PBL

8
 History taking of knee injury
Asma Aljuhaine 2220006750

• A detailed history taken can narrow extensive differential

diagnosis in order to perform the proper physical examination and
appropriate imaging or laboratory studies.

• The history taking of knee injury can be divided into:

o Chief complaint (knee pain/injury)
o Ruling out red flags or warning signals
o Past medical history
o Personal history
o Family history (1)

(WWQQAAPlusB) & (ICE)

• When/ Asking the patient how long ago the injury was because some signs
and how fast they appear can tell us the type of knee injury. Also asking
about the type of pain (rapid or insidious) (continues or discrete). (1) & (2)

• Where & how/ Location (anterior, medial, lateral, or posterior knee) & if
the patient sustained a direct blow to the knee, the foot was planted at the
time of injury, if the patient was decelerating or stopping suddenly, or if he
was landing from a jump, if there was a twisting component to the injury,
and if hyperextension occurred. (1) & (2)

• Quality/ Asking the patient if the pain is (dull, sharp, achy) because the
patient’s exact description of the pain is helpful. (1) & (2)

• Quantity/ Asking the patient about the severity of the pain & how did the
injury affected the quality of life. (1) & (2)

• Aggravating & alleviating/ Asking what makes it better or worse helps

in knowing the type of pain or injury. (1) & (2)
 • Associated symptoms/ The patient should be asked about (mechanical
symptoms) like locking or popping of the knee. (1) & (2)

• Patient’s belief & ideas/ It is important because it will affect the

decision and how the physician is going to proceed forward. (3)

• Concerns/ How is the patient scared that the injury is going to affect
his/her life. (3)

• Expectations/ The patient should be asked what procedures do they

expect to be performed today. (3)

(Past medical history)

• Asking about past knee injuries & any chronic diseases that might be risk
factors of knee injury. (1)
 References

1. Gurumoorthi R, Manojkumar S, Mehta P, Patil V, Ray S, Das G, et al. The art of history
taking in patient with pain: An ignored but very important component in making
diagnosis. Indian Journal of Pain. 2013;27(2):59.

2. Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I.
History, Physical Examination, Radiographs, and Laboratory Tests. American Family
Physician [Internet]. 2003 Sep 1;68(5):907–12. Available from:
https://www.aafp.org/pubs/afp/issues/2003/0901/p907.html

3. Lichstein PR. The Medical Interview [Internet]. Nih.gov. Butterworths; 2012. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK349/
 Knee anatomy
Jood Rayan Daghstani
2220007010

Articular surfaces:
Between of three bones ( femur, tibia , and patella ) to give :
1- Femorotibial joint – between the condyles of the femur and the
condyles of the tibia )
2- Femoropatellar joint ( between the trochlear groove in the femur and
the posterior surface of the patella ) (1) .

Capsule and synovial membrane :

It’s a fibrous connective tissue that surrounds the knee and protect it from
the lateral and posterior aspect , but it deficient anteriorly (2) .
Synovial membrane:
• cover the inner surface of the capsule
• produce the synovial fluid which is responsible for lubrication of the
joint
• Reflect to exclude the cruciate ligaments from it (3) .

Ligaments :
bands connect thigh bone to leg bones (tibia and fibula).
1- Extracapsular ligament
• Collateral ligaments
• Legamentum patella
• Oblique popliteal

2- Intracapsular ligament
• Posterior cruciate ligament
• Anterior cruciate ligament (4) .

Menisci :
It is a c-shape fibrocartilagous structure that deepening the tobiofemoral
joint and absorbing shocks
It is a 2 menisci , medial and lateral (5) .

Bursae :
It is a sac like structure that surround the knee joint and filled with
synovial fluid to prevent friction and facilitate movement
There are 10 bursae around knee joint which distributed anteriorly and
posteriorly
4 anterior bursae :
1- Suprapatellar
2- Prepatellar
3- Superficial infrapatellar
4- Deep infrapatellar
6 posterior bursae :
1- Biceps femoris
2- Popliteal
3- Semimembranos
4- Sartorios , gracilis and semitendenosis
5- Gastrocnemius ( medial and lateral ) (6) .
References:

