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Abbreviation (ISO4): Acta Academiae Medicinae Sinicae      Editor in chief: Xuetao CAO

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2024 , Vol. 46 >Issue 6: 828 - 835

DOI: https://doi.org/10.3881/j.issn.1000-503X.16073

Sports Medicine Forums

Research Progress in Treatment Principles of Acute Closed Soft Tissue Injuries

  • Bingying ZHANG 1 ,
  • Xiaohan ZHANG 1 ,
  • Yi QIAN 2, 3 ,
  • Wenbo TANG 1 ,
  • Feng GAO , 2, 3 ,
  • Jingbin ZHOU , 3, 4
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  • 1School of Sports Medicine and Rehabilitation,Beijing Sport University,Beijing 100084,China
  • 2Department of Sports Trauma Surgery,Sports Hospital,Institute of Sports Medicine,General Administration of Sport of China,Beijing 100061,China
  • 3Key Laboratory of Sports Trauma and Rehabilitation,General Administration of Sport of China,Beijing 100010,China
  • 4Department of Sports and Rehabilitation Medicine,Beijing Chao-Yang Hospital,Capital Medical University,Beijing 100020,China
ZHOU Jingbin,Tel:010-89138391,E-mail:;
GAO Feng,Tel:010-67116611-301,E-mail:

Received date: 2024-03-13

  Online published: 2025-01-06

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Abstract

This article comprehensively reviews the research progress in the management principles of acute closed soft tissue injuries,summarizing the retention and updates of the four main principles (RICE,PRICE,POLICE,and PEACE&LOVE) at different stages.Traditional methods such as compression,elevation,rest,and protection remain valuable.However,with the advancement in rehabilitation philosophy,early active rehabilitation plays an increasingly important role in the tissue healing process.Traditional cold therapy remains a choice because of its benefits.Non-steroidal anti-inflammatory drugs play a positive role in relieving the acute pain and swelling and improving the function of soft tissue,being preferred by both patients and medical practitioners.Therefore,advantages outweigh disadvantages in the clinical application of non-steroidal anti-inflammatory drugs.Finally,modern medical models have begun to incorporate more social and psychological factors,focusing on patients’ mental state and social environment,while guiding patients to actively participate in the rehabilitation process,which can accelerate the recovery process and improve treatment outcomes.

Key words： acute soft tissue injury; sports injury; treatment principles; sports rehabilitation

Cite this article

Bingying ZHANG , Xiaohan ZHANG , Yi QIAN , Wenbo TANG , Feng GAO , Jingbin ZHOU . Research Progress in Treatment Principles of Acute Closed Soft Tissue Injuries[J]. Acta Academiae Medicinae Sinicae, 2024 , 46(6) : 828 -835 . DOI: 10.3881/j.issn.1000-503X.16073

Acute closed soft tissue injuries are a large category of traumatic syndromes caused by direct or indirect violence to soft tissues or musculoskeletal muscles, with a very high incidence, almost everyone will experience it in their lifetime. If not handled properly, it can greatly increase the burden on individuals and society. Therefore, timely and correct treatment of acute closed soft tissue injuries is of great significance[1]. The progress in the principles for managing acute closed soft tissue injuries is mainly divided into four stages (RICE principle, PRICE principle, POLICE principle, PEACE & LOVE principle). In 1978, Mirkin et al.[2] published the book "The Sportsmedicine Book," which first proposed the Rest, Ice, Compression, Elevation (RICE) principle as the basic treatment principle for acute soft tissue injuries. The RICE principle has been widely used as a management plan for acute closed soft tissue injuries for over 40 years, and its status and importance are self-evident. However, in the past few decades, due to the lack of sufficient, high-quality studies confirming the ideal method for handling acute soft tissue injuries, there has been a lot of contradictory and confusing theories in this field. Although the RICE principle is considered an important part of the acute management of soft tissue injuries, its actual effectiveness has been questioned by some scholars, and its position has been challenged. In 2010, Bleakley et al.[3] updated the RICE principle to Protection, Rest, Ice, Compression, Elevation (PRICE) principle. Then, in 2012, the PRICE principle was further updated to Protection, Optimal Loading, Ice, Compression, Elevation (POLICE) principle[4], reflecting the important concept of early rehabilitation. In 2020, Dubois et al.[5] proposed the Protection, Elevation, Avoid anti-inflammatories, Compression, Education (PEACE) and Load, Optimism, Vascularisation, Exercise (LOVE) principles, adding chronic management of tissue healing and elevating the treatment goal to the overall physical and mental well-being of the patient, marking the entry of soft tissue injury management into the stage of comprehensive rehabilitation. To better guide clinical practice, this article mainly reviews the progress in the principles for managing acute closed soft tissue injuries.

