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220 The acronym PRICE (protection, rest, ice, compression and elevation) has been central to acute soft tissue injury management for many years despite a paucity of high-quality, empirical evidence to support the various components or as a collective treatment package. Treatment paradigms in sports medicine must be updated based on contemporary research evidence. As a recent example, the widespread use of non-steroidal antiinfl ammatory drugs in acute soft tissue injury management has been challenged, particularly with ligament and muscle injuries. 1 Ice compression and elevation (ICE) is the basic principle of early treatment. Most research has focused on the analgesic effect of icing or the associated skin or intramuscular temperature changes; a recent randomised controlled trial by Prins and colleagues, 2 which examined the effectiveness of ice on recovery from acute muscle tear, is the fi rst of its kind. Clinical studies into compression are also lacking, and much of its rationale is extrapolated from research relating to deep venous thrombosis prophylaxis and lymphoedema management; there is little clinical research on elevation. 3
Br J Sports Med March 2012 Vol 46 No 4220
The acronym PRICE (protection,
rest, ice, compression and eleva-
tion) has been central to acute
soft tissue injury management
for many years despite a pau-
city of high-quality, empirical
evidence to support the various compo-
nents or as a collective treatment package.
Treatment paradigms in sports medicine
must be updated based on contemporary
research evidence. As a recent example,
the widespread use of non-steroidal anti-
infl ammatory drugs in acute soft tissue
injury management has been challenged,
particularly with ligament and muscle in-
Ice compression and elevation (ICE)
is the basic principle of early treatment.
Most research has focused on the anal-
gesic effect of icing or the associated skin
or intramuscular temperature changes;
a recent randomised controlled trial by
Prins and colleagues,
2 which examined
the effectiveness of ice on recovery from
acute muscle tear, is the fi rst of its kind.
Clinical studies into compression are
also lacking, and much of its rationale is
extrapolated from research relating to
deep venous thrombosis prophylaxis and
lymphoedema management; there is little
clinical research on elevation.
Protection and rest after injury are sup-
ported by interventions that stress shield ,
unload and/or prevent joint movement for
various periods. Recent animal models
show that short periods of unloading
are required after acute soft tissue injury
and that aggressive ambulation or exer-
cise should be avoided. But, rest should
be of limited duration and restricted to
immediately after trauma. Longer peri-
ods of unloading are harmful and produce
1 Health and Rehabilitation Sciences Research Institute,
University of Ulster, Jordanstown, Newtownabbey, UK
2 Sports Institute of Northern Ireland, University of Ulster,
Jordanstown, Newtownabbey, UK
3 Association of Physiotherapists in Sports and Exercise
Medicine, London, UK
4 UKCRC Centre of Excellence for Public Health (NI),
Queens University Belfast, Royal Victoria Hospital,
Belfast, UK
Correspondence to C M Bleakley, Health and
Rehabilitation Sciences Research Institute, University
of Ulster, Jordanstown, Newtownabbey, County Antrim
BT370QB, UK;
PRICE needs updating,
should we call the POLICE?
C M Bleakley, 1,3 P Glasgow, 2,3 D C MacAuley 4
adverse changes to tissue biomechanics
and morphology. Progressive mechani-
cal loading is more likely to restore the
strength and morphological characteris-
tics of collagenous tissue.
5 Indeed, early
mobilisation with accelerated rehabilita-
tion is effective after acute ankle strain.
Functional rehabilitation of ankle sprain,
which involves early weight-bearing usu-
ally with an external support, is superior
to cast immobilisation for most types of
sprain severity.
Functional rehabilitation aligns well
with the principles of mechanotherapy,
whereby mechanical loading prompts
cellular responses that promote tissue
structural change.
10 There are consistent
ndings from animal models that dem-
onstrate how mechanical loading upregu-
lates mRNA expression for key proteins
associated with soft tissue healing.
6 The
diffi cult clinical challenge is fi nding the
balance between loading and unloading
during tissue healing. If tissues are stressed
too aggressively after injury, the mechani-
cal insult may cause re-bleeding or further
damage. Protection of vulnerable tissues
therefore remains an important principle.
