Initial management of soft tissue musculoskeletal injuries

INTRODUCTION — Regular physical activity contributes to the prevention and management of many noncommunicable diseases, such as cardiovascular disease, cancer, and diabetes, and has myriad other benefits. However, the sports and other vigorous physical activities that confer these benefits also entail some risk of musculoskeletal injury, even when appropriate precautions are taken [1,2]. (See "Exercise prescription and guidance for adults".)

The common interventions and medications used to manage acute injuries of muscles, tendons, and other soft tissues and the classification of such injuries are reviewed here. Descriptions of the gamut of soft tissue musculoskeletal disorders and discussions of the diagnosis and management of specific soft tissue injuries are provided separately in a range of UpToDate topics. (See "Overview of soft tissue musculoskeletal disorders".)

APPROACH TO INITIAL MANAGEMENT — We concur with the general recommendations published by the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) and use the following approach when providing care for patients following acute injury of muscles, tendons, or ligaments [3]. A table summarizing these interventions is provided (table 1).

●Protection and rest of injured tissues and joints. The extent of the protection and rest required will depend upon the severity of the injury. Unloading and avoiding movements in the plane of injury is a fundamental principle. As an example, following a moderate tear of the medial collateral ligament of the knee, the patient should wear a knee brace that prevents a valgus (or medial) stress from being exerted upon the injured ligament.

Injuries of the lower extremity that appear severe may warrant nonweightbearing status and the use of crutches or a walker to ensure adequate protection. Some injuries (eg, high-grade ankle sprain) may require long-term protection (eg, compression sleeve, lace-up brace). Aggressive ambulation or exercise should be avoided immediately following injury.

●Ice application to injured tissues and joints. Ice should be applied during the early phases of acute soft tissue injuries to help reduce pain and swelling. One method for ensuring safe application (avoiding frostbite) consists of applying crushed ice covered by a thin, slightly damp barrier (eg, thin towel) to the injured area with a compression wrap for approximately 15 minutes at a time. Each application period alternates with removal of ice for about 45 minutes. This may be continued hourly while the patient is awake.

Most clinicians have patients continue applying ice for 48 to 72 hours for significant injuries. However, icing times may be longer depending on clinical circumstance. As an example, an injured meniscus treated conservatively may continue to have swelling for weeks, and continued ice and compression during that time can help to alleviate swelling and pain.

●Compression of injured tissues and joints. The extent and degree of compression will vary depending on local anatomy and the severity of the injury. Compression helps to reduce swelling acutely and aids in unloading movements in the plane of injury. Compression bandages and other external supports, such as braces, provide biomechanical support, control the range of movement, and give reassurance to patients. The bandages and other implements used for compression should conform to the local anatomy (eg, bony protuberances) without causing pain or constriction of blood flow.

●Elevation of injured extremity. Elevation of the injured tissue above the level of the heart, performed at least periodically during the period following acute injury, helps to reduce swelling and pain. There is no optimal duration for this intervention. While high-quality evidence is lacking, most clinicians continue elevation intermittently for the first 48 to 72 hours after an injury that causes significant swelling. After any elevation, a gradual return to the gravity-dependent position should be achieved.

Some use the mnemonic PRICE (protection, rest, ice, compression, elevation) to recall these initial interventions for acute, soft tissue musculoskeletal injuries. Progressive loading, while an important consideration, usually is not part of initial management.

●Progressive loading of injured tissues, extremities, and joints. Progressive mechanical loading under the supervision of a physiotherapist or other knowledgeable clinician is highly recommended for significant injuries and should be initiated after the acute phase of injury.

Clinical features determine when patients may begin progressive loading. In general, pain must be mild and not increasing significantly with the activity. For walking or running, the individual cannot limp, while for upper extremity activity (eg, throwing), biomechanics should be normal. A growing body of evidence suggests that patients experience earlier recovery and decreased morbidity (eg, diminished mobility) when motion and loads are introduced early, provided this is done safely and gradually.

