To make the whole thing more "complicated", a new set of principles was proposed in 2019 for use as first aid for acute injury (acute soft tissue injuries). The acronym PEACE & LOVE is an updated version that also pays more attention to the way forward after the acute phase, which lasts only a few days. In this article we will go through the principles of PEACE & LOVE, using a sprained ankle as an example.
Acute phase
Immediately after the sprain there is often considerable pain, a lot of swelling and perhaps some discolouration over the foot. You are now in the acute phase, which lasts roughly 1-3 days, and during this period we let peace (PEACE) guide the approach. The principles we use are as follows:
P rotect (Protect)
Offload the ankle for 1-3 days after the injury to protect the area. This can involve using crutches and adjusting your activity level, but take care that crutches are not used for a long time. In general, you should avoid activity and movement that provokes the ankle to a great extent. As soon as movement and activity can be done with acceptable pain, it should be done. Examples are standing or walking on the foot.
E levate (Elevate)
Raise the ankle above heart level to make it easier for accumulated fluid to return from the site of injury. This measure is not well documented, but it has no potential negative consequences either. So feel free to sit with your ankle raised in situations where you are at rest anyway, for example while watching TV.
A void (Avoid)
Avoid anti-inflammatory medication (NSAIDs) and icing the ankle, as this can potentially delay and disrupt the healing process. We do not want to disrupt the natural inflammatory process that takes place, as it is important for complete healing. This is one of the points that differs most from earlier views on first aid for acute injury. Ice has been part of the RICE, PRICE and POLICE acronyms (I for Ice).
C ompress (Compression)
Apply compression to the ankle to stop bleeding from the injured tissue and to minimise unnecessary fluid accumulation. The compression should be firm, but it is desirable to be able to move the ankle joint. The compression can be worn around the clock in the acute phase, and can be used for as long as there is still considerable swelling.
E ducate (Educate)
See a physiotherapist or other healthcare professional for an assessment of the injury, suggestions for how to proceed, and more general information about the condition. The more knowledge you have about the condition, what it takes to get better, and what can be expected in terms of duration, the better.
The ankle has calmed down a little. What do we do now?
When the acute phase is over and the ankle has had a little peace, it is time to start work to restore function in the ankle so that you can return to the activities you want. Now it is time to give the ankle a little love (LOVE), and the principles we use are as follows:
L oad (Load)
The ankle should be loaded as soon as possible and normal everyday activities should be resumed as soon as the pain allows. Bone, muscle and tendon tissue depend on loading to maintain strength, and loading is also what the tissue needs to build itself up stronger again after an injury. We want to find the level and amount of loading that does not cause increased pain. Loading will also promote blood flow and contribute to a reduction in swelling, as we depend on muscle use to pump fluid up and back towards the heart.
O ptimism (Optimism)
The brain has an important role in rehabilitation, as psychological factors have a great influence on pain and limitations, both in the early phase and later in the course. The factors can in fact matter more than the actual degree of injury. It is important to be realistic about the time frame, but at the same time to be optimistic. The ankle can become completely fine again despite extensive injuries.
V ascularisation (Vascularisation)
Activity that promotes blood flow and blood supply to the injured area can be a good addition to rehabilitation. Find a form of activity that does not provoke the ankle but still involves the leg, for example cycling. The focus should be on duration rather than load, and try to get your heart rate up. This kind of exercise can also have a general pain-relieving effect.
E xercise (Exercise)
The ankle depends on specific rehabilitation exercises to restore normal mobility, strength and joint control. In the early phase it is important to avoid severe pain during exercise to allow healing. Gradually we use pain as a guide when adapting the exercise further. Pain during, after and the day after exercise gives valuable information about how well the exercise has been tolerated and whether we can challenge further. A physiotherapist can help you with this part of the rehabilitation and will assess what needs to be worked on. An exercise programme is then created with specific exercises intended to address the deficits you have.
For you who are going back to sport
When the time comes to return to sport, there are a number of things to consider. First, it is important that the specific rehabilitation has gradually come close to the demands of the sport in question. Furthermore, you should consider whether the stability of the ankle is satisfactory, and you should assess strength, mobility, fatigability and so on. Perhaps most important of all is to consider whether you, who have sprained your ankle, trust your ankle again and believe that this is going to be fine.
Even if all these points are in place and you feel ready to return, it is wise to draw up a plan for gradually building up the sporting activity. It can begin with taking part in team training where you avoid contact play, and you can, for example, limit the number of minutes played when it becomes relevant to play matches again. The use of tape or an ankle support can in many cases be necessary for a longer period after the sprain.
Summary
Immediately after an ankle sprain it can be important to offload the injured ankle and begin first aid for acute injury to reduce the swelling. Crutches can be used in the first few days, but they should not be used long-term. Measures to reduce swelling can continue for as long as there is considerable swelling. Avoid using ice and anti-inflammatory medication.
As soon as possible it is important to resume normal loading of the ankle, and to return to normal everyday activities as soon as the pain allows. After the acute phase you should get started with specific rehabilitation of the ankle to regain normal function and, further along the course, to prevent new sprains. Try to stay optimistic: even though it can take a long time, it is possible to get the ankle well again and return to sport at a high level. Good first aid for acute injury can have a considerable effect on how long the problems last after the injury.
Our practitioners have good experience with first aid for acute injury (PEACE & LOVE).
References
- Dubois B, Esculier JSoft-tissue injuries simply need PEACE and LOVE British Journal of Sports Medicine 2020; 54: 72-73.
- Vuurberg G, Hoorntje A, Wink LM, et al Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline British Journal of Sports Medicine 2018; 52: 956.
- Khan KM, Scott AMechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair British Journal of Sports Medicine 2009; 43: 247-252.
- Elise Duchesne, Sébastien S. Dufresne, Nicolas A. Dumont, Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic, Physical Therapy, Volume 97, Issue 8, August 2017, Pages 807–817, https://doi.org/10.1093/ptj/pzx056
- https://www.physio-network.com/blog/ankle-sprain-research/
- https://www.physio-network.com/blog/ice-for-acute-injury/