First Aid for Soft Tissue Injuries

The term soft tissue injury usually refers to injuries to muscles, ligaments and tendons. It excludes fractures but also more severe injuries such as significant haemorrhage, crush syndrome, head injuries or acute spinal cord compression.

Swift and appropriate action is required to facilitate rapid and complete recovery whilst inappropriate management may be counterproductive.

These injuries are very common in sport but also occur in road traffic accidents and in the accidents of everyday life including at work.

Soft tissue sports injuries represent about 5% of attendances at A&E departments across the UK and around 10% result in time off work.¹ These figures are from the 1980s. Such injuries may be treated in A&E departments or in primary care but probably most do not bother the NHS and so it is impossible to be sure about incidence.

Common problems are:

• Sprain is when ligaments are overstretched or torn
• Strain occurs when muscle or tendon is overstretched and partially torn
• Rupture is overstretching and a complete tear of muscle or tendon
• Deep bruising or haematoma with a large amount of blood in a muscle

It is possible to allocate such injuries to 1 of 3 categories:

• First degree or mild injury results from a mild stretch of ligaments or capsular structures, or an over-stretch or direct blow to muscle. There is slight swelling and bruising and pain is felt only at the end of full range of movement or on stretching or contraction of the muscle. The joint is stable, there is little muscle spasm and no loss of function.
• Second degree or moderate injury is due to moderate stretch of ligament or capsular structures, or excessive stretch or a direct blow to muscle, tearing some fibres. There is moderate swelling and bruising, with moderate pain felt on any movement. It impairs the ability of the muscle to contract or be stretched. The joint may show some instability with ligament or capsular injuries. Moderate muscle spasm may be a reflex response. The torn fibres decrease the tensile strength of the ligament or capsule and decrease the contractile strength of the muscle, impairing function.
• Third degree or severe injury is the result of a severe over-stretch of a ligament, or excessive stretch or direct blow to muscle, causing a full tear of the injured structure. There is significant swelling and bruising with severe pain even at rest with significant impairment of function. Ligament injuries produce marked instability and significant reduction in contractile strength, with muscle injuries causing severe muscle spasm, while the injured muscle is incapable of exerting force. Function is severely impaired.

This aims to discover the mechanism of the injury and possibly the degree of force involved. It may have been a forced eversion of the ankle, a rotational strain of the knee or perhaps fingers were forced back. How long ago did it occur? A popping sound, usually with injury to a knee, suggests rupture of a ligament.

If there is any chance of neck injury it must be stabilised before proceeding further.

• Pain, muscle spasm and possible swelling may limit the ability to perform a comprehensive examination, as may facilities available. Severe spasm causes "splinting" of the adjacent joint.
• The lesion is one of inflammation and so the signs of inflammation are present. They are:
  • Calor (heat)
  • Rubor (redness)
  • Dolor (pain)
  • Tumor (swelling)
  • Loss of function
• Look at the injury.
  • Note distortion and swelling.
  • Note bony tenderness and any sign of fracture.
  • Note difficulty or reluctance to move the affected part.
  • How tender is the part?
  • Will the patient weight bear?
  • Note swelling and bruising near the injury. Very rapid development of an effusion of the knee suggests haemarthrosis.
• Check the relevant peripheral pulses. Absence of pulses suggests vascular damage and requires urgent transfer to an A&E department.
• Severe weakness and any loss of sensation suggests nerve damage.
• Note the general condition of the patient. Pallor and a weak pulse suggest blood loss. Tender abdomen with guarding or shortness of breath suggest severe internal injuries and immediate transfer to hospital is required.
• If a joint is dislocated, it should be reduced as soon as possible as swelling will make it more difficult.
• Fingers can often be reduced immediately, provided that the examiner is happy that there is not also a fracture. Grasp the palm with one hand, the finger with the other, distract the patient to try to make him relax and a sharp pull to distract the joint should lead to reduction.
• Reduction of patella subluxation can also be done swiftly but shoulders tend to be rather more difficult and elbows usually require sedation for reduction.
• The question of whether or not to x-ray the affected part can be difficult, especially for the inexperienced. Excessive use of x-rays is to be depreciated but there are medico-legal implications of missing a fracture. For ankle injuries there are evidence based guidelines for when it is safe to avoid x-ray. These are called "The Ottawa Rules" and are explained in the article on Pott's fracture.

Signs that may suggest more severe injury include:

• Severe pain which does not subside
• Immediate and profuse swelling
• Deformity
• Extreme loss of function
• Guarding, or unusual or false motion
• Noises (grating or cracking) at injury site

Early management is important to facilitate rapid healing and to prevent chronic oedema and reduce the risk of recurrent injury. There are 7 factors to be addressed in the first 48 hours:

• Reduce local tissue temperature and metabolic demands
• Manage pain
• Minimise inflammation and exudation
• Protect the damaged tissue from further injury
• Prevent disruption of the newly-formed fibrin bonds
• Aid collagen fibre growth and realignment
• Maintain general levels of cardio-respiratory and musculoskeletal fitness and activity

Teaching of the management of soft tissue injuries has traditionally used the mnemonic RICE, standing for rest, ice, compression, elevation but there have been small additions at times including RICER where the last R stands for rehabilitation and PRICE where the first letter stands for protection.

