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Replacing PRICE with PRINCESS
Recover Faster from Soft Tissue Injuries with PRINCESS

Heal faster with PRINCESS.
Heal faster with PRINCESS.

For years, coaches and athletes have been taught simple phrases to deal with soft tissue injuries like a sprained ankle. It started as ICE, evolved into RICE and was updated to PRICE. Research over the last 20 years has shown that the acronym guiding the management of those injuries desperately needs to be updated. Here's what it currently stands for.

PROTECT the injured area from further trauma. REST for the first 24 hours so swelling can go down and your body can start healing. ICE the affected area to reduce pain and swelling. COMPRESSION to stop hemorrhage and minimize swelling. ELEVATION to lower the pressure in local blood vessels and limit bleeding.

It's simple to remember, but one part is wrong, and it's missing four critical steps. Here's what the most current research shows we should do now.

One, the step you should skip is ice. For decades putting a cold pack on the injury was done to reduce pain and swelling. A familiar scene on television was the injured person using a bag of frozen vegetables after twisting their ankle. But when researchers put it to the test, they found that cooling the injured area slowed down how quickly muscles healed.

Here's why icing doesn't work. Soft tissue injuries must go through three stages of healing; inflammation, repair and remodeling. If you don't experience the first, you can't get to the second or third. Since icing a soft tissue injury reduces inflammation, you're slowing down how fast you can heal.

You need to IMMOBILIZE the area until a medical professional can evaluate the damage. Replacing ICE with IMMOBILIZE until examined is the first change I would make.

Two, you should say NO to anti-inflammatory drugs. Inflammation is part of the healing process, so you're delaying recovery if you take medication to reduce inflammation. Nursing organizations now recommend acetaminophen for mild to moderate pain relief rather than anti-inflammatories.

Three, you've got to make sure compression bandages are applied appropriately. You want to avoid non-elastic dressings that don't flex. They can reduce the blood flow too much, potentially causing ischemia. Use elastic bandages that stay in place but that can still expand and contract with your muscles.

Four, several studies have shown that exercise after an injury can restore mobility, reduce the risk of future injuries and speed healing. We would suggest remembering it as STRENGTH training to speed recovery. Studies show that LIGHT loading of the injured area as soon as 48 hours after injury is beneficial and appropriate. According to researchers, "Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions."

Five, SLEEP. The hormone that regulates inflammation is called cortisol, and it's lowest when you're sleeping. Rest also increases growth hormone, which helps speed healing by increasing protein synthesis.

Princess Acronym

Put it all together, and what do you get? P.R.I.N.C.E.S.S. That's right; you read it here FIRST(because we came up with it). You should give soft-tissue injuries the PRINCESS treatment.

  • PROTECT the injured area from further trauma.
  • REST for the first 24 hours so swelling can go down and your body can start healing.
  • IMMOBILIZE the area until a medical professional can examine and evaluate the damage.
  • NO anti-inflammatories that might slow recovery.
  • COMPRESSION to stop hemorrhage and minimize swelling.
  • ELEVATION for short periods to lower the pressure in local blood vessels and limit bleeding.
  • STRENGTH training with light loading of the injured area and;
  • SLEEP to speed recovery.

The PRINCESS acronym doesn't explicitly cover two things. The first is the importance of educating patients about each of the steps. The second is "addressing psychosocial factors to enhance recovery." In other words, help the patient feel confident and positive about their chances for recovery.

We don't think there need to be special instructions for either of those steps. If your physician isn't fully informing you of what's going on about every procedure and making you feel optimistic about their recommended treatment, perhaps you need a new doctor.

Update: Anti-inflammatories may be a cause of chronic pain.

When someone has an injury like a sprained ankle or pulled muscle, the typical reaction is to use anti-inflammatory painkillers like aspirin, ibuprofen, or dexamethasone. But as we've noted in this article, reducing inflammation can hurt long-term healing.