INITIAL INTERVENTIONS: UTILITY AND EVIDENCE — Some use the mnemonic PRICE (protection, rest, ice, compression, elevation) to recall the initial interventions for acute, soft tissue musculoskeletal injuries (table 1). Evidence supporting this approach is drawn primarily from laboratory rather than clinical studies and from clinical experience [4]. Below, the proposed mechanism, utility, and evidence for each of the major therapeutic interventions following acute soft tissue injury is reviewed in some detail.

Protection and rest — Protection of injured soft tissues (eg, tendons, ligaments) using such implements as casts, splints, braces, and crutches is intended to minimize swelling, pain, and bleeding in the acute setting and to both aid healing and prevent exacerbation of injury by reducing the loads placed on damaged structures. One element of protection is to avoid aggressive ambulation or exercise immediately following injury.

Some animal studies show that protection (unloading the tissue) during acute stages after soft tissue injury helps to restore the strength and morphological characteristics of collagen tissue [5-7]. Mechanical loading increases gene expression for proteins involved in tissue (eg, tendon) healing, and the absence of appropriate loading may reduce such expression.

While protection is helpful during the early stages of acute soft tissue injuries, prolonged protection can be harmful. Some animal studies report that two to three weeks of unloading (eg, nonweightbearing) results in undesirable changes to biomechanics and tissue morphology, although such changes are generally reversible [8-11]. The clinician should keep in mind the importance of making a safe transition from protection to tissue loading as healing proceeds [3,4].

Immobilization versus early mobilization — Evidence suggests that functional treatment (ie, early mobilization with external support as needed) is more effective than cast immobilization for acute, nonsevere ankle sprains and comparable injuries. If strict immobilization is used to treat more severe sprains, it should be used for no more than 10 days [12]. While immobilization allows injured ligaments and tendons to regenerate, it can adversely affect surrounding structures, possibly leading to joint stiffness, degenerative changes in articular cartilage, osteopenia, muscle atrophy, and loss of strength [13-16]. For this reason, it is important that periods of immobilization be as short as possible [4].

A systematic review found that immobilization for up to 10 days can be helpful for reducing swelling and pain, but more than four weeks can adversely affect outcomes [17].

Optimal loading — Optimal loading is defined as the load applied to structures following injury that maximizes physiologic adaptation, such as increased tensile strength and collagen reorganization.

At the initial evaluation of an injured patient, the clinician should perform a functional assessment that allows them to advise the patient of the optimal load for starting their recovery. As an example, for a patient with quadriceps tendinopathy, the clinician might use the following activities in succession to assess function and associated symptoms and prescribe appropriate activity based on the results:

●Walk

●Slow jog

●Stationary cycling with no added resistance

●Straight leg raise

●Short-arc quad extension without added weight

●Partial squat

Patients able to perform all the exercises would start with a more advanced rehabilitation program entailing greater loads, while those unable to perform one or more of them without undue pain would start with a more basic program.

When determining appropriate loading following injury, the clinician must account for the location and severity of the injury and the risk of exacerbation with excessive loading. Key determinations for appropriate loading include:

●Selection of exercises – Isometric, neuromuscular, and proprioceptive exercises are often used during the acute stages to improve mobility and function and minimize strength loss.

●Frequency and duration of each exercise – This depends on the severity of injury and other factors.

●Magnitude and intensity of resistance (if any is used) – Pain, as well as performance, is used to help determine magnitude and intensity; excessive pain should be avoided to ensure optimal repair. However, mild pain (<3/10 on Likert scale) when performing exercises is generally acceptable.

Patients must be taught how to perform exercises safely.

Mechanical loading of healing soft tissues affects the neuromuscular system and influences the expression of important genes involved in protein synthesis [3,18]. The best time to introduce such loading remains a subject of research, but clinical consensus is to start these as early as possible based on a functional assessment.

Taping — Taping is among the most frequently used interventions for treatment and prevention of soft tissue injury [19]. Immediately following such injury, taping can provide pain relief by preventing excessive movement. In clinical practice, taping makes the most sense for stabilizing and protecting smaller joints such as the fingers, wrist, or ankle and for compression of muscle injuries. During early healing, the amount of tape, and thus the degree of support, can be reduced, allowing for a gradual, controlled reintroduction of loads over days to weeks [4].