1 Conservative Philosophy: Elevation and Compression, Rest and Protection

1.1 Compression and Elevation

Compression and elevation are commonly used to reduce swelling. Studies have shown that compression seems to reduce swelling in acute ankle sprains, accelerate the recovery process, and improve functional performance and quality of life[6-7]. However, the current literature on compression is of low quality, and it is unclear regarding the optimal method, frequency, duration, and treatment position for compression. Furthermore, there are currently only studies on acute ankle sprains, making it impossible to draw definitive conclusions[8-9].
Rucinski et al.[10]'s research indicates that elevation is the best treatment for reducing swelling after an ankle sprain. This short-term benefit has been confirmed; however, this benefit can be easily offset by gravity, so its long-term benefits are still questionable[11]. When compression and elevation are used in combination, the effectiveness in eliminating swelling is also contradictory, and due to the small sample size of the studies, no definitive conclusions can be drawn[8]. However, if compression therapy is used correctly and contraindications are considered, serious adverse events such as skin necrosis, nerve damage, or thromboembolic events rarely occur[12]. Although elevating the limb may cause discomfort to the patient, studies show that there is no statistically significant difference between elevating 10 cm and 30 cm in terms of reducing swelling, alleviating pain, and improving function. Therefore, using a pillow to elevate the affected limb is sufficient to reduce swelling and make the patient feel comfortable[11]. Given that both therapies have no common serious adverse reactions, these two therapies are still worth retaining in actual clinical practice.

1.2 Rest and Protection

Rest and protection after injury refer to interventions such as stress protection, unloading, and joint immobilization of the injured area at different periods following the injury. Some studies have shown that temporary rest is needed after acute soft tissue injuries, and excessive walking or exercise should be avoided[13-14]. However, the duration of rest should be limited, as prolonged unloaded conditions are not conducive to tissue healing. Research has indicated that early weight-bearing under brace protection after an acute ankle sprain yields better outcomes than plaster fixation, hence early mobilization and accelerated rehabilitation are effective[15].