But, too much emphasis creates a default
mindset that loading has no place in acute
management. Rest may be harmful and
inhibits recovery. The secret is to fi nd the
‘optimal loading’.
Optimal loading means replacing rest
with a balanced and incremental reha-
bilitation programme where early activity
encourages early recovery. Injuries vary so
there is no single one size fi ts all strategy
or dosage. A loading strategy should refl ect
the unique mechanical stresses placed
upon the injured tissue during functional
activities, which varies across tissue type
and anatomical region. For example, a
muscle injury to the lower limb has cyclic
loading through normal ambulation. The
upper limb may require additional cyclic
load to be factored into the rehabilitation
program in order to maximise mechanical
POLICE, a new acronym, which rep-
resents protection, optimal loading, ice
compression and elevation, is not simply
a formula but a reminder to clinicians to
think differently and seek out new and
innovative strategies for safe and effective
loading in acute soft tissue injury man-
agement. Optimal loading is an umbrella
term for any mechanotherapy interven-
tion and includes a wide range of manual
techniques currently available; indeed
the term may include manual techniques
such as massage refi ned to maximise the
mechano-effect. Paradoxically, crutches,
braces and supports, traditionally associ-
ated with rest, may have a greater role in
adjusting and regulating optimal loading
in the early stages of rehabilitation.
POLICE should make us think more
about research into designing rehabilita-
tion strategies that are appropriate to the
nature and severity of injury in different
sports and activities. If the primary princi-
ple of treatment is to restore the histologi-
cal and mechanical properties of injured
soft tissue, optimal loading may indeed
be sport specifi c. The challenge is in deter-
mining what is ‘optimal’ in terms of the
dosage, nature and timing.
POLICE is not just an acronym to guide
management but a stimulus to a new fi eld
of research. It is important that this research
includes more rigorous examination of the
role of ICE in acute injury management.
Currently, cold-induced analgesia and the
assurance and support provided by com-
pression and elevation are enough to retain
ICE within the acronym.
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.
Accepted 3 August 2011
Published Online First 7 September 2011
Br J Sports Med 2012;46 :220–221.
1 . Paoloni JA , Milne C , Orchard J , et al . Non-
steroidal anti-infl ammatory drugs in sports
medicine: guidelines for practical but sensible use.
Br J Sports Med 2009 ; 43 : 863 – 5 .
2 . Prins JC , Stubbe JH , van Meeteren NL , et al .
Feasibility and preliminary effectiveness of ice therapy
in patients with an acute tear in the gastrocnemius
muscle: a pilot randomized controlled trial.
Clin Rehabil 2011 ; 25 : 433 – 41 .
3 . Bleakley CM , Glasgow PD , Philips P , et al ; for the
Association of Chartered Physiotherapists in Sports
and Exercise Medicine (ACPSM). Guidelines on
the Management of Acute Soft Tissue Injury Using
Protection Rest Ice Compression and Elevation.
London: ACPSM, 2011:15–21.
4 . Bring DK , Reno C , Renstrom P , et al . Joint immobilization
reduces the expression of sensory neuropeptide
receptors and impairs healing after tendon rupture in a
rat model. J Orthop Res 2009 ; 27 : 274 – 80 .
5 . Martinez DA , Vailas AC , Vanderby R Jr , et al .
Temporal extracellular matrix adaptations in ligament
during wound healing and hindlimb unloading.
Am J Physiol Regul Integr Comp Physiol
2007 ; 293 : R1552 – 60 .
6 . Eliasson P , Andersson T , Aspenberg P . Rat Achilles
tendon healing: mechanical loading and gene
expression. J Appl Physiol 2009 ; 107 : 399 – 407 .
02_bjsports-2011-090297.indd 22002_bjsports-2011-090297.indd 220 2/14/2012 6:04:48 PM2/14/2012 6:04:48 PM on March 6, 2012 - Published by bjsm.bmj.comDownloaded from
Br J Sports Med March 2012 Vol 46 No 4 221
7 . Bleakley CM , O’Connor SR , Tully MA , et al . Effect
of accelerated rehabilitation on function after
ankle sprain: randomised controlled trial. BMJ
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8 . Jones MH , Amendola AS . Acute treatment of
inversion ankle sprains: immobilization versus
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2007 ; 455 : 169 – 72 .