In clinical practice, taping is applied more widely than the evidence suggests, with acute ankle injuries, patellofemoral pain, lateral elbow tendinopathy, and shoulder pain being the most common conditions. In addition to available evidence, clinicians should consider the diagnosis, setting (eg, competition, acute care, rehabilitation), and patient preferences and expectations when determining whether and how to use taping.

Patellar taping, often used in clinical practice to treat patients with anterior knee pain, can help to maintain tracking of the patella within the patellar groove [20]. Overall, evidence suggests that patellar taping serves as a useful adjunct to stretch the lateral soft tissues, balance quadriceps firing, and strengthen the vastus medialis [21].

Various types of tape (eg, standard athletic tape, kinesiotape) and application techniques have been used to treat acute soft tissue injuries. However, it is difficult to draw valid conclusions about possible benefit as there is little high-quality evidence about tape in the treatment of acute soft tissue injuries and because the duration of effect is limited. As an example of the latter phenomenon, an observational study of 15 young male athletes reported that tape intended to restrict ankle motion lost much of its effectiveness after 30 minutes of training [22]. A review of taping reported mixed results for rigid taping of ankle sprains (grade I, II, III) and unfavorable results for kinesiotape [23]. A 2012 meta-analysis of 10 controlled studies (only one involving injured patients) of kinesiotape found little quality evidence supporting its effectiveness, and positive outcomes were of questionable clinical significance [24].

Bracing — The highest-quality prevention research has focused on the effects of rigid or semirigid prefabricated braces on ankle sprain. Few studies have investigated bracing for other injuries. Moreover, effectiveness likely varies by injury. The appropriate use of braces for specific injuries is discussed separately. (See "Ankle sprain in adults: Management" and "Medial (tibial) collateral ligament injury of the knee", section on 'Prophylactic bracing' and "Anterior cruciate ligament injury" and "Lateral collateral ligament injury and related posterolateral corner injuries of the knee", section on 'Prevention'.)

Ice

Rationale and general approach — In clinical practice, ice is part of the initial care for all soft tissue musculoskeletal injuries, assuming there are no explicit contraindications (see 'Precautions' below). This is based on its effectiveness in reducing swelling and assisting with analgesia. Ice lowers tissue temperature, thereby constricting blood vessels and restricting blood flow to the injured area, which in turn reduces swelling, inflammation, and local metabolism [3,25,26].

For acute, soft tissue musculoskeletal injury, we generally apply ice for approximately 15 minutes every one to two hours. We typically use prefabricated ice packs and apply them with a compression wrap. Ice can be applied for the first one to two days depending on its effectiveness in providing symptom relief and the extent and severity of the injury. For athletes receiving ice treatment on the sideline for a minor injury during play, we suggest a short period of ice application (5 to 10 minutes), followed by a brief warmup, prior to return to activity [3].

This approach is supported by guidelines published by the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) [3]. By limiting the time between applications, reductions in deep tissue (muscle) temperature are maximized while risks (eg, skin frostbite) are minimized. Optimal analgesia is achieved by applying ice for 5- to 15-minute periods. One randomized trial reported that intermittent ice application produced greater reductions in pain after acute soft tissue injury [27].

Individual clinicians may prefer different application methods, but combining ice and compression is common. This can be done by securing an ice pack in place with an elastic wrap or standard tape. Ice compression braces and devices for extremities and joints that use static or circulating ice water are common on sidelines at sporting events and in athletic training rooms. A study comparing the effects of 15-minute ice pack application, ice massage, and cold-water immersion on motor nerve conduction concluded that all three methods were effective in reducing skin temperature and altering sensory conduction (ie, providing hypoalgesia) [28].

Precautions — Clinicians should remain watchful while ice is applied and should refrain from applying it in some circumstances, including the following:

●Patients with a true cold allergy

●Digits affected by Raynaud phenomenon

●Tissues affected by severe peripheral vascular disease that may predispose to skin necrosis

●Open wounds

●Areas with a local infection

Ice should be used with caution when there is a history of frostbite, as affected regions may be sensitive to cold and prolonged, continuous application of ice may damage the skin and soft tissues. (See "Frostbite: Emergency care and prevention".)