2 Positive Philosophy: Early Active Rehabilitation

The healing process after tissue injury must go through the inflammatory phase, repair phase, and remodeling phase. The inflammatory phase is the first stage of tissue healing, during which blood vessels dilate and permeability increases, and white blood cells migrate to the damaged area to clear necrotic tissue cells[16]. The body relies on the lymphatic system to drain metabolic products from the injured site; since the lymphatic system is a passive, unidirectional method of excess fluid transport, it requires the autonomous contraction of surrounding tissues at the wound site to generate propulsion. Therefore, simple rest cannot adequately empty the metabolic products from the damaged area, and such congestion will prolong the inflammatory process, preventing the tissue from smoothly entering the repair and remodeling phases[17]. Angiogenesis occurs during the repair phase, a process that strongly depends on vascular endothelial growth factor (VEGF)-A within skeletal muscles. Research by Høier et al.[18] indicates that due to the inhibition of VEGF-A, revascularization in animal skeletal muscles decreases. Moreover, Gustafsson et al.[19] demonstrated that a single session of dynamic exercise upregulates VEGF gene expression in human skeletal muscle. Thus, it can be inferred that active contraction of skeletal muscles around the wound site will enhance the body's ability to revascularize damaged tissues. Hittel et al.[20] showed that aerobic and resistance exercises lower myostatin levels in human muscles. Therefore, activity after tissue injury reduces the likelihood of muscle atrophy. Sandri et al.[21] pointed out that maintaining muscle size and fiber composition requires muscle contractions. It is evident that prolonged rest has negative effects on the biomechanics and morphology of tissues, whereas progressive loading is more likely to help restore the morphological characteristics and strength of collagenous tissues.
However, if the tissue is subjected to excessive stress after injury, it may lead to rebleeding or further damage; therefore, protecting vulnerable tissues remains an important principle[4]. However, overemphasizing protection can create a mistaken mindset that moderate activity is not needed during the acute phase. Thus, finding the optimal load is particularly crucial.
Positive early active movement helps with the early recovery of mobility, strength, and proprioception after injury[22]. After a short period of rest and protection, normal activities should be resumed as soon as possible. Without exacerbating pain, optimal loading can promote the repair and remodeling of tendons, muscles, and ligaments through mechanical transmission[23].
The optimal load can be defined as the load applied to the organizational structure that maximizes the physiological adaptability of the body, including all mechanical interventions in rehabilitation training[23]. Since different types of soft tissue injuries require different rehabilitation protocols, there is no one-size-fits-all rehabilitation template. However, the optimal load can induce a series of changes through various cellular and neural mechanisms, so by controlling the variables of the load (magnitude, speed, direction), it can have a profound impact on the structure and function of a broader neuromusculoskeletal system. Research by Arampatzis et al.[24] shows that the magnitude of the load is an important factor in promoting mechanical and morphological changes in the Achilles tendon. A load at 90% of maximum voluntary effort increases the stiffness, elasticity, and hypertrophy in specific areas of the Achilles tendon. However, at 50% of maximum voluntary effort, these changes do not occur, indicating that there is a threshold for the load that promotes mechanical and morphological changes in the Achilles tendon. Changing the speed and direction of the load are also key determinants of therapeutic outcomes. Under the same total load, fast movements such as jumping and running provide more stimuli for increasing bone density and strength[25]. Moreover, according to the theory of motor learning, changing the speed and direction of the load prompts learners to continuously adjust the details of their movements, ultimately resulting in mature, coordinated movements[26]. As tissues adapt to the load, the sensory information provided to the central nervous system during movement also changes, leading to adaptive changes in the nervous system's response to the load.
The concept of optimal load emphasizes the importance of promoting soft tissue repair and functional recovery in neuromusculoskeletal rehabilitation training by precisely controlling the magnitude, speed, and direction of the load. However, despite current research revealing the positive role of optimal load in promoting mechanical and morphological changes in specific soft tissues such as the Achilles tendon, there are still some key issues and challenges. First, how to accurately define the quantitative standards of optimal load for different types and degrees of soft tissue injuries remains a question that needs further exploration. Additionally, individual differences play a significant role in the rehabilitation process, and how to adjust load parameters based on an individual's specific circumstances to achieve the best rehabilitation outcomes is also a focus of future research. Finally, with the development of technology, integrating high-tech equipment and methods such as wearable devices and virtual reality into rehabilitation training to monitor and adjust load parameters in real-time may become an important trend[27]. This not only provides patients with more personalized and dynamic rehabilitation plans but also offers researchers new avenues to study the effects of optimal load in practical applications.