9 . Kerkhoffs GM , Rowe BH , Assendelft WJ , et al .
Immobilisation and functional treatment for acute
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10. Khan KM , Scott A . Mechanotherapy: how physical
therapists’ prescription of exercise promotes tissue
repair. Br J Sports Med 2009 ; 43 : 247 – 52 .
02_bjsports-2011-090297.indd 22102_bjsports-2011-090297.indd 221 2/14/2012 6:04:49 PM2/14/2012 6:04:49 PM on March 6, 2012 - Published by bjsm.bmj.comDownloaded from
doi: 10.1136/bjsports-2011-090297
September 7, 2011
2012 46: 220-221 originally published onlineBr J Sports Med
C M Bleakley, P Glasgow and D C MacAuley
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... 5 Rehabilitation of HSI has evolved to address inflammation, promote biological healing and emphasise optimal loading throughout the rehabilitation. 6 The individual hamstring muscles have often been treated uniformly as they work in conjunction, but evidence has emerged, demonstrating that they have different functional roles, capabilities and injury mechanisms, 7 based on their anatomy and nerve supply, 8 fibre type composition 9 10 and connective tissue (CT) architecture. 8 11 12 Each muscle may therefore require a different rehabilitation approach, 11 13 14 influencing exercise selection in rehabilitation. ...
... Round 1 of the survey obtained baseline information from our experts on which areas of rehabilitation and RTS required more research. The open-ended responses were grouped and analysed thematically (see tables [5][6][7]. ...
... After initial protection, the primary rehabilitation goal is to progressively load recovering tissue to promote its optimal adaptation back to full strength, elasticity, capability and function. 6 The type of muscle contraction prescribed in exercise (eccentric, 35 isometric 86 and concentric 87 ) produces different force outputs and loads on muscle tissues, leading to different adaptation and requiring different periodisation and recovery times. 88 89 Early eccentric loading was typically avoided by our experts due to perceived reinjury risk and loading commences with isometric contraction at shortened lengths. ...
Hamstring injuries (HSIs) are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades. HSI often recur and many areas are lacking evidence and guidance for optimal rehabilitation. This study aimed to develop an international expert consensus for the management of HSI. A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering round questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. Expert response rates were 35/46 (76%) (first round), 15/35 (attendees/invitees to meeting day) and 99/112 (88.2%) for final survey round. Statements on rehabilitation reaching consensus centred around: exercise selection and dosage (78.8%-96.3% agreement), impact of the kinetic chain (95%), criteria to progress exercise (73%-92.7%), running and sprinting (83%-100%) in rehabilitation and criteria for return to sport (RTS) (78.3%-98.3%). Benchmarks for flexibility (40%) and strength (66.1%) and adjuncts to rehabilitation (68.9%) did not reach agreement. This consensus panel recommends individualised rehabilitation based on the athlete, sporting demands, involved muscle(s) and injury type and severity (89.8%). Early-stage rehab should avoid high strain loads and rates. Loading is important but with less consensus on optimum progression and dosage. This panel recommends rehabilitation progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting (85.5%). Experts focus on the demands and capacity required for match play when deciding the rehabilitation end goal and timing of RTS (89.8%). The expert panellists in this study followed evidence on aspects of rehabilitation after HSI, suggesting rehabilitation prescription should be individualised, but clarified areas where evidence was lacking. Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit optimising: prescription of running and sprinting, the application of adjuncts in rehabilitation and treatment of kinetic chain HSI factors.
... The main injecting solution was prepared by mixing 1 ml of triamcinolone acetonide (40 mg), 0.5 ml each of 0.5% Ropivacaine, and 2% Lignocaine. (4). Under the guidance of the USG, a 22-gauge needle was inserted from the skin to the outer (superficial) sheath of the AFTL (Figure 2) and 50% of the solution was injected (~1 ml), the rest of the solution (~1 ml) was inserted into the inner (deep) sheath of the AFTL (Figure 3) which was seen to get slightly diluted inside the ankle joint. ...