The application of ice may cause reductions in nerve conduction velocity, isometric strength, and rate of force production, particularly when applied for longer periods [3]. Reflexes and motor function may also be impaired after icing, possibly making patients more susceptible to injury up to 30 minutes after treatment. These considerations are particularly important for clinicians caring for an acutely injured athlete wishing to return to play after treatment for a minor soft tissue injury. Applying ice for a short period (about 10 minutes) has minimal impact on light exercise, walking, or simple physical therapy exercises. For athletes receiving ice treatment during play, we suggest a short period of ice application, followed by a progressive sideline warmup, prior to return to activity [3].

Evidence — Although a handful of laboratory and small clinical studies have evaluated the effectiveness of ice for treating soft tissue injuries, neither the optimal method for application nor the ideal duration of treatment is known, and no consensus guidelines for treatment with ice are available [29,30]. Different cooling methods achieve different rates of cooling and temperatures. Evidence is limited, and studies focused on skin temperature must be interpreted cautiously as skin temperature does not accurately predict intramuscular temperature.

One useful and relatively well-studied form of ice application involves crushed ice placed in a plastic bag, which maintains a temperature close to 0°C throughout its application [3]. A 2001 systematic review suggests applying melting ice water through a wet towel for repeated 10-minute periods [31]. The authors of the review reported that intermittent application allowed muscle temperature to be kept low while skin temperature returned to normal.

A comparative study involving 12 healthy participants compared the effectiveness of ice cubes, crushed ice, and wetted ice (ice with water) applied for 20 minutes and found that wet ice produced the largest reductions in surface temperature while ice cubes and wet ice were superior to crushed ice in reducing intramuscular temperature [32]. Assessing the temperature produced with gel-based cold packs is more challenging and not well described.

According to laboratory studies, ice application reduces skin temperature to below 13°C after 5 to 15 minutes, which is the generally accepted threshold for local anesthesia. However, it is difficult to achieve this temperature in clinical practice. Clinical studies report that intense cooling results in underlying muscle and tendon tissue temperatures of 21 to 25°C [33]. In lean athletes, the lowest muscle surface temperature (measured 1 cm deep to the subdermal adipose tissue) achieved is 21°C [3,34]. Based on these data, the metabolic effects of ice application may be limited for injuries involving deeper tissue or in patients with abundant adipose tissue overlying the site of injury [4]. External compression with an elastic wrap increases the effectiveness of ice in reducing tissue temperatures in such cases (eg, deep tissue injury, large amounts of adipose tissue) [35,36].

Intermittent removal of ice allows skin to rewarm, thereby avoiding excessive reduction in skin or nerve temperature and preventing tissue damage [3,4]. To avoid potential side effects of prolonged continuous ice application while maximizing therapeutic effects, the safest approach may be to use regular intermittent applications and increase the interval between them to allow skin temperatures to rewarm.

Case reports of foot drop following ice application underscore the risk of transient injury to superficial nerves such as the common peroneal and the need for caution at the locations of such nerves (eg, lateral knee, medial elbow). Similar to local ice application, immersion in cold water produces therapeutic effects and is associated with a decrease in conduction along motor nerves [28].

One scientific report states that 10 minutes of ice application had no adverse effect on muscle response time or muscle response amplitude in participants with a simulated lateral ankle sprain [37]. In a small randomized trial, application of an ice-cold spray to the ankle did not affect dynamic joint stability in healthy athletes [38]. Participants with a previous ankle injury showed a significant reduction in dynamic stability, but factors such as fatigue may have contributed to this result.

Compression — A compression bandage is commonly applied immediately following an acute soft tissue injury and generally maintained for the first 72 hours or longer depending on the severity of the injury. Properly applied compression provides a degree of support and protection and helps to ensure uniform pressure in the tissues, thereby reducing the accumulation of fluid and consequent discomfort.

