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Introduction

Before reading this document it is important to recognise the precise remit of these guidelines and to understand the target population to whom these clinical guidelines should be applied. A number of factors need to be considered:

• When an individual is injured, many different tissues in the body may be damaged by the mechanism of injury - for example, bones may be broken, major blood vessels or nerve trunks may be ruptured, severed or compressed and the central nervous system may be damaged through head and spinal injuries
• Furthermore, a relatively straightforward soft tissue injury may be complicated by other factors - for example, a rugby player sustaining a knee ligament injury in a tackle may also sustain concussion in the same incident
• Although PRICE is generally accepted as being an appropriate form of management immediately following acute soft tissue injury, there are other alternatives which can be used in conjunction with PRICE and which should not be ignored
• There are different degrees of severity of injury to the soft tissues that must be considered in decisions about management

This introduction will therefore attempt to provide definitions of terms to identify different types of injury, degrees of soft tissue injury and alternative approaches to management during the first 72 hours.

1.1 Degrees of severity of soft tissue injury

A soft tissue injury is an acute connective tissue injury that may involve muscle, ligament, tendon, capsular structures and/ or cartilaginous structures. These injuries can be categorised into three grades or degrees of severity of injury.

First degree (mild)

The result of a mild stretch of ligament or capsular structures, or over-stretch or direct blow to muscle. There is minimal swelling and bruising but mild pain is felt at the end of range of movement or on stretch or contraction of muscle. There is no joint instability, minimal muscle spasm and no loss of function.

Second degree (moderate)

The result of moderate stretch of ligament or capsular structures, or excessive stretch or direct blow to muscle, causing tearing of some fibres. There is moderate swelling and bruising, with moderate pain felt on any movement which interferes with the ability of the muscle to contract or lengthen. There may be some joint instability with ligament / capsular injuries. Moderate muscle spasm may result as a reflex response to both ligamentous / capsular injuries and muscle injuries. Due to the tearing of some fibres, there is a decrease in the tensile strength of ligament / capsule or a decrease in the contractile strength of muscle, both of which cause interference with function.

Third degree (severe)

The result of a severe over-stretch of ligament, or excessive stretch or direct blow to muscle, causing a complete tear of the injured structure. There is significant swelling and bruising with severe pain even at rest which significantly interferes with function Ligament injuries result in gross instability and significant decrease in tensile strength, with muscle injuries causing severe muscle spasm and ’splinting’, while the injured muscle is incapable of exerting force. Function is severely impaired.

1.2 Other injuries

Here follows a brief definition of some of the injuries that may occur in conjunction with soft tissue injury as defined in this document. As a general rule, any patient presenting with any of the injuries listed below should receive immediate emergency first aid and should be referred on for further investigation. The list is in alphabetical order and consequently the order gives no indication of severity.

Abdomino-thoracic injury

Any injury which results in chest pain, shortness of breath, severe abdominal pain, haematuria.

Blocked airway

Any injury that causes respiratory arrest.

Cuts / lacerations

Any injury that results in open, bleeding wounds.

Head injury /unconsciousness

Any injury that results in altered cerebral function, leading to disturbed consciousness, vomiting, drowsiness or amnesia.

Nerve injury

Any injury causing changes in motor and/or sensory function.

Spinal injury

Any injury to the back or neck that causes changes in motor or sensory function. Any injury that is suggestive of bony injury.

Vascular injury

Any injury resulting in loss of distal pulses, changes in skin colour and temperature or drop in blood pressure.

Furthermore, the patient’s previous and current medical history, drug history and general health should be taken into consideration to indicate if therapeutic intervention is contraindicated by current medication or health status. An injury management flowchart is included as Appendix B.

1.3 Alternative modalities

- which may be used in the management of soft tissue injuries

Although this document provides guidelines for the management of soft tissue injuries using Protection, Rest, Ice, Compression and Elevation, it must be recognised that in conjunction with PRICE, other forms of intervention may be used. These may include non-steroidal anti-inflammatory drugs, electrotherapeutic modalities, manual therapy, taping and rehabilitation.

A table summarising alternative modalities and indications for use can be found in Appendix C.