1- Beutler A, Alexander A. Login e-resources portal [Internet]. IAU. 2023

[cited 2023Feb16]. Available from: https://www-uptodate-
com.library.iau.edu.sa/contents/physical-examination-of-the-
knee?search=examination+of+knee+joint&source=search_result&a
mp;selectedTitle=1~150&usage_type=default&display_rank=1
#H45480421.
2- Hacking C. Knee Capsule: Radiology reference article [Internet].
Radiopaedia Blog RSS. Radiopaedia.org; 2020 [cited 2023Feb16].
Available from: https://radiopaedia.org/articles/knee-capsule
3- Knipe H. Knee synovial membrane: Radiology reference article
[Internet]. Radiopaedia Blog RSS. Radiopaedia.org; 2017 [cited
2023Feb16]. Available from:
https://radiopaedia.org/articles/knee-synovial-
membrane#:~:text=The%20synovial%20membrane%20of%20the,t
he%20femur%2C%20tibia%20and%20patella.
4- Knee ligaments: Anatomy, ACL, MCL, PCL, LCL, torn ligament
[Internet]. Cleveland Clinic. [cited 2023Feb16]. Available from:
https://my.clevelandclinic.org/health/body/21596-knee-
ligaments
5- Hacking C. Knee Menisci: Radiology reference article [Internet].
Radiopaedia Blog RSS. Radiopaedia.org; 2023 [cited 2023Feb16].
Available from: https://radiopaedia.org/articles/knee-menisci
6- Murphy A. Knee Bursae: Radiology reference article [Internet].
Radiopaedia Blog RSS. Radiopaedia.org; 2021 [cited 2023Feb17].
Available from: https://radiopaedia.org/articles/knee-bursae
 Structure that are vulnerable to knee injury, and mechanical
factors that cause injury to the knee joint.

( Layan Alghamdi )

Vulnerable structures

 Anterior Cruciate Ligament [1]

 Posterior Cruciate Ligament Injuries [2]
 Collateral Ligament Injuries [3]
 Meniscal Tears [4]
 Tendon Tears [5]

Mechanical factors that cause significant injury to the knee joint

Contact injury:

Direct contact to the knee or another body part by another player or

object during the course of play.[6]

non-contact injury:

Occurs when a person themselves generates great forces at the knee.[7]

References:

1. D; CFVBSS. Anterior cruciate ligament injury: Diagnosis, management, and

prevention [Internet]. American family physician. U.S. National Library of
Medicine; [cited 2023Feb17]. Available from:
https://pubmed.ncbi.nlm.nih.gov/20949884/
2. CD; ACRKLDFDJH. Posterior cruciate ligament injuries [Internet]. Current
opinion in rheumatology. U.S. National Library of Medicine; [cited
2023Feb17]. Available from: https://pubmed.ncbi.nlm.nih.gov/11845019/
3. Andrews K, Lu A, Mckean L, Ebraheim N. Review: Medial collateral
ligament injuries [Internet]. Journal of orthopaedics. U.S. National Library of
Medicine; 2017 [cited 2023Feb17]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5581380/
4. V; LPHA. Meniscal injuries: A critical review [Internet]. Journal of back and
musculoskeletal rehabilitation. U.S. National Library of Medicine; [cited
2023Feb17]. Available from: https://pubmed.ncbi.nlm.nih.gov/22388443/
5. Tendon tears [Internet]. Summa Health. [cited 2023Feb17]. Available from:
https://www.summahealth.org/orthopedic/our-services/foot-and-ankle/tendon-
tears
6. aJapan Institute of Sports Sciences bJapan Woman's College of Physical
Education. A retrospective study of mechanisms of anterior cruciate... :
Medicine [Internet]. LWW. [cited 2023Feb17]. Available from:
https://journals.lww.com/md-
journal/fulltext/2019/06280/a_retrospective_study_of_mechanisms_of_anterio
r.18.aspx
7. WE; YBG. Mechanisms of non-contact ACL injuries [Internet]. British
journal of sports medicine. U.S. National Library of Medicine; [cited
2023Feb17]. Available from: https://pubmed.ncbi.nlm.nih.gov/17646249/
 Osteoarthritis definition, clinical presentation, diagnosis and brief Management

Manar Alarfaj 2220003369

What is osteoarthritis (OA)?
It is a disease of the bone joints that can cause severe pain and swelling, it is caused when the
cartilage around the ends of the bone joints wears away over years and leaves the bones rubbing
against each other. This can make them inflamed and painful.(1)

Clinical presentation:
• Pain or aching in a joint during activity, after long activity or at the end of the day.
• Joint stiffness usually occurs first thing in the morning or after resting.
• Limited range of motion that may go away after movement.
• Crepitus, clicking or popping sound when a joint bends.
• Swelling around a joint.
• Muscle weakness around the joint.
• Joint instability or buckling (as when a knee gives out)
(2)