The elastic bandages commonly used for this purpose are inexpensive, versatile (a range of bandage widths and lengths are available), and effective (figure 1 and picture 1). Although rarely measured, a light to moderate pressure of 15 to 35 mmHg is suggested. Excessive compression may restrict blood flow and cause discomfort. Elastic bandages are applied starting at the distal end of an injured extremity and gradually advanced towards the more proximal aspect [4,39]. Each successive layer of the bandage should overlap the underlying layer by about half its width. Commercial compression sleeves with variable degrees of compression have become common products used in sport (picture 2 and picture 3 and picture 4).

A combination of compression and ice can be applied by wrapping ice packs with such an elastic bandage. In a randomized trial involving 14 college students, application of an ice bag using an elastic bandage was more effective in reducing tissue temperature than alternative wraps [35]. While few high-quality studies of compression bandages have been performed, a systematic review noted that compression is an effective treatment for ankle sprains, reducing swelling and discomfort [12,40]. In a related systematic review, compression garments were reported to be effective for improving recovery from muscle damage following intense training and competition [41]. (See "Ankle sprain in adults: Management".)

Elevation — Elevation refers to raising of the injured tissue (usually the injured limb) above the level of the heart in the case of injuries of the upper extremity and above the pelvis with injuries of the lower extremity. This decreases hydrostatic pressure, thereby reducing the accumulation of interstitial fluid and aiding healing [4,42]. To achieve elevation, the patient can use a sling for injuries of the upper extremities and place lower extremities on a chair and pillows [4]. We suggest elevating the injured limb as much as possible during the initial 72 hours after acute injury.

Rapid return of the limb to a gravity-dependent position allows fluid to reaccumulate in the limb and increases pain, a process termed the "rebound effect" [3,39]. In an observational study of 12 patients with an acute ankle sprain, elevation produced a substantial reduction in swelling around the joint [43]. However, swelling returned five minutes after the injured extremity was immediately returned to a dependent position.

A randomized-crossover study noted that elevation during 30 minutes of cryotherapy treatment did not alter tissue temperature [44]. Any benefits from elevation appear to be independent of temperature changes.

ANALGESIC MEDICATIONS — Physicians who prescribe medications for the treatment of musculoskeletal injury in professional and elite athletes must comply with the anti-doping rules for the sport in which the athlete is involved. The World Anti-Doping Agency (WADA) publishes an updated Prohibited List each year, and more information on prohibited drugs in Australia, Canada, Japan, New Zealand, Switzerland, the United Kingdom, and the United States can be found in the Global Drug Reference Online (Global DRO) [45,46]. These issues are discussed in detail separately. (See "Prescription and non-prescription medications permitted for performance enhancement" and "Prohibited non-hormonal performance-enhancing drugs in sport".)

Oral and topical analgesics — Analgesics may be prescribed to relieve pain following acute injury in conjunction with ice and compression [4].

Paracetamol (acetaminophen) — Paracetamol (acetaminophen) is a common first-line analgesic medication for acute and chronic sports injuries. Paracetamol has antipyretic effects but does not affect the inflammatory process. Adult oral doses are 500 to 1000 mg every four to six hours (maximum daily dose 4 g). While the analgesic effects of paracetamol are comparable to nonsteroidal antiinflammatory drugs (NSAIDs) over two to three days and beyond, paracetamol has a better side effect profile [4,47,48]. However, paracetamol should be used with caution in patients with advanced hepatic disease, malnutrition, or alcohol use disorder. High doses of paracetamol are hepatotoxic and may be fatal in overdose. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation".)

Nonsteroidal antiinflammatory drugs

General use — NSAIDs have analgesic and antiinflammatory properties effected through inhibition of cyclooxygenase (COX) and are effective pain medications for acute musculoskeletal injury. The mechanism of action, pharmacology, clinical utility, and adverse effects of NSAIDs are all reviewed in detail separately. (See "NSAIDs: Therapeutic use and variability of response in adults" and "NSAIDs (including aspirin): Pharmacology and mechanism of action" and "Nonselective NSAIDs: Overview of adverse effects" and "Overview of COX-2 selective NSAIDs".)

