Injury Management - Faster Return to Play
I ended the first part of this article introducing the "POLICE" method. This is a more up-to-date injury management method compared to the very commonly used "RICES" technique. It also corresponds with the article I referred to in my last post by Dr. Gabe Mirkin, that talks about what ice does during the healing process and how we are using it wrong. The goal of this article is to challenge medical professionals, coaches, athletes and parents to consider the possibility that we use ice too much and for the wrong reasons. Additionally, I would like to propose changes that can make the injury management process more efficient to get our athletes back to sport/activity quicker than we have in the past.
The "POLICE" method is an acronym for: Protect the injury, Optimal Loading, Ice, Compression and Elevation. Obviously the ice, compression and elevation are aspects from the 'RICES" method, but in this updated management technique, the way each are used vary from what has been previously practiced for decades. These aspects have been shown through research and in the clinic to produce superior results in comparison to these previously used methods.
Protect the Injury: In the past when an athlete had sustained an injury (after ruling out a fracture or dislocation) one thing commonly advised was to let the athlete rest. The thought process being, if the athlete is allowed rest, the injured area would heal faster. Let's use a lateral ankle sprain for example. After the athlete rests for for a few days, their injured area may have healed to a certain extent, but with any injury a proper rehabilitation program should be implemented and executed to ensure the athlete has regained pre-injury levels of pain, ROM, strength and functional ability. After this resting period, two things have happened: 1) Time has been lost and 2) The tissue flexibility and joint mobility of the injured area have occurred. Then consider those limitations with the addition of the inflammation that occurred from the original injury. So now, these limitations must be addressed before advancing to advanced ROM, strengthening, proprioception or sport-specific exercises. Giving the athlete time to rest, in many cases only adds on to their time away from sport. This idea of protecting the injury aims to ensure that a fracture or dislocation is not present and should include immediate removal from competition for an injury evaluation. But again, from this point if no serious complications from the injury are present, begin optimal loading.
Optimal Loading: Once again, after fracture or dislocation has been ruled out, optimal loading is replacing what used to be the resting portion of injury management. This early implemented ROM, starting with gentle assisted active ROM, advancing to full active ROM and finally to resisted ROM allows us to do various things at once: Retain the joint mobility, actively keep and restore muscular flexibility and when accompanied with compression and elevation, the muscle contractions from the ROM exercises can assist in ridding the injured area of inflammation.
Ice: The most commonly used modality for injury management, and the most commonly misused. "Ice and elevate, ice and elevate," the phrase we have heard repeatedly after an injury occurs. I would like to be clear this is not completely wrong, but also not completely correct either. Additionally, the reason we have been using ice so generously these past decades has been misguided. Historically the use of ice has been aimed to reduce swelling, but this is a very common misconception because ice does not reduce swelling. It's proven benefits are helping to prevent future swelling from occurring, and the main reason I use it with the athletes I work with everyday is pain management. The other important aspect of using ice is the duration it is on the target area. Another common recommendation with ice is "20 minutes on, 20 minutes off." The origins of this phrase are unknown to me, but the duration of the ice application depends on what tissue is being targeted. For example, ice application for a lateral ankle sprain may only need to be 20 minutes, depending on pain, amount of swelling etc. But in the case of a quadriceps contusion, ice application may need to be upwards of 35-40 minutes. If the effects of the ice are going to be effective, the target tissue has to reach a cold enough temperature for them to take effect. Therefore various duration periods are needed depending on the tissue being targeted.
Compression: An extremely important and arguably the most important aspect of injury management. If used swiftly and correctly, it can prevent and manage the amount of swelling. Keeping the same example from before, after an acute ankle sprain occurs, the inflammatory process begins. (The damaged tissue releases substances that start the "swelling" process. These chemicals help to remove the area of damaged or dead tissue, in addition to any other waste in the area). When the athlete is taken off the field, an ace wrap should be applied immediately. The tension used on the wrap should be tight distally (around the mid-foot) and as the wrap ascends above the ankle, the tension on the wrap should be reduced. This allows the swelling to not move distally below the ankle where it usually likes to settle inferior to the medial malleolus (outside ankle bone). When this is coupled with adequate elevation and ROM activity, much of the potential swelling can be minimized and prevented.
Elevation: As stated multiple times in this post, this final aspect of injury management is most effective when it is coupled with compression and ROM. The general rule of thumb commonly recommended when people ask about how high to elevate the injured area is above the heart. Although this can help to an extent, the more elevation you can have, the more use of gravity will be present and the more effective it will be with pulling the swelling away from the injured area. Finishing off again with the ankle sprain example, I will have my athletes prop their injured leg up against a wall so it is almost at 90 degrees. This is what I have seen the most progress with due to the increased use of gravity from the extreme elevation levels.
As with anything, each individual aspect of the POLICE method will vary with each situation and each injury. But these can be used as a guide to help get your athletes back on the field quicker than they have in the past just by modifying these aspects of injury management that we have been using for decades.
If you have an questions, comments or concerns feel free to ask me on Instagram, Twitter or Snapchat @toddsabol_pav or email me at email@example.com. Hope you enjoy!
-Heal By Moving-