Diagnosis of Osteoarthritis:

• Providing to a doctor a medical history that includes your symptoms, any other medical
problems you and your close family members have, and any medications you are taking.
• Having a physical exam to check your general health, reflexes, and problem joints.
• Joint aspiration. After numbing the area, a needle is inserted into the joint to pull out fluid.
This test will look for infection or crystals in the fluid to help rule out other medical
conditions or other forms of arthritis
• Having images taken of your joint using:
• X-rays, which can show loss of joint space, bone damage, bone remodeling, and bone
spurs. Early joint damage does not usually appear on x-rays.
• Magnetic resonance imaging (MRI), which can show damage to soft tissues in and
around the joint. Generally, MRI helps health care providers evaluate a joint that is
locking or giving out.
• Having blood tests to rule out other causes for symptoms.

(3)
Management:

Non-pharmacological:
• Exercise
• Losing weight
• Splints
(4)(5)
Pharmacological:
• Painkillers (Paracetamol or Opioids)
• Intra-articular injections of hyaluronic acid (HA)
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Capsaicin cream
• Steroid injections
 (4)(5)
Therapy:
• Physical therapy
• Occupational Therapy
• Transcutaneous electrical nerve stimulation (TENS)

(4)(5)
Surgical:
• Arthroplasty
• Osteotomy
• Arthrodesis

(4)(5)

References:
1- Osteoarthritis (OA) (2020) Centers for Disease Control and Prevention. Centers for Disease
Control and Prevention. Available at: https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
(Accessed: February 16, 2023).

2- Osteoarthritis: Symptoms, diagnosis, and treatment: Arthritis foundation (no date)

Osteoarthritis: Symptoms, Diagnosis, and Treatment | Arthritis Foundation. Available at:
https://www.arthritis.org/diseases/osteoarthritis (Accessed: February 16, 2023).

3- Niams health information on osteoarthritis (2022) National Institute of Arthritis and

Musculoskeletal and Skin Diseases. U.S. Department of Health and Human Services. Available at:
https://www.niams.nih.gov/health-topics/osteoarthritis/diagnosis-treatment-and-steps-to-take
(Accessed: February 16, 2023).

4-Deveza, L.A. (2022) Management of osteoarthritis, UpToDate. Available at: https://www-

uptodate-com.library.iau.edu.sa/contents/overview-of-the-management-of-
osteoarthritis?search=management+of+osteoarthritis&source=search_result&selectedTit
le=1~150&usage_type=default&display_rank=1#H3729865440 (Accessed: February 17,
2023).

5- Treatment and support - Osteoarthritis (2021) NHS choices. NHS. Available at:
https://www.nhs.uk/conditions/osteoarthritis/treatment/#:~:text=The%20main%20treatments
%20for%20the,help%20make%20everyday%20activities%20easier (Accessed: February 16,
2023).
 Summary of Clinical Decision Rules for Selective Knee X-ray Ordering
Shikhah Alomran 2220006089

Rules for selective knee x-ray ordering:

Researchers have been developing techniques that could limit the use of radiography in the evaluation of
extremities injuries. The most well-known recommendations for the proper use of radiography in sudden
knee injuries are the clinical decision rules developed in Ottawa and Pittsburgh. (1)(2)

Ottawa knee rules: Pittsburgh decision rules:

1- Age: 55 years or over (1) 1- Blunt trauma or a fall as mechanism of injury (2)
2- Tenderness: at head of the fibula 2- Age younger than 12 years or older than 50 years
(1) (2)
3- Isolated tenderness: of the patella 3- Inability to walk four weight-bearing steps
(1)
immediately after or in the emergency department (2)
4- Inability to flex knee to 90
degrees (1)
5- Inability to bear weight ( Take
four steps ) immediately and at
presentation (1)

Reasons of unnecessary use of x-ray:

1- People's growing interest in health knowledge. (3)

2- Referring medical professionals are less tolerant of uncertainty. (3)
3- Referring doctors are less qualified to conduct clinical evaluations. (3)
4- The infatuation with technical advancements. (3)
5- Increased accessibility to radiological equipment. (3)
6- Failure to obtain an adequate history. (3)
7- Patient’s expectations. (3)

Consequences of exposure to X-ray:

Risks from exposure to ionizing radiation include:

• Development of cancer. (4)
• Damage to DNA. (4)
• Tissue effects: cataracts, skin reddening, and hair loss. (4)
• Reactions associated with an intravenously injected contrast agent, or “dye”. (4)

References:

1- Stiell IG. Prospective validation of a decision rule for the use of radiography in acute knee
injuries. JAMA: The Journal of the American Medical Association. 1996;275(8):611.
2- Cheung TC, Tank Y, Breederveld RS, Tuinebreijer WE, de Lange-de Klerk ESM, Derksen
RJ. Diagnostic accuracy and reproducibility of the Ottawa knee rule vs the Pittsburgh
decision rule. The American Journal of Emergency Medicine. 2013;31(4):641–5.

3- Lysdahl KB, Hofmann BM. What causes increasing and unnecessary use of radiological
investigations? A survey of Radiologists' perceptions. BMC Health Services Research.
2009;9(1).

4- Medical X-ray Imaging [Internet]. U.S. FOOD & DRUG. 2020 [cited 2023Feb16]. Available
from: https://www.fda.gov/radiation-emitting-products/medical-imaging/medical-x-ray-
imaging
 Special test for ligament integrity Jana AlMansour

PBL 8 Summary

Varus test ( Lateral collateral ligament) :

Pros: used to indicate both isolated and combined tears

cons: 25% sensitive with unreported speci city (1)

Valgus test ( Medial collateral ligament)

Pros: 86% sensitive

Cons : unreported speci city (2)

Anterior drawer test (Anterior cruciate ligaments)

Pros: 93% speci c

Cons: 48% sensitive (3)

Lachman test :

Pros: 93% speci c and 87% sensitive; best test to assess ACL integrity

Cons: false positive due to isolated PCL injury and limited ndings due to hemarthrosis (3)

Posterior drawer test ( Posterior cruciate ligament) :

Pros: 90% sensitive and 99% speci c

Cons: limited ndings when patient is a icted with hemarthrosis due to swelling (4)
McMurry test ( Menisci ) : Jana AlMansour

Pos:79.7 percent sensitivity

Cons : 78.5 percent speci city (5)

Reference :

1.Varus stress test of the knee: Lateral collateral ligament injury [Internet].
Physiotutors. 2022 [cited 2023Feb16]. Available from:
https://www.physiotutors.com/wiki/varus-stress-test/
2.Karbach LE, Elfar J. Elbow instability: Anatomy, biomechanics, diagnostic
maneuvers, and testing [Internet]. The Journal of hand surgery. U.S. National
Library of Medicine; 2017 [cited 2023Feb16]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821063/
3.Makhmalbaf H, Moradi A, Ganji S, Omidi-Kashani F. Accuracy of Lachman and
anterior drawer tests for anterior cruciate ligament injuries [Internet]. The
archives of bone and joint surgery. U.S. National Library of Medicine; 2013
[cited 2023Feb16]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151408/
4.Feltham GT, Albright JP. The diagnosis of PCL Injury: Literature Review and
introduction of two novel tests [Internet]. The Iowa orthopaedic journal. U.S.
National Library of Medicine; 2001 [cited 2023Feb16]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888203/
5.McMurrays Test [Internet]. Physiopedia. [cited 2023Feb16]. Available from:
https://www.physio-pedia.com/McMurrays_Test
Legal & Ethical Issues of Medical Student Diagnosis and Treatment of Friend or Relative
Shaima ElYahia 2220005581

Unauthorized practice: -

• Illegal medical practice occurs when someone gives medical advice or

treatment without a license to practice medicine. Unauthorized practice
include diagnose, treat, operate, or prescribe any medication without any
certificate.
• An example of unauthorized medicine is when a medical student gives a
diagnosis or treatment to their friends or relatives.
• Illegal medical practice has a criminal and can carry severe penalties.
Such as jail or detention, fines, probation, remedies, etc.

Ethical issue: -

Doctors are encouraged to consider referrals to another or other providers

first, and only to friends and relatives if there are no other options.
However, There are four major cornerstones of medical ethics: autonomy,
beneficence, non-maleficence, and justice.
• Autonomy: It is the right to be in control of individuality and feel free
to refuse treatment options for a variety of reasons.
• Beneficence: includes preventing harm, repairing harm, and doing good.
• Non-maleficence: Is the need to act in a manner that does not cause
physical, mental, or emotional harm to others.
• Justice: means treating people equally and justly.