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... Cryotherapy is a well-known technique used to provide analgesia, especially in the early treatment of musculoskeletal injuries (8). Cryotherapy increases the excitability threshold of sensory neurons at the site of application as a result of the decrease in neuronal metabolism and sodium-potassium pump activity, thereby providing the analgesic effect by decreasing the nerve conduction velocity (9). ...
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Objectives: Cryotherapy is a well-known technique used to provide analgesia, especially in the early treatment of musculoskeletal injuries. This study aims to evaluate the effectiveness of pre-injection, post-injection, and combined cryotherapy on pain intensity associated with ultrasound-guided musculoskeletal injection. Methods: In this retrospective study, a total of 120 participants who had received an ultrasound-guided musculoskeletal injection were subsequently categorized into four groups according to the timing of cryotherapy: PRE (cryotherapy only before injection), POST (cryotherapy only after injection), BOTH (cryotherapy both before and after injection), CON (no cryotherapy). Participants’ visual analogue scale (VAS) scores before, during and after the injection were compared. Results: Timing of cryotherapy had a significant effect on VAS Score (p < 0.001). Lowest VAS scores after injection were observed when cryotherapy was applied both before and after injection (0.63 ± 0.12). Conclusion: Cryotherapy before and/or after injection decreases VAS scores either during injection and/or after injection. Also, the downward trend in VAS scores across all time intervals appears only when cryotherapy was applied both before and after injection. Keywords: Cryotherapy, Musculoskeletal disorders, VAS Score
... In the literature, specialists recommend treatments for muscle lesions according to the three stages of recovery mentioned in subchapter 3.3. Treatment recommendations are given in Table 2. Table 2 Literature recommendations for muscle lesion recovery according to the stage of recovery [4], [9], [11], [17], [25] Recovery phase ...
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Muscle lesions are among the most common injuries encountered in performance sports. Despite their high incidence, their diagnosis, classification and treatment are constantly being debated. Most of the time, the severity of the injury indicates the recovery strategy (conservative, physical therapy, surgical etc). Currently, due to advances in medical, pharmacological, and physical therapy, the treatment of muscle injuries can be greatly improved. Incomplete or incorrect recovery from a muscle injury can have a series of negative effects (financial or sport performance), which can affect the long-term career of athletes. Considering the incidence and costs that an injury can generate, in this paper, we set out to identify and present the latest approaches, used by specialists in the field, to facilitate the fastest recovery of athletes.
... This allows a rehabilitation plan to be designed and administered in regards to the healing time of the damaged tissue. The widely recognized RICE protocol of rest, ice, compression, and elevation is recommended for early management, while the POLICE (protection, optimal loading, ice, compression, and elevation) paradigm [15] highlights the need for safe and effective loading in acute soft tissue injury management. Additionally, a significant component of the rehabilitation process is a timely introduction to a series of sportspecific exercises [16]. ...
