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The early management of ACL tears (part 2 of a course on cruciate ligament rehabiliation)

In Part 1 I discussed the function of the ACL, and how it can become torn. In this part I will run over the first-aid steps which should be applied in the first 24 hours after injury, and then progress to the examination that the doctor should perform.

ski injury

You may have injured your knee during competitive sport where a therapist was on hand to give immediate help and advice. If so, you are fortunate. Many injuries occur during leisure activities and if this is the case, you may have struggled home hoping it would 'feel better tomorrow'. Once 24hrs have passed you have missed your window of opportunity at A & E (ER, Casualty Department) and will now have to make an appointment to see your family doctor and, if necessary, wait for a specialist referral.

Your family doctor may have direct access to physiotherapy but all this takes time. Of course, if you have private health care or can afford to pay you will be able to see a clinician quickly.

Damage to the 'soft tissues' (ligaments, muscles, tendons, joint capsule etc) will cause inflammation, this is your body's natural response to injury and is the first phase of the healing process. The inflammatory phase should start to settle approximately 5 days from injury however, this can be prolonged by inappropriate management. This phase prepares the area for healing but sometimes the body's response is excessive, leading to increased pain, heat, swelling and loss of movement. Correct management will ensure that this phase is not extended.

Regardless of how quickly an accurate diagnosis is made, early treatment to reduce swelling and inflammation and regain movement is imperative. The following sections outline some simple guidelines which you can follow at this early stage. The sooner you implement the principles of (P)RICE the better - you cannot progress exercises or activity until swelling and inflammation are under control.

The (P)RICE Regime

A simple mnemonic is often used to remember the important elements of early management of knee injuries. Sometimes people quote the RICE mnemonoc and sometimes the PRICE one. The principles of (P)RICE should be followed from the time of injury.

  • P = Protection
  • R = Rest
  • I = Ice
  • C = Compression
  • E = Elevation

P=Protection

immobiliser brace

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, which aggravates the pain! 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 giving way.

R = 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 prevent the knee becoming stiff and improve the alignment and ultimate strength of any healing 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.

I = 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.

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.

icing the knee

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.

C = 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.

E = Elevation

knee elevation

Immediately following injury, ie. while you are lying down and 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 of P.R.I.C.E.

  • 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.
Updated: 17 Aug, 2013
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