It is not ethical for medical student to diagnose and treat since he/she
does not have the enough knowledge to apply these four principles.

Legal issues: -

The potential for medical malpractice liability exists in nearly everyone

who works in the medical sector. Medical students should be aware of their
own limitations and rules of conduct to avoid unnecessary risk of
liability. Medical students do not have legal authority to practice
medicine, regardless of their ability or degree of training. Everything a
student does must be reviewed and checked by a licensed physician.
Moreover, Students should not even be allowed as much autonomy as nurses or
physicians. The legal assumption is that students are there to be taught.
Requests for medical advice from relatives and friends are usually based on
existing family and friendship ties, a history of trust, and shared
experiences. When a requester seeks medical advice beyond the ability or
knowledge level of a medical student. Medical students may give harmful,
misleading, abusive, or wrong advice. The requester considers the medical
student to be one of the medical staff responsible for the incident. Then
the medical student feels ambiguous.

References: -

1. California, S. of. (n.d.). Consumers. Medical Board of California. Retrieved February 17, 2023,
from https://www.mbc.ca.gov/Consumers/unlicensed-practice.aspx
2. What is the unauthorized practice of Medicine? Findlaw. (2016, June 21). Retrieved February 17,
2023, from https://www.findlaw.com/healthcare/patient-rights/what-is-the-unauthorized-practice-of-
medicine.html
3. The impact of Apelin level on the incidence of major adverse ... - UNIZG.HR. (n.d.). Retrieved
February 17, 2023, from https://repozitorij.mef.unizg.hr/islandora/object/mef%3A3409/datastream/
PDF/view
4. Eniola, K. (2017, June 30). The ethics of caring for friends or family. Family Practice
Management. Retrieved February 17, 2023, from https://www.aafp.org/pubs/fpm/issues/2017/0700/
p44.html
5. Eastwood, G. L. (2009, December). When relatives and friends ask physicians for medical advice:
Ethical, legal, and practical considerations. Journal of general internal medicine. Retrieved
February 17, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2787942/
 Physical Examination of Knee joint.
Raniya Alsalamah – 2220007037

Before Starting the Examination:

• Hand washing.
• Introduce yourself.
• Confirm patient details.
• Explain the examination.
• Gain consent.

Proper exposure of both knees to ensure adequate inspection.

1- Look
• Observe gait: Inspection begins when the patient enters the exam room. Watch the
patient walk. Changes in gait and walking aids may provide clues to injury patterns. (1)
• Swelling: Look for swelling. (1)
• Atrophy: Look for quadriceps wasting. (1)
• Deformity: Varus (knee bends outward) or valgus (knee bends inward). (1)
• Skin changes: Scars (surgical or traumatic), rash. (1)

2- Feel
• For muscle wasting. (1)
• Bony landmarks: Joint line – popliteal pulse – tibial tuberosity – border of patella – insertion
of hamstring – border of quadriceps – femoral condyle. (1)
• Temperature. (2)
• Swelling: (fluid, soft tissues –” boggy” feeling of synovial swelling). (2)

3- Move (Active and Passive)

• Test for flexion and extension (and feel for crepitus) as well as stability of the ligaments
of the knee joint. (3)
• Keep one hand on the knee joint and use the other to move the joint. Normal flexion is
135 degrees and extension is 5 degrees. (3)

Video of the Examination To the minute 4:33:

https://www.youtube.com/watch?v=17ZKya9yR2Y
References:

1- Beutler A. Physical examination of the knee [Internet]. UpToDate. 2022 [cited 2023Feb17].
Available from: https://www.uptodate.com/contents/physical-examination-of-the-
knee#H133526799
2- Stanford Medicine 25. Knee exam [Internet]. Stanford Medicine 25. [cited 2023Feb17]. Available
from: https://stanfordmedicine25.stanford.edu/the25/knee.html
3- Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part I. history,
physical examination, radiographs, and laboratory tests [Internet]. American Family Physician.
2003 [cited 2023Feb17]. Available from:
https://www.aafp.org/pubs/afp/issues/2003/0901/p907.html
 Knee Movements
Reem AlArfaj-2220004367
• Movement of knee:
§ Flexion:
1-Semitendinosus muscle
2-Semimembranosus muscle
3-Biceps femoris muscle
§ Extension:
1-Vastus intermedius muscle
2-Vastus medialis muscle
3-Vastus lateralis muscle
4-Rectus femoris muscle
§ Rotation