For acute soft tissue injury, we suggest using the selected NSAID at the standard therapeutic dose for three to five days depending on the degree of pain. As an example, dosing for ibuprofen would be 200 to 400 mg every four to six hours as needed or 600 to 800 mg every six to eight hours as needed (maximum daily dose 3.2 g). When used for a brief, circumscribed period (eg, five to seven days), oral NSAID therapy is generally safe, but it is best to avoid extended use and to maximize the use of other interventions (eg, protection, ice, compression, elevation) that reduce the need for such medication [47].

Use for prophylaxis — Despite little evidence of effectiveness for this purpose, NSAIDs are widely used by athletes for prophylaxis. During the Olympic Games, World Cup, and other high-level competitive sport events, NSAIDs are the drugs used most often prior to competition to reduce discomfort and postexercise soreness. Over 92 percent of Italian professional footballers (soccer players) and one-half of players participating in the 2002, 2006, and 2010 World Cups used NSAIDs for this purpose [49].

Prophylactic use of NSAIDs should not be encouraged, as there is no compelling evidence that it reduces delayed-onset muscle soreness (DOMS) or injury risk [50,51]. As an example, a randomized trial in male distance runners found no evidence that ibuprofen reduced pain or muscle damage or improved performance [50]. Moreover, heavy NSAID use can adversely affect the cardiovascular, renal, and gastrointestinal systems [52-57].

Adverse effects — The most common side effects of NSAIDs are gastrointestinal, including epigastric pain, nausea, and reflux. To reduce such effects, lower doses can be used, and medication can be taken with food or in combination with an H2 antagonist (eg, ranitidine) or, if necessary, with a proton pump inhibitor. (See "Nonselective NSAIDs: Overview of adverse effects".)

Clinicians should be cautious when prescribing NSAIDs to iron-deficient patients, as occult gastrointestinal bleeding may contribute to iron depletion. COX-2 inhibitors and some nonselective NSAIDs (eg, diclofenac) are associated with an increased risk of thrombotic events and are contraindicated in ischemic heart and cerebrovascular disease. These medications should be used with caution in patients with risk factors for cardiovascular events. (See "NSAIDs: Adverse cardiovascular effects".)

There is evidence that NSAIDs can modulate protein metabolism in tissues through inhibition of COX activity, which may explain the reduced anabolic response to exercise [58]. NSAIDs may interfere with muscle hypertrophy and strength gains in response to chronic strength training in young adults [58]. Some animal studies suggest that NSAIDs, both nonselective and COX-2 selective, may impair the healing of tendon, ligament, and bone injuries. This is discussed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Healing of musculoskeletal injury'.)

Topical NSAIDs — Topical NSAIDs are effective for providing pain relief at the site where they are applied and are suitable for the symptomatic treatment of acute, soft tissue musculoskeletal injury, including ligament sprains, tendon and muscle strains, and overuse injuries [59-61]. Applying the medication topically decreases systemic exposure, potentially making it safer than oral NSAIDs [62]. Topical NSAIDs are available as creams, gels, sprays, and prolonged-release patches [63]. Dosing for topical NSAIDs varies by preparation and the size of the joint or injured region. The frequency is typically two to four times daily for 7 to 10 days.

According to a 2010 systematic review of 47 studies involving 3455 subjects, topical diclofenac, ibuprofen, ketoprofen, and piroxicam were more effective in relieving acute musculoskeletal pain than placebo [62]. Few systemic side effects or discontinuations due to side effects have been reported [59,60,64].

Topical NSAIDs are best avoided in the presence of a compromised skin barrier or open wound [65]. Use of topical NSAIDs varies widely among countries and clinicians. This may be due in part to their effectiveness being attributed largely or in part to the placebo effect.

Codeine — Codeine is a potent opioid analgesic sometimes prescribed to athletes for more severe, acute injuries. Potential side effects include nausea, dizziness, and constipation, which may limit its long-term use. Analgesic effects are comparable to NSAIDs at four to seven days [4,48]. Clinicians must be aware of the potential for opioid dependence. (See "Management of acute pain in opioid naïve adults in the ambulatory setting".)