• Protection usually involves immobilizing the injury to reduce pain and prevent disruption of the healing process. This may involve splints, casts, taping or bandaging. All modalities must allow room for swelling without compromising circulation. Crutches can support weight bearing and slings may immobilize an arm or shoulder.
• Rest is to avoid further injury and disruption of the forming fibrin but also to reduce increased blood flow. After 3 days it is recommended that gentle movements should start but this time may be shorter or longer depending upon the severity of the injury. Many people will start the following day.
• Ice is an inexpensive form of cryotherapy. A pack of frozen peas is often advocated as a household remedy that provides a cold and deformable application. The temperature of a domestic freezer is around -18°. Plain ice and especially anything from a freezer should not be applied directly to the skin but wrapped in a towel or tea towel. Crushed ice in a plastic bag or commercially available gel bags are other modes of application. Claims for benefits of cold include decrease in pain, decrease in metabolism, decrease in swelling, decrease in muscle spasm, decrease in circulation (but also cold-induced vasodilation) and effects on the inflammatory process. The evidence base for the benefit is very limited or contradictory.^2,3 The optimum regime is probably to apply ice for 20 minutes, remove it for 10 minutes and repeat the process over 2 hours. Ice should not be applied for more than 30 minutes without a break for fear of "ice burns".
• Compression is to reduce oedema. External compression can stop bleeding, inhibit seepage into underlying tissue spaces and help disperse excess fluid. Fluid is pushed back into the capillaries and lymph vessels. External compression increases the effectiveness of the muscle pump in aiding venous return. A number of devices are available including adhesive and non-adhesive bandages, elastic tubular support and plastic or inflatable splints. Try to apply the pressure uniformly or at least so that it increases from distally to proximally and not vice versa. Compression must be capable of accommodating oedema as it forms after the injury to prevent ischaemia. Replace the compression after 24 hours and continue for at least 72 hours. If the problem is less severe it is not necessary to be so meticulous and the value of double elastic tubing in grade I or II ankle sprain is dubious.⁴
• Elevation is to give gravitational aid to other techniques to reduce oedema. As far as possible elevate the injured area above the level of the heart in the first 72 hours and have it comfortably supported. Avoid simultaneous compression and elevation. Beware of letting the elevated limb become immediately dependent as there may be "rebound" with increased oedema.
• Rehabilitation may not be regarded as strictly part of first aid but it follows on so swiftly that it should be considered at an early stage. Sportsmen and women are much more enthusiastic about rehabilitation than rest and the need for each in order must be emphasized from the outset. Isometric exercise may be accepted from an early stage if injuries permit. If the upper body is injured the lower body may still be exercised and vice versa. Cardio-respiratory fitness may be maintained if the exercises do not compromise the injured part.

Many reviews on soft tissue injury lament the paucity and quality of the evidence and call for more research. Trials are often of small size and underpowered.

Topical NSAIDs

Oral NSAIDs are often used in soft tissue injury. They are certainly effective analgesics⁵ but whether they contribute any significant anti-inflammatory effect is unknown. Inflammation is part of the healing process but it can also be destructive. They do appear to reduce pain and facilitate active rehabilitation.⁶ The wisdom of most pharmaceutical advisers in PCTs has long been that topical NSAIDs are no better than rubefacients and so the latter should be used as they are much cheaper. However, the published literature on topical NSAIDs versus placebo in soft tissue injury tends to be very positive.⁷ Selective publication of positive results may be involved and sponsorship of trials by the pharmaceutical industry may also cause bias but the evidence is too strong to ignore. Bandolier published a systematic review of RCTs⁸ for sprains, strains and soft tissue injury and found that topical NSAIDs were significantly more effective than placebo with a NNT of 3.9. However, they did note that the results were less impressive in the larger trials and this observation is compatible with selective publication. Clinical Evidence found the same review and noted the small numbers giving inadequate power in many of the RCTs. It also noted a review of topical NSAID in osteoarthritis⁹ that found no benefit. It is possible that the drug does not get into joints as well as soft tissues.

Ultrasound

The value of ultrasound in the treatment of acute ankle sprains appears to be limited.¹⁰

Mechanical Neck Disorders

The level of evidence is not good but there does seem to be consensus that active mobilization rather than rest is the best treatment for whiplash injury and similar disorders of the neck.^11,12 Active management of low back pain has been standard practice since the Clinical Standards Advisory Group report of 1994 and the neck is the upper back. We should rarely see patients with soft collars as they are ineffective¹³ and may delay healing by promoting stiffness and a poor attitude to mobility.

Protective Effect of Warm-up

The value of warm up before exercise to prevent soft tissue injuries has been enshrined in "tablets of stone" for many years. The British Journal of Sports Medicine has insisted on this and even calls its introductory editorial "warm up". However, the evidence of the value of warm up in preventing injury is dubious.^9,14 The level of evidence is poor but it would be inappropriate to discourage warm up with stretching.