• Structures limit the movement of knee

1-Cruciate ligaments
2-Collateral ligaments
• Nerve supply at the knee joint
1-Femoral nerve
2-Obturator nerve
3-Common Peroneal
4-Tibial nerve
• Blood supply at the knee joint
1-Femoral Artery
2-Popliteal Artery
3-Anterior tibial artery
4-Posterior tibial artery

• References:
Drake, R. (2020). Lower Limb. In Gray's anatomy for students (pp.
582,586,590,598-606). essay, Elsevier.
Reema Alruwais 2220004091

Biomechanics of Knee

Introduction : knee joint The knee joint is one of the

largest and most complex joints in the body. It is constructed by 4 bones and an extensive network
of ligaments and muscles.It is a bi-condylar type of synovial joint,
which mainly allows for flexion and extension (and a small degree of medial and lateral rotation). (1)

-Knee flexion-extension arc (2)

1. Screw home arc:
• It is also called locking mechanism
• -5 to 10: The range where the knee is locked
• Rotation occurs between the femur and tibia during final degree of extension
• The femur begins to internally rotates as the knee extends and the joint is locked.
• The knee is unlocked by the action of the popliteus and the femur begins to externally
rotate as knee flexion is initiated.

2. Functional arc
• 10 to 120 : The range is associated with further external rotation of
the femur.
• as the knee flexes, the smaller lateral femoral condyle also begins to
slide posteriorly = the overall effect of externally rotating the femur.

3. Deep flexion arc

• 120 to 145 /160 : femur continues external rotation and the two
femoral condyle translate posteriorly.
• The rollback and slide of the femur allows the condyle to clear the
tibia to achieve deep flexion.

-Medial and lateral rotation (3)

-Role of patella in quadriceps function (extension):

It lengthens the moment arm of the quadriceps by increasing the distance of the
quadriceps tendon and patellar tendon from the axis of the knee joint. (3)
References

1-Knee [Internet]. Physiopedia. [cited 2023Feb17]. Available from: https://www.physio-

pedia.com/Knee

2-Malik SS, Malik SS. Orthopaedic Biomechanics made easy. Cambridge: Cambridge University
Press; 2019.

3-Biomechanics of joints. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2013.
 FIRST AID FOR INJURED KNEE

BY ROQAYA AL-DABOOS

RICER Method:

The RICER method is an effective procedure used in the initial

treatment of a soft tissue injury(1)
Rest: It is suggested that you take a break from the activity that caused the injury
in order to give the injury time to heal.

Ice: The injury should be iced on and off in 20-minute intervals, avoiding direct
contact of the ice to the skin.

Compression: Bandaging the injury will compress it, and prevent any further
bleeding or swelling to occur.

Elevation: Elevating the injury above your heart while you are resting will aid in the
reduction of swelling.

Referral: Referral to an appropriate medical professional for guidance and

management.(1)

H.A.R.M Protocol:

It stands for Heat, Alcohol, Running/exercise, and Massage. In order to

maximize healing and recovery after an injury, you should avoid four factors.
RICER focuses on reducing bleeding and swelling, whereas HARM discusses
factors to avoid that will increase circulation to the injured area.(2)

Heat – Heat will cause blood vessels to dilate which in turn will increase
the flow of blood to the area. Avoid hot baths, showers, saunas, heat packs,
and heat rubs.
Alcohol – Similar to heat, alcohol has an effect of dilating blood vessels,
which in turn will increase the flow of blood to the area. Alcohol can also
mask pain and the severity of the injury, which may put you at greater risk
for re-injury 7. Avoid drinking alcohol in the initial stages of healing any
injury.
Running/exercise – An increase in heart rate increases the flow of blood
around the body. This will cause blood to accumulate in the area faster.
Take the opportunity to rest.
Massage – Massaging the area, once again, will stimulate the flow of blood
to the area. Avoid massage in the initial stages of injury(2)
Resources
1. Marketing FSPH. Ricer and no harm treatments for soft tissue injuries [Internet].
Friendly Society Private Hospital. 2021 [cited 2023Feb17]. Available from:
https://thefriendlies.org.au/ricer/
2. Motion P. Managing acute soft tissue injuries with ricer and harm: Pivotal [Internet].
Pivotal Motion Physiotherapy. 2021 [cited 2023Feb17]. Available from:
https://pivotalmotion.physio/managing-acute-soft-tissue-injuries/