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Platelet-rich plasma (PRP) injections are extremely popular in the management of sports injuries in elite athletes. However, data on the use of various administration protocols of PRP are contradictory. The efficacy of platelet-rich plasma in the treatment of muscle injuries in professional soccer players has to be contextualized within the sport-specific rehabilitation program. Despite the questionable role of PRP, a well-structured rehabilitation program is still regarded as the gold standard. We examined the efficacy of various PRP protocols in the management of muscle injuries in professional soccer players in respect to treatment duration and injury recurrence. A retrospective cohort study. Muscle injuries in professional soccer players (n=79, height 182.1 ± 5.9 cm, weight 76.8 ± 5.8 kg, BMI 23.1 ± 1.4 kg/m²) from three elite soccer clubs from the Russian Premier League were recorded during the 2018-2019 season. The injuries were graded based on MRI, using the Brit-ish Athletic Muscle Injury Classification. Treatment protocols included the POLICE regimen, short courses of NSAID administration, and the specific rehabilitation program. The sample group of players were administered PRP injections. The average treatment duration with PRP injection was significantly longer than conventional treatment without PRP, 21.5 ± 15.7 days and 15.3 ± 11.1 days, respectively (p = 0.003). Soccer-specific rehabilitation and obtaining MRI/US before the treatment was associated with significantly reduced injury recurrence rate (p < 0.001). There was no significant difference between the PRP injection protocol applied to any muscle and the treatment duration in respect of grade 2A-2B muscle injuries. The total duration of treatment of type 2A-2B injuries was 15 days among all players. In the group receiving local injections of PRP, the total duration of treatment was 18 days; in the group without PRP injections, the treatment duration was 14 days. In our study, PRP treatment was associated with longer treatment duration, regardless of which muscle was injured. This may reflect the tendency to use PRP in higher-degree injuries. Soccer-specific rehabilitation significantly reduced the injury recurrence rate when compared to the administration of PRP injections. MRI/US imaging before returning to play was also associated with a lower injury recurrence rate. There was no significant difference between the PRP injection protocol applied to any muscle and the treatment duration in treatment of type 2A-2B muscle injuries. Citation: Bezuglov, E.; Khaitin, V.; Shoshorina, M.; Butovskiy, M.; Karlitskiy, N.; Mashkovskiy, E.; Goncharov, E.; Pirmakhanov, B.; Morgans, R.; Lazarev, A. Sport-Specific Rehabilitation, but Not PRP Injections, Might Reduce the Re-Injury Rate of Muscle Injuries in Professional Soccer Players: A Retrospective Cohort Study.
... For the most immediate treatment of these injuries, the concept of the POLICE protocol is used, represented by optimized load and relative rest, cryotherapy, compression and limb elevation. 12 Other protocols were created mainly to guide the initial stages of rehabilitation of athletes, but the POLICE protocol remains the reference of choice for use in the acute phase of sports trauma. ...
Soccer is one of the most popular sports around the world. The large number of practitioners, associated with technical and tactical characteristics, make it subject to a large number of injuries. Therefore, it is necessary the continuous training of health professionals who act as rescuers in soccer matches. In addition, due to a series of factors, there is currently an increase in the number of potentially more serious injuries, especially concussions. This has caused concern not only for health professionals, but also for the institutions that regulate the practice of sport. In professional soccer, there is a minimum requirement of material and human resources that guarantee greater safety for competitors, something not observed in amateur. The dissemination of basic first aid knowledge is extremely relevant and should cover the entire public involved in the sport.
... Old conservative protocols, RICE (i.e., rest, ice, compression and elevation) and POLICE (i.e., protection, optimal loading, ice, compression and elevation) [21], were developed from existing data at the time that have now been partially refuted. Newer protocols such as PEACE (i.e., protection, elevation, avoid anti-inflammatory, compression and education) and LOVE (i.e., load, optimism, vascularization and exercise) [22] focus on education, vascularization, early loading and exercise. ...
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A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = −1.23; 95% IC −1.73, −0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.
... external load), while maintaining the required physiological stress (i.e. internal load) to achieve intended functional adaptations (Bleakley et al., 2012;Glasgow et al., 2015). Jogging or running at faster speeds are often needed to achieve the desired physiological stimulation (Farina et al., 2017), yet are often not welltolerated by load-compromised individuals. ...