Now new studies show that not only do anti-inflammatories slow down healing, but they might also contribute to long-term chronic pain. Researchers said they found "a significantly elevated risk for chronic pain with NSAID usage." Plus, "higher percentages of neutrophils at the acute pain state protected against chronic pain development." *1

It's a revolutionary idea being examined with a much larger clinical trial. The early study is below, and we'll follow up as more info comes out.

Neutrophils may be one of the keys. "Neutrophils are the most abundant leukocytes in the circulation, and have been regarded as first line of defense in the innate arm of the immune system. They capture and destroy invading microorganisms, through phagocytosis and intracellular degradation, release of granules, and formation of neutrophil extracellular traps after detecting pathogens. Neutrophils also participate as mediators of inflammation." *2

*1 Acute inflammatory response via neutrophil activation protects against the development of chronic pain

Marc Parisien, Lucas V. Lima, Concetta Dagostino, Nehme El-Hachem, Gillian L. Drury,, Audrey V. Grant, Jonathan Huising, Vivek Verma, Carolina B. Meloto, Jaqueline R. Silva, Gabrielle G. S. Dutra, Teodora Markova, Hong Dang, Philippe A. Tessier, Gary D. Slade, Andrea G. Nackley, Nader Ghasemlou, Jeffrey S. Mogil, Massimo Allegri, Luda Diatchenko
SCIENCE TRANSLATIONAL MEDICINE, 11 May 2022 • Vol 14, Issue 644 • DOI: 10.1126/scitranslmed.abj9954

Click Here for the Study


*2 Neutrophil: A Cell with Many Roles in Inflammation or Several Cell Types?

Carlos Rosales
frontiers in Physiology, 2018 Feb 20. doi: 10.3389/fphys.2018.00113

Click Here for the Study


Additional Reference Links:

What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?

Michel P.J van den Bekerom, MD, Peter A.A Struijs, MD, PhD, Leendert Blankevoort, PhD, Lieke Welling, MD, PhD, C. Niek van Dijk, MD, PhD, and Gino M.M.J Kerkhoffs, MD, PhD
JAT Journal of Athletic Training, 2012 Aug; 47(4): 435–443. doi: 10.4085/1062-6050-47.4.14

Click Here for the Study


Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

Gwendolyn Vuurberg, Alexander Hoorntje, Lauren M Wink, Brent F W van der Doelen, Michel P van den Bekerom, Rienk Dekker, C Niek van Dijk, Rover Krips, Masja C M Loogman, Milan L Ridderikhof, Frank F Smithuis, Sjoerd A S Stufkens, Evert A L M Verhagen, Rob A de Bie, Gino M M J Kerkhoffs
BMJ Journals - British Journal of Sports Medicine, Received 26 May 2017, Revised 11 January 2018, Accepted 2 February 2018, Published Online First 7 March 2018

Click Here for the Study


The Role of Nonsteroidal Anti-Inflammatory Drugs in the Treatment of Acute Soft Tissue Injuries

Jay Hertel, MEd, ATC
JAT Journal of Athletic Training, 1997 Oct-Dec; 32(4): 350–358. PMCID: PMC1320354

Click Here for the Study


Evidence on NSAID use in soft tissue injuries

Kyle Williams
Nursing Times, 01 NOVEMBER, 2012

Click Here for the Study


Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial

Chris M Bleakley, research associate, Seán R O’Connor, research assistant, Mark A Tully, research fellow, Laurence G Rocke, consultant in emergency medicine, Domhnall C MacAuley, visiting professor of health sciences, Ian Bradbury, assistant director of statistics, Stephen Keegan, statistician, Suzanne M McDonough, professor of health and rehabilitation sciences
the bmj, (Published 10 May 2010) BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1964

Click Here for the Study


Soft tissue injuries simply need PEACE & LOVE

Blaise Dubois @blaisedubois and Jean-Francois Esculier @JFEsculier
British Journal of Sports Medicine, Posted on April 26, 2019 by BMJ

Click Here for the Study

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Updated 5/17/2022