Injected therapies

Glucocorticoids — Glucocorticoid injection is best avoided in the following circumstances [66]:

●Immediately following (within first few days) injury to muscles, tendons, or ligaments

●Immediately prior to a competitive sporting event

●Surgery to repair the injury is planned

●In the presence of an infection

Glucocorticoids are useful in the management of many subacute and chronic muscle and tendon injuries and select acute soft tissue injuries (eg, bursitis). Such use is discussed separately in the UpToDate topics devoted to these injuries. (See "Overview of the management of overuse (persistent) tendinopathy" and "Rotator cuff tendinopathy".)

Glucocorticoids are strong antiinflammatory agents that reduce vascular permeability and leukocyte activation and block inflammatory mediators. Physicians often use glucocorticoid injection to relieve pain and inflammation, thereby helping patients to regain normal movement and perform therapeutic exercises once the acute phase of injury has passed. The many possible adverse effects of long-term glucocorticoid treatment are reviewed separately. (See "Major adverse effects of systemic glucocorticoids" and "Joint aspiration or injection in adults: Complications".)

Immediately following tendon injury, injection of glucocorticoid is not recommended, as it inhibits collagen synthesis, which adversely affects tendon healing. There is limited evidence that single injections of glucocorticoid are not myotoxic. However, when such injections are combined with local anesthetics, myotoxic effects may be observed [67].

Local anesthetics — Outside of analgesia for procedures (eg, skin suturing), local injection of anesthetics into sites of acute muscle, tendon, or ligament injury should be avoided. Limited evidence suggests that commonly used local anesthetics (ie, amino esters, amino amides) are toxic to these tissues and impair healing [67,68]. (See "Clinical use of local anesthetics in anesthesia" and "Subcutaneous infiltration of local anesthetics".)

Unproven therapies

●Platelet-rich plasma – Platelet-rich plasma (PRP) is a product obtained by centrifuging autologous whole blood to isolate a preparation with a high platelet content. The role of PRP in the treatment of soft tissue injuries is discussed separately. (See "Biologic therapies for tendon and muscle injury".)

●Actovegin – Actovegin is a deproteinized calf serum ultrafiltrate reported to contain trace elements, amino acids, electrolytes, carbohydrate, and fat metabolites; however, the active ingredients have not been identified. The drug purportedly has antioxidant, antiapoptotic, and macrophage-modulating properties in vitro. Limited studies suggest that actovegin may modulate inflammation, but no high-quality clinical studies support its use for muscle injuries [67,69].

●Homeopathic injections – Traumeel is a homeopathic drug available as a topical gel, ointment, and injection that contains arnica, belladonna, calendula, heparin, and echinacea and purportedly has antioxidant and antiinflammatory effects. There are no high-quality studies of the drug's efficacy for treatment of muscle injuries or its adverse effects.

OTHER POSSIBLE INTERVENTIONS

Interventions to avoid acutely — During the first few days following an acute injury involving muscles, tendons, or ligaments, the following interventions and activities should be avoided [4,70]:

●Heat – Patients should avoid hot baths, showers, or saunas; applying heat packs; or having a heat rub or massage. (See 'Heat' below.)

●Alcohol – Patients should avoid consuming more than small amounts of alcohol (ie, no more than one drink daily) as it may mask pain and obscure the severity of injury, thereby increasing the risk of exacerbating damage. Excessive alcohol consumption may impair protein synthesis, tissue healing, muscle function, and other metabolic processes, thereby hindering recovery [71]. (See "Overview of the risks and benefits of alcohol consumption".)

●Exercise – Until sufficient healing has occurred, allowing for injured tissues to be stressed, patients should avoid exercise of moderate or greater intensity or any activity that causes pain at the injury site or that might cause further damage.

●Massage or comparable soft tissue therapy – Patients should avoid massage or any form of vigorous soft tissue therapy (eg, fascial release, Graston technique) involving injured tissue for the first 24 to 48 hours as this may cause further bleeding and swelling at the injury site [4].

Heat — Neither heat nor contrast baths (alternating hot and cold baths) are recommended following acute soft tissue injury, as they may increase blood flow at the site, leading to an increase in swelling and pain. While evidence is limited, this proscription is supported by the results of several small studies. As an example, in a trial of 30 patients comparing the effect of cold, heat, and contrast baths, cold therapy was most effective at reducing edema during days three through five following ankle sprain [72].