Acute physiological, perceptual and biomechanical consequences of manipulating both exercise intensity and hypoxic exposure during treadmill running were determined. On separate days, eleven trained individuals ran for 45 s (separated by 135 s of rest) on an instrumented treadmill at seven running speeds (8, 10, 12, 14, 16, 18 and 20 km.h⁻¹) in normoxia (NM, FiO2 = 20.9%), moderate hypoxia (MH, FiO2 = 16.1%), high hypoxia (HH, FiO2 = 14.1%) and severe hypoxia (SH, FiO2 = 13.0%). Running mechanics were collected over 20 consecutive steps (i.e. after running ∼25 s), with concurrent assessment of physiological (heart rate and arterial oxygen saturation) and perceptual (overall perceived discomfort, difficulty breathing and leg discomfort) responses. Two-way repeated-measures ANOVA (seven speeds × four conditions) were used. There was a speed × condition interaction for heart rate (p = 0.045, ηp2 = 0.22), with lower values in NM, MH and HH compared to SH at 8 km.h⁻¹ (125 ± 12, 125 ± 11, 128 ± 12 vs 132 ± 10 b.min⁻¹). Overall perceived discomfort (8 and 16 km.h⁻¹; p = 0.019 and p = 0.007, ηp2 = 0.21, respectively) and perceived difficulty breathing (all speeds; p = 0.023, ηp2 = 0.37) were greater in SH compared to MH, whereas leg discomfort was not influenced by hypoxic exposure. Minimal difference was observed in the twelve kinetics/kinematics variables with hypoxia (p > 0.122; ηp2 = 0.19). Running at slower speeds in combination with severe hypoxia elevates physiological and perceptual responses without a corresponding increase in ground reaction forces. Highlights • The extent to which manipulating hypoxia severity (between normoxia and severe hypoxia) and running speed (from 8 to 20 km.h⁻¹) influence acute physiological and perceptual responses, as well as kinetic and kinematic adjustments during treadmill running was determined. • Running at slower speeds in combination with severe hypoxia elevates heart rate, while this effect was not apparent at faster speeds. • Arterial oxygen saturation was increasingly lower as running speed and hypoxic severity increased. • Overall perceived discomfort (8 and 16 km.h⁻¹) and perceived difficulty breathing (all speeds) were lower in moderate hypoxia than in severe hypoxia, whereas leg discomfort remained unchanged with hypoxic exposure.
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Dor na virilha é um problema que ocorre na área entre o abdome e as pernas, recorrente em atletas sendo a terceira maior causa de afastamentos no futebol. Métodos inadequados de treinamento, condicionamento físico, alterações estruturais, sobrecarga, fraqueza muscular e alterações articulares são considerados seus principais fatores de risco, no entanto, não há um consenso na literatura de qual forma é a mais eficaz para avaliar, tratar e prevenir. O objetivo do presente trabalho é realizar uma revisão critica de literatura identificando programas e ferramentas de maior eficácia de avaliação, reabilitação e prevenção de jogadores de futebol que apresentem como diagnóstico de dor na virilha. A busca do presente estudo foi sistematizada através de bases eletrônicas, sendo: Biblioteca virtual de saúde; Pubmed e Google Scholar. Dezesseis artigos foram encontrados, classificando os achados mais importantes da literatura; Exames de ressonância magnética mostram ser importante para estabelecer um bom diagnóstico diferencial, o questionário HAGOS parece ser uma grande ferramenta para avaliação, quantificando o estado atual do atleta, diversas técnicas envolvem para a reabilitação, cabe o terapeuta saber interceder de maneira exata, exercício de copenhagen aponta melhor maneira de evitar qualquer tipo intercorrência das várias causas de dor na virilha.
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Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. This paper reclaims the term “mechanotherapy” and presents the current scientific knowledge underpinning how load may be used therapeutically to stimulate tissue repair and remodelling in tendon, muscle, cartilage and bone. The purpose of this short article is to answer a frequently asked question “How precisely does exercise promote tissue healing?” This is a fundamental question for clinicians who prescribe exercise for tendinopathies, muscle tears, non-inflammatory arthropathies and even controlled loading after fractures. High-quality randomised controlled trials and systematic reviews show that various forms of exercise or movement prescription benefit patients with a wide range of musculoskeletal problems.1–4 But what happens at the tissue level to promote repair and remodelling of tendon, muscle, articular cartilage and bone? The one-word answer is “mechanotransduction”, but rather than finishing there and limiting this paper to 95 words, we provide a short illustrated introduction to this remarkable, ubiquitous, non-neural, physiological process. We also re-introduce the term “mechanotherapy” to distinguish therapeutics (exercise prescription specifically to treat injuries) from the homeostatic role of mechanotransduction. Strictly speaking, mechanotransduction maintains normal musculoskeletal structures in the absence of injury. After first outlining the process of mechanotransduction, we provide well-known clinical therapeutic examples of mechanotherapy–turning movement into tissue healing.
