RICER: When soft tissue injuries like sprains and strains occur, the body sends a large volume of blood to the injury site resulting in bleeding, swelling and pain. If the initial injury treatment is inadequate, bulky painful scar tissue can develop.
By following the guidelines of RICER and using the correct first aid procedure in the hours following injury, you will improve your chances of a full recovery.
What does RICER Stand For?
RICER is an acronym, it stands for Rest, Ice, Compression, Elevation and Referral. It's essential to follow the RICER method during the acute stage of the injury - the first 24 to 48 hours. The sooner you treat a soft tissue injury, the greater the chance of a complete recovery. Without treatment scar tissue can limit future movement and strength in the muscle or joint.
So, what does each step of RICER mean and why does it matter?
If you experience an injury, stop. If you are playing sport, it’s often hard to sit on the sidelines but you risk making the injury worse if you continue. Sitting still will also allow you to start the steps below immediately rather than waiting. Take the weight off the injured part of the body by using crutches if you have a foot injury or a sling for an arm or hand injury.
To reduce the swelling and pain, apply ice for 20 minutes 3-5 times per day. Have at least 1.5 hours rest between applications. Keep the ice treatment going for up to 72 hours to provide relief from pain and swelling. Use ice cubes in a wet towel or a bag of frozen vegetables.
Wrap a bandage around the injury plus above and below the injury site to provide a good compression. The bandage should be firm but not too tight that it can interrupt the blood flow. The bandage will help contain the swelling.
If the injury is on the lower leg or foot, such as a sprained ankle, elevate the leg above the hip. When sitting, use another chair to rest your leg and when lying in bed, place a pillow under your leg. If the injury is on the arm, use a sling.
You may need to seek medical advice for an assessment of the severity of your injury. A scan may be required to decide on the treatment. A medical professional can then prepare an injury management plan to plan your recovery and rehabilitation.
After the Injury: Avoid HARM Factors
HARM is a first aid acronym that stands for Heat, Alcohol, Running, Massage. Avoid each of these four factors during the first 48 to 72 hours after an injury to allow your recovery to begin.
Despite what you may have heard, heat can aggravate a soft tissue injury. Heat can increase swelling and bleeding so don’t apply heat packs, hot rubs and swap a hot, soaking bath with a warm, quick shower.
Similar to heat, alcohol can increase the swelling and bleeding. Keep up your fluids with water.
If you’re injured rest, don’t keep playing. You can aggravate an injury and increase swelling or bleeding. Stop exercising that part of your body and check with a professional when you can resume.
Don’t massage the site of an injury as it can aggravate the injured tissue.
What to do After RICER/HARM Stage is Over - Treatment and Rehabilitation
Now that the first 72 hours have passed since the injury, you need to take a different action. If you haven’t already, you may decide to seek medical advice.
After a physical examination, a doctor may want to further investigate your injury by ordering x-rays, an ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scan. The scan provides a visual of inside the area of the injury.
Physiotherapy and Massage
By this stage, the swelling should start to subside. You can now begin light activity to start blood circulation and the lymphatic system which will help clear the body of waste products and toxins which can accumulate after an injury. The activity may be uncomfortable but shouldn’t be painful.
Many people are ready to start physiotherapy to complete their recovery. A physiotherapist may use ultrasound, a Transcutaneous Electrical Nerve Stimulation (TENS) machine and heat to increase blood supply to the injury to deliver oxygen and nutrients. The ultrasound uses high frequency sound waves for stimulating the area and the TENS machine is a light electrical pulse. A lamp or hot water bottle can provide heat to stimulate blood flow.
For removing the scar tissue, deep tissue massage is needed. If you can massage the area yourself, start with light strokes and increase the pressure. The more massage you perform, the deeper you will be able to massage the area.
To make a full recovery, you may need to continue with the rehabilitation phase even when you feel like your recovery is complete. This will ensure you regain your full strength, flexibility, power, balance and coordination. Continue with light activity to ensure the blood flow continues and the lymphatic system is actively eliminating waste products. Continue with stretches and exercises to regain as much movement as possible.
Types of Soft Tissue Injuries
A sporting injury or accident is known as an acute injury because it occurs suddenly and is unexpected. Other injuries occur through overuse. These types of injuries are often accompanied by warning signs. If you are aware of the warning signs you can take action to prevent the injury occurring.
The most common acute injuries are sprain, strains and bruising.
Sprains & Strains
A sprain usually occurs in a joint with small tears of the ligaments and capsule causing the sprain injury. The most common location for sprains is the ankle accounting for 25% of all musculoskeletal injuries. Half of these injuries are sport related.
A strain is when one or more tendons stretch or tear through overuse or force. Tendons anchor muscles and joints. The most common locations for strains are the lower back and hamstring which often occur during contact sport.
Young children are unlikely to suffer a sprain or strain because their growth plates are weaker than their muscles and tendons. Children are more likely to suffer from a fracture. Sprains and strains are classified on their severity into three grades.
