk of exposure to further injury i.e.- get the player off the pitch; it may mean using a stick or crutches to prevent weight bearing on the knee or it could mean wearing a splint or even plaster in more severe injuries.

Rest

Relative rest is a more appropriate term to use – it is certainly important to completely rest the injured knee for the first 24 hours but limited activity is then possible by using crutches to relieve weight. Any activity at this stage should be pain-free.

Gentle pain-free movement will improve the alignment of developing collagen fibres and enhance the ultimate strength of the new tissue.

A fine line exists between enough activity and too much activity, both of which can be detrimental to the healing process.

Total inactivity can lead to a delay in healing, adhesion formation, muscle weakness and reduced sensory awareness (this is called ‘proprioception’ and is important for balance and co-ordination).

Too much activity can cause stress to healing structures and an increased and prolonged inflammatory phase.

As a general guide movements should be kept within a pain-free range and repeated ‘little and often’. Do not be tempted to add resistance in the form of weights at this stage.  

Ice

Ice or cold therapy is effective in reducing excessive inflammation following injury. It should be applied as soon as possible - within 1 hour preferably. It is more effective at preventing swelling than reducing it once it has developed. Applied immediately, ice will also help to decrease soft tissue damage, pain and muscle spasm.

Application:

BEWARE - Frost-bite can occur if the skin temperature drops to -3.9 ° C or below. If you use a bag of frozen peas (a two pound bag is the right size and moulds nicely to the shape of the knee) wrap it in a damp towel before you apply it to the skin. Gel packs can reach very low temperatures in the freezer, so again be sure to protect the skin with a layer of damp towel.

Apply ice for a maximum of 15-20 minutes, every two hours. Continue until the tendency to swell stops - this is usually 12 - 72 hours after injury.

Compression

Compression should be applied to the injured area as soon as possible to reduce internal bleeding and control swelling formation. If ice has been applied then the compression should be administered immediately after the ice. Compression should be applied from below the injury site (just above the ankle), across it and continue for some way above (mid thigh). It will remain effective until swelling has dispersed.

Elevation

Immediately following injury, ie. while ice is in situ, elevate your leg so that the knee is higher than your heart; this will limit the development of swelling.

Depending where you are when you become injured, it may be impractical to elevate the leg to this height – if this is the case then at least try to put your leg up on a chair so that it is horizontal. Keep the leg elevated as much as possible, certainly in the first 24 hours.

Summary

• Apply ice – 2lb bag of peas or gel pack wrapped in a damp towel.
• Elevate the leg 15-25 cm above heart level.
• Leave for 15-20 minutes – remove ice – maintain elevation.
• Apply compression.
• Reapply ice up to 2 hourly.
• Use a stick or crutches for any unavoidable moving about.

As inflammation settles down you will move into the repair phase of healing. It is important at this stage to gradually increase movement in the joint (getting the knee absolutely straight is very important) and to begin graduated strengthening exercises – be careful not to push too hard or you may make the knee swell again. You should also be able to get about more easily now. It is very important that you regain full movement and strength before you attempt to return to sport.

If swelling in the knee persists, you are unable to put weight through the leg or the knee is unstable when you walk, you may have a more serious injury and should see a doctor or physiotherapist to get an accurate diagnosis.