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Healing after mobilization versus immobilization was assessed in a model of rat Achilles tendon rupture, by RT-PCR at 8 and 17 days and by histological analyses at 14 and 28 days postrupture. The expression of mRNA for extracellular matrix (ECM) molecules (collagen type I and type III, versican, decorin, and biglycan), and the subjective histological maturation of the healing area were analyzed. Effects of immobilization on healing were related to changes in the peripheral expression of substance P (NK(1))- and calcitonin gene-related peptide (CRLR and RAMP-1)- receptors. At 8 days postinjury, mRNA levels for ECM molecules were equal in both groups. However, by day 17, the ECM mRNA expression in the mobilized group had increased up to approximately 14x that of the immobilized group, which were comparable to intact tendon values. Histological analysis confirmed a higher regenerating activity in the mobilized group, with an increased amount of blood vessels, fibroblasts, and new collagen. The expression of sensory neuropeptide receptors in the mobilized group exhibited a significant increase from 8 to 17 days postinjury similar to the increased ECM mRNA expression, whereas the immobilized group at 17 days exhibited levels comparable to the intact tendon values. Therefore, immobilization postrupture appears to hamper tendon healing, a process which may prove to be directly linked to a downregulated peripheral sensitivity to sensory neuropeptide stimulation.
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To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention. Randomised controlled trial with blinded outcome assessor. Accident and emergency department and university based sports injury clinic. 101 patients with an acute grade 1 or 2 ankle sprain. Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group). The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks. An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity (53 minutes, 95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group). An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care. Current Controlled Trials ISRCTN13903946.
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Injured tendons require mechanical tension for optimal healing, but it is unclear which genes are upregulated and responsible for this effect. We unloaded one Achilles tendon in rats by Botox injections in the calf muscles. The tendon was then transected and left to heal. We studied mechanical properties of the tendon calluses, as well as mRNA expression, and compared them with loaded controls. Tendon calluses were studied 3, 8, 14, and 21 days after transection. Intact tendons were studied similarly for comparison. Altogether 110 rats were used. The genes were chosen for proteins marking inflammation, growth, extracellular matrix, and tendon specificity. In intact tendons, procollagen III and tenascin-C were more expressed in loaded than unloaded tendons, but none of the other genes was affected. In healing tendons, loading status had small effects on the selected genes. However, TNF-alpha, transforming growth factor-beta1, and procollagens I and III were less expressed in loaded callus tissue at day 3. At day 8 procollagens I and III, lysyl oxidase, and scleraxis had a lower expression in loaded calluses. However, by days 14 and 21, procollagen I, cartilage oligomeric matrix protein, tenascin-C, tenomodulin, and scleraxis were all more expressed in loaded calluses. In healing tendons, the transverse area was larger in loaded samples, but material properties were unaffected, or even impaired. Thus mechanical loading is important for growth of the callus but not its mechanical quality. The main effect of loading during healing might thereby be sought among growth stimulators. In the late phase of healing, tendon-specific genes (scleraxis and tenomodulin) were upregulated with loading, and the healing tissue might to some extent represent a regenerate rather than a scar.
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Previous data from spaceflight studies indicate that injured muscle and bone heal slowly and abnormally compared with ground controls, strongly suggesting that ligaments or tendons may not repair optimally as well. Thus the objective of this study was to investigate the biochemical and molecular gene expression of the collagen extracellular matrix in response to medial collateral ligament (MCL) injury repair in hindlimb unloaded (HLU) rodents. Male rats were assigned to 3- and 7-wk treatment groups with three subgroups each: sham control, ambulatory healing (Amb-healing), and HLU-healing groups. Amb- and HLU-healing animals underwent bilateral surgical transection of their MCLs, whereas control animals were subjected to sham surgeries. All surgeries were performed under isoflurane anesthesia. After 3 wk or 7 wk of HLU, rats were euthanized and MCLs were surgically isolated and prepared for molecular or biochemical analyses. Hydroxyproline concentration and hydroxylysylpyridinoline collagen cross-link contents were measured by HPLC and showed a substantial decrement in surgical groups. MCL tissue cellularity, quantified by DNA content, remained significantly elevated in all HLU-healing groups vs. Amb-healing groups. MCL gene expression of collagen type I, collagen type III, collagen type V, fibronectin, decorin, biglycan, lysyl oxidase, matrix metalloproteinase-2, and tissue inhibitor of matrix metalloproteinase-1, measured by real-time quantitative PCR, demonstrated differential expression in the HLU-healing groups compared with Amb-healing groups at both the 3- and 7-wk time points. Together, these data suggest that HLU affects dense fibrous connective tissue wound healing and confirms previous morphological and biomechanical data that HLU inhibits the ligament repair processes.
