Advertisement

Should Sports Injuries and Surgeries Be “POLICED”?

      As a sports medicine specialist, I have noted trends and patterns, as well as fads, in treating sports medicine patients. Our patients might be more demanding and exacting than the “typical” patient. Athletes want to get better faster. I say sports medicine is “getting a patient better faster sooner, as safe as possible.” We are taught to treat sports injuries with “RICE” (rest, ice, compression, elevation) or “PRICE” (protection, rest, ice, compression, elevation), depending when and on which side of the Atlantic one was trained. In 2012, Bleakley et al (
      • Bleakley C.M.
      • Glasgow P.
      • MacAuley D.C.
      PRICE needs updating, should we call the POLICE?.
      ) coined the acronym “POLICE” for a new approach to treating sports injuries because they believed the British mnemonic “PRICE” needed updating. They removed the “R,” which stood for rest, because evidence showed that with many sports injuries some activity could be maintained and even be beneficial (
      • Bleakley C.M.
      • Glasgow P.
      • MacAuley D.C.
      PRICE needs updating, should we call the POLICE?.
      ). They replaced it with “OL” (optimal loading). Absolute rest just promoted atrophy; cross-training helps to maintain fitness. Protected exercise with various devices such as a pool and antigravity treadmills is allowed at the proper recovery time point (
      • Saxena A.
      • Granot A.
      Use of an anti-gravity treadmill in the rehabilitation of the operated Achilles tendon: a pilot study.
      ). I believe an updated mnemonic based on current research is due: “POLICED” (Table).
      TableSports injuries and surgeries should be “POLICED”
      LetterDescription
      PProtection (ie, bracing, splint, immobilization, tape, compression)
      OLOptimal loading (ie, pool, elliptical, antigravity treadmill, stationary bicycle)
      IIce (ie, cryotherapy with and without compression)
      C“Core” strength (ie, gluteal muscle strengthening)
      EEducation (ie, exercises, biofeedback, coaching); evidenced-based
      DDiet (ie, vitamin D, other factors)
      Sports medicine has been at the forefront of rehabilitation for many aspects of musculoskeletal injury and surgery. Weakness of the gluteal muscles (aka “the core”) has been correlated and associated with many lower extremity conditions (
      • Nadler S.F.
      • Malanga G.A.
      • DePrince M.
      • Stitik T.P.
      • Feinberg J.H.
      The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.
      ). I therefore modified the “C” in POLICE to stand for “core” and combined “compression” with “ice.” Ice or cryotherapy is commonly performed with compression and even elevation; thus, they can share a letter. The “E” for elevation now becomes “education.” Many studies have shown that patient education is key to maintaining a healthy training program and good patient compliance (
      • Woodley B.L.
      • Newsham-West R.J.
      • Baxter G.D.
      Chronic tendinopathy: effectiveness of eccentric exercise.
      ). Again, using research findings, low vitamin D levels have been associated with the occurrence of stress fractures and other health issues such as diabetes, hence the “D” (
      • Miller J.R.
      • Dunn K.W.
      • Ciliberti Jr., L.J.
      • Patel R.D.
      • Swanson B.A.
      Association of vitamin D with stress fractures: a retrospective cohort study.
      ,
      • Stadlmayr A.
      • Aigner E.
      • Huber-Schönauer U.
      • Niederseer D.
      • Zwerina J.
      • Husar-Memmer E.
      • Hohla F.
      • Schett G.
      • Patsch W.
      • Datz C.
      Relations of vitamin D status, gender and type 2 diabetes in middle-aged Caucasians.
      ).
      This is the first ever issue of the Journal dedicated to sports medicine topics. The primary authors (most are Fellows in the American College of Foot and Ankle Surgeons® and all are members of the American Academy of Podiatric Sports Medicine [AAPSM]) specialize in this relatively small, but important, subspecialty that keeps patients doing the activities they love and need to do. We have 3 well-known authors, international AAPSM members and my close friends: Nicola Maffulli, MD, PhD, President of the International Society for Muscle, Ligament and Tendons; Ludger Gerdesmeyer, MD, PhD, past President of the International Society for Musculoskeletal Shockwave Therapy; and Markus Walther, MD, PhD, immediate past President of the German Association for Foot and Ankle Surgery.
      Documenting the outcomes of procedures has become commonplace in medicine. Registries are being created for many orthopedic conditions and “return to play” is becoming an important patient-reported outcome. Our sports medicine patients want to know the outcomes, in particular, can they get back to their sport and how long will it take. I am proud and grateful to the authors and their contributions to this landmark issue and its forthcoming Part 2. This should help serve as a guide to future practitioners, especially those in sports medicine of the foot and ankle. The procedures presented in this issue are compelling, relevant, and, possibly, practice changing. One might not realize but certain techniques used on nonathletes such as gastrocnemius recession or flexor hallucis longus transfer for main body Achilles tendinopathy have not been proved and have even been discouraged for use in athletes (
      • Nawoczenski D.A.
      • Barske H.
      • Tome J.
      • Dawson L.K.
      • Zlotnicki J.P.
      • DiGiovanni B.F.
      Isolated gastrocnemius recession for Achilles tendinopathy: strength and functional outcomes.
      ). Other techniques, “old” and “new,” should be similarly “POLICED” (pun intended!). I truly hope you will enjoy this and the forthcoming issue.

      References

        • Bleakley C.M.
        • Glasgow P.
        • MacAuley D.C.
        PRICE needs updating, should we call the POLICE?.
        Br J Sports Med. 2012; 46: 220-221
        • Saxena A.
        • Granot A.
        Use of an anti-gravity treadmill in the rehabilitation of the operated Achilles tendon: a pilot study.
        J Foot Ankle Surg. 2011; 50: 558-561
        • Nadler S.F.
        • Malanga G.A.
        • DePrince M.
        • Stitik T.P.
        • Feinberg J.H.
        The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.
        Clin J Sport Med. 2007; 10: 89-97
        • Woodley B.L.
        • Newsham-West R.J.
        • Baxter G.D.
        Chronic tendinopathy: effectiveness of eccentric exercise.
        Br J Sports Med. 2007; 41: 188-198
        • Miller J.R.
        • Dunn K.W.
        • Ciliberti Jr., L.J.
        • Patel R.D.
        • Swanson B.A.
        Association of vitamin D with stress fractures: a retrospective cohort study.
        J Foot Ankle Surg. 2016; 55: 117-120
        • Stadlmayr A.
        • Aigner E.
        • Huber-Schönauer U.
        • Niederseer D.
        • Zwerina J.
        • Husar-Memmer E.
        • Hohla F.
        • Schett G.
        • Patsch W.
        • Datz C.
        Relations of vitamin D status, gender and type 2 diabetes in middle-aged Caucasians.
        Acta Diabetol. 2015; 52: 39-46
        • Nawoczenski D.A.
        • Barske H.
        • Tome J.
        • Dawson L.K.
        • Zlotnicki J.P.
        • DiGiovanni B.F.
        Isolated gastrocnemius recession for Achilles tendinopathy: strength and functional outcomes.
        J Bone Joint Surg Am. 2015; 97: 99-105