- Grade 1 – Some pain and swelling occurs due to some torn fibres, but the injury does not impact on the strength or junction of the area.
- Grade 2 – Pain and swelling occurs when many fibres are torn resulting in some loss of function and strength.
- Grade 3 – Surgical repair is often required in these injuries because the soft tissue is completely torn and considerable function and strength loss is likely. In other instances, immobilisation and physiotherapy may be used instead of surgery.
Bruises are caused by blood vessels bursting and blood being trapped below the skin’s surface. Also known as a contusions, bruising can be the result of strains, sprains, accidents, concussion, falls and blows. Internal bruising can occur in muscles on the legs through sport and to internal organs through accidents.
Type of Overuse Injuries
Playing sport without giving your body enough time to recover after each session or using the wrong techniques can lead to an overuse injury. Swinging a golf club or throwing a ball can overload a muscle and lead to an overuse injury. Using the same muscles at work and using incorrect posture and techniques can result in repetitive strain injuries.
It takes time to sustain an overuse injury and requires time to recover from the injury.
Pay Attention to Overuse Injury Warning Signs
Often our body tries to tell us that an injury is imminent if we don’t take preventive action. Some people are oblivious to the signs while others choose to ignore them and continue until an injury forces them to stop. Sometimes the signs can continue for a long period until it becomes a chronic injury or pain that is difficult to fix.
The four signs that an injury could occur include:
You may notice that one arm or leg isn’t as strong as the other. If it’s your arm, try lifting the same weight using each arm and see if there is a difference. If your leg doesn’t seem right, stand on one leg then the other to measure results.
Joint swelling can reduce the amount of motion you have. Again, try comparing one side of the body to the other.
You may not experience pain before an injury, but tenderness is a common sign. Use your finger to press into a muscle, joint or bone to see if it’s sore which can indicate you have the beginning of an injury.
Pain in Joints
If you can feel pain in your elbow, knee, wrist or ankle, you may have a joint injury, not a muscular injury.
Common Complications of Soft Tissue Injuries
A complication of a soft tissue injury can occur in the early, intermediate or much later stages. Some people will recover from a soft tissue injury much sooner than another person with the same type of injury. Others will go on to suffer complications. While it is rare for a soft tissue injury to be fatal, a severe complication can occur. Those with recurring injuries and the elderly are most at risk. The most common complications are:
Even following RICER and HARM procedures followed by rehabilitation, muscle scarring can still occur. A torn muscle doesn’t repair the tear with new muscle. Instead, the repair occurs with scar tissue. Scar tissue is the main reason for re-injury often months after you think the initial injury has repaired.
Intramuscular scarring can alter the effectiveness of a muscle. The fibrous scar tissue is tough and inflexible. As scar tissue forms around the injury site, it can contract and deform the surrounding tissue. This restriction reduces its strength and flexibility and increases fatigue.
The weak spot is prone to re-injury. Relapses are common in soft tissue injuries either because the treatment wasn’t sufficient or the patient returned to exercise too early.
Deep Vein Thrombosis
Deep Vein Thrombosis (DVT) can occur soon after an injury. The damaged blood vessel causes the surrounding blood to thicken into a clot. The danger occurs when the blood clot forms in the leg and travels to the lungs known as a pulmonary embolism.
Extreme Bruising & Hematomas
Most of the time bruises are harmless, but severe bruising can result in blood pooling at the site of an injury causing a lump known as a hematoma. If the hematoma becomes very painful or causes pressure, a doctor may need to drain it. Elderly people bruise easier than younger people because their blood vessels are weaker and their skin is thinner with less collagen and protective fat.
When extremely painful swelling occurs within hours of an injury, it may be a sign that the injury has disrupted the blood flow. It is most common in injuries located on the arm, leg, foot or buttocks and can cause permanent damage to the muscle.
When an injured person returns to activity too quickly following bruising, bone tissue may grow where muscle tissue was to repair the injury. Usually, it isn’t dangerous and ice, rest and injury can prevent it occurring, but in extreme cases, surgery can be needed to remove the unwanted tissue.
This complication is not usually seen in an otherwise healthy person who has suffered a mild soft tissue injury. However, if the trauma is severe such as a crushing injury, bacteria can invade tissue which can result in gangrene. A lack of blood supply to an area means no oxygen, nutrients or antibodies are getting through to cells so they can’t survive, the tissue decays, and gangrene can begin. People with diabetes, blood vessel disease, obesity or HIV are more at risk.
When to Seek Further Treatment
Many people think it’s just a sprain or strain and they don’t need medical treatment but if the swelling or pain persists after 48 hours, see a GP or physiotherapist to check that no other complications have occurred.
If your injury has healed, but you are experiencing stiffness, weakness or balance issues, seek advice from your doctor or physiotherapist.
As long as you followed the 5 RICER steps for first aid treatment after a soft tissue injury you will have given yourself the best chance of healing without further pain and complications.