3 Existing Controversies: Cryotherapy and Nonsteroidal Anti-Inflammatory Drugs

3.1 Cryotherapy

The application of cryotherapy is currently the most controversial part of the principles for managing soft tissue injuries. Before the introduction of the PEACE&LOVE principles, cryotherapy had always been an important component in the treatment of acute soft tissue injuries. However, the PEACE&LOVE principles have taken a stance to question cryotherapy. Regarding cryotherapy, Dubois et al[5] pointed out that despite its widespread use, there is no high-quality evidence to demonstrate the effectiveness of using cryotherapy methods in treating soft tissue injuries. Moreover, it may also disrupt the natural inflammatory process, angiogenesis, and revascularization, delay the infiltration of neutrophils and macrophages, and increase immature muscle fibers, which could potentially adversely affect the healing of soft tissues.
For a long time, it has been believed that cryotherapy reduces the metabolic rate by lowering the temperature and blood flow at the site of injury, thereby suppressing the inflammatory response after acute injury. However, in 2015, Mirkin[28] published an article titled "Why Ice Delays Recovery" on his personal blog, openly questioning the RICE principle he proposed in 1978[2], indicating that cryotherapy and complete rest may hinder the process of tissue healing.
Mirkin's viewpoints mainly support the following two aspects: (1) Tissue healing requires a natural inflammatory process. Cryotherapy causes vasoconstriction near the injury site, blocking the blood flow that transports inflammatory healing cells; moreover, the blood vessels do not dilate for several hours after ice application. This reduction in blood flow can lead to tissue death and even permanent nerve damage[29]. (2) Although cryotherapy helps alleviate pain, it also has negative effects on an athlete's strength, speed, endurance, and coordination. However, a brief rewarming period can offset these negative effects[30]. It is noteworthy that these negative effects are based on longer cryotherapy durations (>20 min). Meanwhile, studies have shown that 12-15 min of cryotherapy can inhibit pain and muscle spasms, but cryotherapy exceeding 30 min may accelerate frostbite and nerve paralysis. Due to heat conduction, during the removal of cryotherapy, deep muscles will transfer heat to more superficial tissues, thus preventing the deep muscles from warming up[31]. Therefore, intermittent short-term cryotherapy remains beneficial.
In 2021, Fousekis et al.[32] proposed the CARE principle for acute moderate to severe soft tissue injuries, which states that the rationale for avoiding cryotherapy in the PEACE & LOVE principle is based on limited animal studies[17,33]. Animal studies have shown that the optimal tissue temperature for reducing cellular metabolism and oxygen demand without causing tissue damage is 10-15 ℃[34]. However, compared to rodents, the reduction in human muscle temperature is not significant, and no in vivo muscle tissue temperatures below 20 ℃ have been observed[35]. Additionally, the reduction in metabolic activity and inflammatory response caused by cryotherapy in humans may be influenced by the degree of tissue damage and the thickness of adipose tissue[35]. Some studies have shown that cryotherapy has little effect on tissue temperatures deeper than 2 cm below human adipose tissue, and the temperature changes in deep tissues can be negligible compared to those in superficial tissues[31]. Therefore, it is not rigorous to directly extrapolate the results of animal studies to humans.
Based on conclusions drawn from animal studies, cryotherapy has been applied to individuals after injury and exercise in order to reduce metabolic activity and inflammatory responses. However, whether cryotherapy can lower muscle metabolic capacity in humans remains a topic of discussion. Only one study that indirectly measured human muscle metabolic activity was able to demonstrate that the use of cryotherapy post-exercise reduced muscle metabolic activity[36]. Similarly, only a few studies have shown that applying cryotherapy after human exercise can decrease the inflammatory response[37⇓-39], while most studies indicate no reduction in the inflammatory response[40⇓⇓⇓⇓-45]. Additionally, some research suggests that using cold water immersion or local cooling with ice packs post-exercise may exacerbate the inflammatory response[46⇓⇓-49]. Therefore, it is currently unclear whether cryotherapy can reduce metabolic activity and inflammatory responses in the human body, and more clinical evidence is needed.
At the same time, the CARE principle argues that the PEACE&LOVE principle's recommendation to avoid cold therapy during the acute phase does not take into account an important factor influencing the choice of rehabilitation plan, namely, the severity of the injury. In clinical studies, the degree of inflammation is typically measured using subjective scales for tissue pain, function, and swelling, or by measuring the volume of swelling. For acute moderate to severe soft tissue injuries, significant edema may form, leading to compression of tissues and nerves, resulting in restricted movement and decreased function[50]. Furthermore, significant joint swelling is also associated with joint-originated muscle inhibition and reduced joint function[51]. Therefore, Fousekis et al.[32] believe that the goal of cold therapy should not be to completely avoid edema (which is unfeasible), but rather to reduce its severity. Immediate application of cold therapy during the acute phase of moderate to severe soft tissue injuries can mitigate the aforementioned adverse effects.
Therefore, although cryotherapy is considered to have a negative effect on the natural inflammatory process and may affect the overall healing process of soft tissues in the PEACE&LOVE principle, the relevant evidence is limited. Given the clinically proven benefits of cryotherapy such as pain relief and reduction of swelling, traditional cryotherapy still has its advantages (especially when the injury is severe and swelling becomes a limiting factor for recovery after soft tissue damage), thus it does not need to be completely abandoned[52]. Clinicians can maximize the rational use of cryotherapy and bring benefits to patients by controlling factors such as the form of cryotherapy, timing of intervention, duration, and frequency, to avoid potential negative effects.