To investigate the feasibility of a randomized controlled trial and the preliminary effectiveness of ice therapy in the acute phase of a gastrocnemius tear for the quality of functional recovery. A pilot version of an intended prospective randomized controlled clinical trial was conducted. A total of 19 patients with an acute tear in the gastrocnemius muscle were randomly allocated to either active or control treatment. The intervention consisted of the repeated application of crushed ice. Primary outcome measures were functional capacity and reconvalescence time. Secondary outcome measures were pain and work absenteeism. The number of patients we could include within the 6-hour time window and dropping out from the pilot study were regarded as indicators of the feasibility of ice therapy. A total of 16 patients were excluded from the study because diagnosis was not made within 6 hours after onset of the complaint. The 19 patients included completed the treatment. For functional capacity, reconvalescence time, work absenteeism and pain relief, no significant differences between the intervention and control group were found. The execution of a randomized controlled trial on ice therapy for acute gastrocnemius tear is feasible though quite an enterprise. First, it is recommended to improve the recruitment processes. Second, power analysis demands inclusion of 396 participants. Preliminary effectiveness in our limited-sized trial indicates that the use of ice is not beneficial for people who receive ice therapy.
Non-steroidal anti-inflammatory drugs (NSAID) are commonly used in sports medicine. NSAID have known anti-inflammatory, analgesic, antipyretic and antithrombotic effects, although their in-vivo effects in treating musculoskeletal injuries in humans remain largely unknown. NSAID analgesic action is not significantly greater than paracetamol for musculoskeletal injury but they have a higher risk profile, with side-effects including asthma exacerbation, gastrointestinal and renal side-effects, hypertension and other cardiovascular diseases. The authors recommend an approach to NSAID use in sports medicine whereby simple analgesia is preferentially used when analgesia is the primary desired outcome. However, based both on the current pathophysiological understanding of most injury presentations and the frequency that inflammation may actually be a component of the injury complex, it is premature to suppose that NSAID are not useful to the physician managing sports injuries. The prescribing of NSAID should be cautious and both situation and pathology specific. Both dose and duration minimisation should be prioritized and combined with simple principles of protection, rest, ice, compression, elevation (PRICE), which should allow NSAID-sparing. NSAID use should always be coupled with appropriate physical rehabilitation. NSAID are probably most useful for treating nerve and soft-tissue impingements, inflammatory arthropathies and tenosynovitis. They are not generally indicated for isolated chronic tendinopathy, or for fractures. The use of NSAID in treating muscle injury is controversial. Conditions in which NSAID use requires more careful assessment include ligament injury, joint injury, osteoarthritis, haematoma and postoperatively.
Background: Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem. Objectives: The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods. Search strategy: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field. Selection criteria: Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded. Data collection and analysis: Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test. Main results: Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation. Reviewer's conclusions: Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.
Inversion ankle sprains are one of the most common injuries in sports. Although these injuries are often considered minor, they can lead to persistent disability in athletes. We conducted a systematic review of the literature to evaluate the effect of immobilization versus early functional treatment on time to return to preinjury activity after inversion ankle sprain. Residual subjective instability, recurrent injury, and patient satisfaction were secondary outcomes. A systematic review identified 9 randomized controlled trials. Return to preinjury activity was less with early functional treatment in 4 of 5 studies that evaluated this outcome. Subjective instability was less in 3 of 5 studies. Similarly, reinjury rate was less in 5 of 6 studies. Patient satisfaction was not substantially different in the two studies that evaluated this outcome. Limitations of the identified trials included small sample size, heterogeneity of treatment methods, and lack of standardized outcome measures. However, based on our review the current best evidence suggests a trend favoring early functional treatment over immobilization for the treatment of acute lateral ankle sprains.