Muscle tears, ligament strains and other acute soft tissue injuries are common in the world of sport and exercise. There are records that the Ancient Egyptians used cold compresses to reduce swelling and stop bleeding in and around 2,500 BC. There are also reports that Hippocrates, the famous Greek physician, recommended the use of snow or ice as the first line of treatment for inflammation and musculoskeletal injuries between 460 and 370 BC.
A few millennia later and we are still using the power of ice to treat soft tissue injuries with P.R.I.C.E (Protection, Rest, Ice, Compression and Elevation) (also referred to as R.I.C.E. by dropping the protection part) being one of the most commonly used management approaches for muscle and ligament injuries. Research has shown that this form of treatment induces a number of clinical and physiological effects including analgesia, reduced oedema, reduced tissue damage and a more rapid return to normal function.
However, continuous advances in medicine, techniques and the understanding of sports injuries have led to the development of a number of new management approaches that will become more mainstream in the coming years. This article considers a number of these future management approaches and the research evidence surrounding them, including platelet rich therapies, electromagnetic field therapies and cryotherapy.
Platelet rich therapies
Platelet rich therapies have been advocated for use as a sole or complementary treatment for soft tissue injuries. They are commonly used alongside other conservative interventions or after surgery has been performed. Physical examination or imaging techniques, such as dynamic musculoskeletal ultrasound, are performed in order to identify the key area of injury and area of maximum tenderness before injecting the platelet rich plasma.
The site of platelet rich therapy application can also be indirectly visualized when arthroscopic surgery is performed. The plasma itself is derived by extracting whole blood from the patient and centrifuging the blood to give a platelet rich fraction. This platelet-rich fraction has high concentrations of platelet and growth factors such as insulin-like, epidermal, transforming, platelet-derived, endothelial cell, fibroblast and vascular endothelial growth factors, which are thought to be responsible for enhancing the recovery of soft tissues.
Platelet rich therapy delivers growth factors to the site of the injury where they are thought to enhance the regeneration of soft tissues and increase angiogenesis. The role of platelet rich therapy is therefore to act as a biological enhancer by promoting and accelerating the healing process within the biocellular environment. As the method utilises the patient's own blood product, incidence of reported side effects is very low, with most studies reporting a small area of tenderness and swelling around the injection site.
However, evidence for the effectiveness of this treatment is currently very limited, with much of this coming from low quality clinical trials. Nevertheless, there are a number of randomised controlled trials currently underway to assess the effectiveness of this approach.
Electromagnetic field therapy
The use of electromagnetic fields and electric current stimulation to enhance soft tissue healing is not new - indeed, pioneer studies in this area began in the late 1960s. However, several recent advances have been made in the understanding of the basic principles surrounding this management technique. The key theory surrounding this therapy is that the cells involved in soft tissue injury healing are electrically charged, therefore any endogenous bioelectricity will encourage the migration of these cells to the wound area, promoting angiogenesis and other healing processes.
As such, studies have reported that electromagnetic field signals promote the differentiation of cells and enhance proliferation of keratinocytes. In vitro studies have shown low frequency electric stimulation of keratinocytes increases cell growth and significantly increases human keratinocyte proliferation. Electromagnetic fields have been reported to influence a large number of biological systems, including skin, bone, nerves, muscles, ligaments and tendons
Evidence from clinical trials have shown that pulsed electromagnetic energy therapy has a significant impact on the reduction of swelling and pain, and an improvement in mobility for patients suffering from ankle sprains, whiplash and other soft tissue injuries, particularly when the treatment was utilised within the first 72 hours after injury. However, further studies need to be completed to ensure the safety of this treatment and to assess the effects of different electromagnetic field modalities on soft tissue healing before the management approach becomes mainstream.
Cryotherapy is a technique that has been utilised in sports and exercise medicine for many years. Recently even Ronaldo installed a cryotherapy chamber in his house.
Cooling the body for therapeutic purposes through the application of ice packs or via immersion in cold water baths is a common and popular means of reducing the inflammation and soft tissue damage surrounding sporting injuries. Advancements in this technique have seen a recent surge towards the use of whole body cryotherapy (WBC) techniques. WBC involves exposing the patient to cold dry air, typically between - 100°C and - 140°C - for between 2 and 5 minutes in an environmentally controlled room. The patients typically wear minimal clothing over their bodies, but reduce the risk of cold related injuries by wearing gloves, a nose and mouth mask, a headband to cover the ears and dry socks and shoes.
The technique itself was originally developed to treat rheumatoid arthritis, multiple sclerosis and other chronic medical conditions. Recently, WBC has been increasingly adopted for the use of injury management in athletes, with its therapeutic benefits including analgesic effects, a reduction in inflammation, decreased tissue temperature and enhanced recovery. The technique is usually initiated within 24 hours post exercise and can be repeated numerous times in the same day or over a number of weeks depending on the severity of the injury.
The accessibility of the WBC technique is increasing for athletes despite the fact that it is considerably more expensive than the traditional cryotherapy methods. In addition, there is still no significant evidence to support any additional clinical effect over the less expensive and more traditional methods. Nevertheless, a recent study reported observational evidence that WBC can modify a number of important physiological and biochemical parameters within the human body. These parameters include positive effects on creatine kinase and lactate dehydrogenase (two muscular enzymes that are commonly associated with muscle damage), adaptive changes in antioxidant status and a decrease in proinflammatory cytokines.
Studies have also reported that there are no negative or deleterious effects of WBC, with exposure to the method having no impact on immunological or cardiac function.
Despite the lack of major evidence in support of this soft tissue injury management technique, the common supposition from experts is that the extreme nature of the method will offer a significant advantage over the traditional ice pack or other cooling methods.
The few randomised control trials that have been completed in this field have shown that WBC has a consistent effect on some physiological and cellular events that are directly associated with inflammation of soft tissue following injury. These include white blood cell activity within the blood vessels surrounding the injury site, an increase in cell metabolism and apoptosis. Studies have also shown that athletes who used WBC following single or multiple training sessions have an enhanced cytokine profile, therefore leading to a reduction in inflammation.
Current research within the field of sporting injuries suggests an increase in the use of novel treatment techniques such as those discussed in this article. Whilst current evidence surrounding their use is largely theoretical or observational, significant interest from athletes and sporting bodies will encourage further use and an increase in high quality randomised control trials to provide the required evidence in support of their mainstream adoption for soft tissue injury management.