3.2 Nonsteroidal Anti-inflammatory Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs), also known as non-steroid anti-inflammatory drugs, are a class of medications with antipyretic and analgesic effects, and they also have anti-inflammatory properties when administered at higher doses. It is generally believed that NSAIDs exert their antipyretic, analgesic, and anti-inflammatory effects by inhibiting cyclooxygenase-2 (COX-2)[53]. The PEACE & LOVE principle recommends avoiding the use of NSAIDs, especially at high doses, during the acute phase. Some studies have shown that NSAIDs do not improve the healing of bones, tendons, and ligaments[54], but there is still controversy regarding their use in the treatment of muscle injuries[55-56].
Satellite cells (myogenic stem cells, myoblasts) responsible for muscle regeneration are crucial for muscle recovery after injury[57]. In the case of acute injury, muscle regeneration is closely related to different stages of inflammation, and the coordinated recruitment of inflammatory cells can assist in the activity of satellite cells, ensuring optimal muscle recovery[58⇓-60]. Studies on animals with COX-2 inhibition or COX-2 deficiency have shown that blocking this pathway reduces the proliferation, differentiation, and fusion of satellite cells, leading to impaired skeletal muscle growth, delayed repair, and increased fibrosis[61-62]. Clinical studies have demonstrated that using NSAIDs after acute hamstring injuries does not improve treatment outcomes[63]. Mikkelsen et al.[64] used a model of muscle damage induced by maximal eccentric contractions in humans to show that infusion of indomethacin (a non-specific COX inhibitor) for 7.5 hours on the day of exercise inhibits the increase in satellite cells on the 8th day post-exercise. Mackey et al.[65] collected muscle biopsy samples from 14 healthy male endurance athletes before and 1, 3, and 8 days after a 36 km run, who received daily injections of 100 mg indomethacin or placebo, and found that the use of anti-inflammatory drugs reduced the number of satellite cells. However, it has been reported that in rats, the number of ED2 macrophages (cells associated with muscle repair) increased after ibuprofen injection when the hind limbs were reloaded after 10 days of immobilization[66]. There are also studies showing that NSAID administration does not affect the proliferation of satellite cells in rat muscles recovering from contusion[67]. The results in the literature are not entirely consistent, therefore, further research is needed to understand how NSAIDs affect the interaction between inflammation and regeneration processes in skeletal muscle.
Although NSAIDs have been questioned for their anti-inflammatory pharmacology, their clinical effects in pain relief, reducing swelling, and improving function are undeniable. The latest clinical practice guidelines for the treatment of musculoskeletal injuries with topical NSAIDs indicate that topical NSAIDs have advantages such as rapid onset, high local concentration, less systemic exposure, and fewer systemic adverse reactions, making them more suitable for the treatment of musculoskeletal injuries compared to oral NSAIDs; moreover, topical NSAID patches and plasters are favored by patients due to their convenience, comfort, safety, and effectiveness; given the high efficacy and safety of topical NSAIDs, they are recommended as first-line drugs for the treatment of musculoskeletal injuries[68]. Research also shows that incorporating NSAIDs into physical therapy regimens offers many benefits to individuals with soft tissue injuries, such as promoting early activity, increasing treatment tolerance, and improving rehabilitation outcomes, with NSAIDs complementing other physical therapy methods to ultimately promote optimal functional recovery in individuals[69].
Regarding the controversy over whether NSAIDs affect the muscle regeneration and repair process, more high-quality clinical studies are needed to prove it. However, given that NSAIDs have a positive effect in alleviating acute pain and swelling from soft tissue injuries and improving function, and that patients and medical staff have a high preference for their use, the benefits of clinical application outweigh the drawbacks.