Low back pain may be an exception to this proscription and is discussed separately. (See "Treatment of acute low back pain", section on 'Nonpharmacologic therapies'.)

While contrast baths may be helpful for subacute injuries, sympathetic-mediated pain, and stiff joints, they are not recommended in the acute setting [4,73].

Manual treatment — Manual treatment or therapy is defined by hands-on interventions that actively manipulate tissues. Such treatments may include:

●Soft tissue manipulation (eg, massage, myofascial release, Graston technique)

●Joint mobilization and manipulation

●Nerve mobilization and neurodynamic methods

While of possible benefit for subacute and chronic musculoskeletal injuries, such therapies are best avoided during the first few days following an acute injury. Manual therapies involve a certain level of force and have the potential to further damage acutely injured tissue. Manual therapies usually target specific tissues or structures, such as stiff joints, tight muscles, pinched nerves, or fascial adhesions in connective tissue, and provide relief through changes in pain sensation, muscle activation, and mobility.

While some clinicians or therapists may use manual techniques as part of the treatment of specific acute, soft tissue injuries, there is no high-quality evidence supporting the use of massage, tissue mobilization, or manual drainage techniques for such injury.

Stretching — Stretching as part of the therapy for specific soft tissue injuries is discussed in the UpToDate topics devoted to these injuries; stretching is generally not part of the management of acute (<72 hours) soft tissue, musculoskeletal injury. Static or dynamic stretching, sometimes in combination with other soft tissue manipulation techniques, is often used to help restore mobility around an injured or affected joint during rehabilitation. Stretching is part of the therapy for muscle contusion, myositis ossificans, and exercise-associated muscle cramps [4,74]. (See "Quadriceps muscle and tendon injuries", section on 'Myositis ossificans'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues in muscle and tendon injury diagnosis and management".)

SUMMARY AND RECOMMENDATIONS

●Initial management – Basic initial management of acute, soft tissue musculoskeletal injuries consists of the interventions below (table 1), which are supported by limited evidence (see 'Approach to initial management' above):

•Protection and rest

•Ice

•Compression

•Elevation

•Analgesia

●Protection and rest – Immobilization and reduction or elimination of the loads placed on injured tissues is intended to minimize swelling, pain, and bleeding; aid healing; and prevent exacerbation of injury. This may be accomplished with devices such as casts, splints, braces, compression dressings, tape, and crutches; and by modifying load-bearing and activity demands. Mobility should be reintroduced as early as possible to prevent joint stiffness and muscle atrophy. (See 'Protection and rest' above.)

●Ice – Ice reduces swelling and assists analgesia, and its application is part of the initial care for all soft tissue musculoskeletal injuries, assuming there are no explicit contraindications (eg, cold allergy, tissue affected by severe peripheral vascular disease). (See 'Rationale and general approach' above and 'Precautions' above.)

Ice may be used as follows:

•For most injuries, apply for approximately 15 minutes every one to two hours during the first one to two days. We generally use prefabricated ice packs and apply them with a compression wrap.

•For athletes being treated with ice on the sideline for a minor injury during play, we suggest a short period of ice application (5 to 10 minutes) followed by a brief warmup prior to return to activity.

●Compression – A compression bandage is commonly applied immediately following an acute soft tissue injury and generally maintained for the first 72 hours or longer depending on the severity of the injury. Properly applied compression provides some support and protection and helps to ensure uniform pressure in tissues, thereby reducing fluid accumulation and increasing comfort. (See 'Compression' above.)

●Elevation – Elevation consists of raising the injured tissue (usually the injured limb) above the level of the heart for injuries of the upper extremity and above the pelvis for injuries of the lower extremity. This decreases hydrostatic pressure, thereby reducing the accumulation of interstitial fluid and aiding healing. (See 'Elevation' above.)

●Analgesic medications – Pain associated with most soft tissue musculoskeletal injuries can be managed adequately with basic interventions (eg, ice, elevation) and over-the-counter pain medications (eg, acetaminophen, nonsteroidal antiinflammatory drugs [NSAIDs]). These and other medications are discussed in the text. (See 'Analgesic medications' above.)