Phase 1, Initial Days After Injury: PEACE
P for Protect
Unload or restrict movement for 1 to 3 days to minimise bleeding, prevent distension of injured fibers and reduce risk of aggravating the injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality. Rely on pain signals to guide removal of protection and gradual reloading.
E for Elevate
Elevate the limb higher than the heart to promote interstitial fluid flow out of tissue. Despite weak evidence supporting its use, elevation is still recommended given its low risk-benefit ratio.
A for Avoid anti-inflammatory modalities
Anti-inflammatory medications may potentially be detrimental for long-term tissue healing. The various phases of inflammation contribute to optimal soft tissue regeneration. Inhibiting such an important process using pharmacological modalities is not recommended as it could impair tissue healing, especially when a higher dosage is taken.
We also question the use of cryotherapy. Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft tissue injuries.Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibers, which may lead to impaired tissue regeneration and redundant collagen synthesis.
C for Compress
External mechanical pressure using taping or bandages helps limiting intra-articular edema and tissue hemorrhage.Despite conflicting studies,compression after an ankle sprain seems to reduce swelling and improve quality of life.
E for Educate
Therapists should educate patients on the benefits of an active approach to recovery.[5, 10] Passive modalities such as electrotherapy, manual therapy or acupuncture, early after injury has a trivial effect on pain and function compared with an active approach; it may even be counter-productive in the long term. Indeed, nurturing the ‘need to be fixed’ can create dependence to the therapist, be a significant nocebo, and thus contribute to persistent symptoms. Better education on the condition and load management will help avoid overtreatment which has been suggested to increase the likelihood of injections or surgery and higher costs to healthcare systems because of disability compensation (e.g. in low back pain).[13, 14] In an era of technology and hi-tech therapeutic options, we strongly advocate for setting realistic expectations with patients about recovery times instead of chasing the magic treatment approach.