4 Sublimated Humanistic Care: Patient Education and Positive Attitude

The latest PEACE&LOVE principles particularly emphasize the importance of education, breaking the traditional model where doctors unilaterally provide treatment, and encouraging patients to actively participate in the entire rehabilitation process, which is more conducive to maintaining long-term treatment outcomes. At the same time, interventions such as manual therapy, medication, and injections should be regarded as supplementary measures; clinicians must consider their risks and benefits and truthfully inform the patients[70]. Apart from education, the degree of optimism in patients is also associated with better outcomes and prognosis. Psychological factors such as depression and fear may hinder the rehabilitation process[71]. Failing to understand the psychosocial factors of the patient and their disease can lead to mismanagement, thereby prolonging the recovery time. Early recognition and awareness of the psychosocial aspects of the disease can improve patient compliance and satisfaction, ultimately enhancing the treatment outcome. Therefore, clinicians must understand the impact of psychosocial factors and take into account their influence on the patient's complaints during the treatment process.

5 Conclusions and Future Prospects

The initial concept of the management principles for acute closed soft tissue injuries mainly focused on rest and protection, cryotherapy, compression, and elevation, which were in a passive rehabilitation phase. Subsequent updates incorporated the concept of optimal loading, emphasizing the importance of early rehabilitation. The latest principles also pay attention to the overall physical and mental condition of the injured person, reflecting the concept of holistic rehabilitation. In summary, given that compression and elevation therapies do not have common serious adverse reactions, despite the limited number and low quality of documents proving their benefits, these therapies are still worth retaining in clinical practice, especially in the management of acute ankle sprains. Short-term rest and protection of the injured tissues remain important, but normal activities should be resumed as soon as possible. How to adjust the optimal load based on individual circumstances and different types and degrees of soft tissue injuries is a focus for future research. Under the background of interdisciplinary integration between medicine and engineering, applying modern engineering technologies and methods to the medical field may become an important trend for improving rehabilitation outcomes. Regarding existing controversies, given the benefits of cryotherapy in reducing pain and swelling, intermittent short-term cryotherapy remains safe. High-quality studies are still needed to prove whether cryotherapy can reduce the body's natural inflammatory response. NSAIDs have positive effects in alleviating acute pain and swelling in soft tissues and improving function, with high preference among patients and healthcare providers, making their clinical application more beneficial than harmful. At the same time, it is necessary to further study how NSAIDs affect the interaction between inflammation and regeneration processes in skeletal muscles. Currently, there has been rapid progress in physical therapy for acute soft tissue injuries, such as various manual therapies, exercise therapies, and physical factor therapies, even the combined use of multiple treatment methods, but due to the theme of this review, these are not detailed here. Finally, the modern medical model has started to incorporate more psychosocial factors, paying attention to the psychological state and social environment of individuals, while guiding them to actively participate in the rehabilitation process, which can accelerate recovery and improve treatment outcomes. Through further targeted in-depth research, it is believed that the management of acute closed local soft tissue injuries will become more effective, benefiting patients.
Conflict of Interest All authors declare no conflict of interest
Statement of Authors' ContributionsZhang Bingying: participated in the selection and design of the research, drafted the paper, and revised it according to the editorial suggestions; Zhang Xiaohan, Qian Yi: made critical revisions to important academic content; Tang Wenbo: participated in the selection and design of the research; Gao Feng: participated in the selection and design of the research, and made critical revisions to important academic content; Zhou Jingbin: participated in the selection and design of the research

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