Return to play | MEAT Movement Exercise Analgesia Treatment

Ross Hauser, MD

This article continues discusses from two of our companion articles. RICE Therapy and Immobilization Syndrome.

MEAT is an acronym for Movement Exercise Analgesia Treatment a treatment protocol for the resumption of activities with an eye towards a quicker “return to play,” for athletes and “return to work.”

Movement and exercise, the first two recommendations of MEAT, have been shown to be very effective at enhancing ligament and tendon healing.

In recent years, the importance of controlled early resumption of activities to promote restoration of ligament and tendon function is better understood and recommended in ligament and tendon injury. This is described in a well cited paper from JA Buckwalter at the University of Iowa. Also described are the negative effects of prolonged rest.1

Immobilization delays healing, increases recovery time, and can even cause further joint damage

While immobilization of the affected joint has long been prescribed following ligament injury, studies demonstrate that the healing ability of ligaments is dramatically affected by the presence or absence of joint motion. The rationale for immobilization was to prevent further tissue damage and decrease recovery time. However, the opposite holds true, as immobilization delays healing, increases recovery time, and can even cause further joint damage.

In their published study, researchers at the University of Queensland in Australia found:

  • Mobilization increases blood flow and so reduces muscle atrophy, disuse osteoporosis, adhesions, and joint stiffness.
  • Early mobilization seems to decrease pain, swelling, and stiffness, and patients generally prefer it to immobilization.
  • Early mobilization results in earlier return to work, a greater range of motion, and fewer complications and residual symptoms. They concluded: “The best evidence at hand suggests the medical profession generally errs too conservatively on the side of immobilization.”2

Knee Ligaments and Return to Play

Perhaps the most important ligaments for the athlete are those in the knee. Numerous studies have shown that exercise increases the strength of the knee ligaments when they are injured. In one study, the anterior cruciate ligament was strengthened by a statistically significant amount with exercise. Exercising the knee six days per week, instead of three days per week also produced the most improvement in ligament strength.3

The medial collateral ligament (MCL) of the knee has also been shown to heal better with early motion and exercise in athletes. One study showed that compared to immobilization, movement of the knee for 12 weeks after a medial collateral ligament injury increased the stability of the knee by over 50 percent.

The authors concluded, “In confirmation with previous studies, prolonged immobilization was shown to have deleterious effects on MCL healing. The results of this study indicated that early mobilization is the treatment of choice in cases of isolated MCL injury.”4

Doctors at the University of Alberta, Edmonton were able to demonstrate that mobilization benefited the healing of the injured MCL while immobilization delayed the healing and significantly decreased the ability of the scarred MCL to resist strain“with a majority of immobilized scars failing during repetitive loading.”5,6

Treatment of ligaments with exercise and mobility is significantly better for healing

The same results have been demonstrated in the healing of lateral ankle sprains. The early mobilized group had less pain and returned to full capacity quicker compared to the immobilized group.7 Even in lateral ankle ligament ruptures causing gross mechanical instability early mobilization resulted in a better early functional result.8

Even the tendons of the hand have been shown to benefit from mobilization. After injury, treating the flexor tendon of the hand with early mobilization demonstrated the most significant healing.9

It is clear that the treatment of ligaments with exercise and mobility is significantly better for healing than immobility and rest. Early motion and exercise of ligaments results in increased strength compared to stabilized ligaments. Mobilization benefits the injured ligament by causing it to form more connective tissue, resulting in tissue that is stronger and stiffer than the immobilized joint and soft tissue. Motion causes an increase of blood flow to the affected joint, providing the damaged ligament tissue with nutrients and metabolites necessary for tissue repair and healing.10

Do not get too excited, however, because ligament repair and regeneration begins within the first few days and occurs for the next six weeks. From week six until 12 months, the injured ligament undergoing repair remodels, contracts, and gains some tensile strength.

Once a joint becomes unstable due to ligament injury, the rate of improvement is very slow. Even though ligaments heal for a full year after the injury, after 12 months the strength of the ligament is generally only 50 to 70 percent of the original ligament strength. This means that even after a year, a large percentage of patients will still have objective mechanical laxity and subjective joint instability.

Imagine the status of the ligament strength at just day four or even two weeks after the injury? The ligament would not be strong. This fact is an example of why the modalities offered along with rest and immobility such as ice, cortisone shots, anti-inflammatories, braces, and taping are so dangerous. They cover up the fact that the athlete has an injury. The athlete goes out and plays even though his ligament is only 25 percent of the strength of his original, uninjured, ligament. Sports medicine specialists are wondering why the athlete does not heal. Get a clue. It is their treatments that are preventing the healing.

The best treatment approach for the athlete and anyone with an injured ligament is to heal the injured ligament back to 100 percent as quickly as possible. There is only one treatment that can do this. That treatment is Prolotherapy. Prolotherapy injections cause a localized inflammatory response, which will stimulate an influx of blood supply and reparative cells to the injured ligamentous area. This cascade of healing also includes deposits of collagen, which when mature will tighten and strengthen the injured ligament. Prolotherapy, along with the recommended MEAT protocol, encourages ligament healing with a controlled exercise plan to maintain mobility. This treatment combination will successfully treat the injured ligament.

1 Buckwalter J. Activity vs. rest in the treatment of bone, soft tissue and joint injuries. Iowa Orthopedic Journal. 1995;15:29-42.

2 Nash C. Resting injured limbs delays recovery: a systematic review. The Journal of Family Practice. 2004;53(9). Retrieved online on 3/5/14 from

3 Viidik, A. Elasticity and tensile strength of the anterior cruciate ligament in rabbits as influenced by training. Acta Physiol Scand. 1968; 74:373-380.

4 Woo, S. Treatment of the medial collateral ligament injury. American Journal of Sports Medicine. 1987; 15:22-29.

5 Thornton G, et al. Healing ligaments have decreased cyclic modulus compared to normal ligaments and immobilization further compromises healing ligament response to cyclic loading. Journal of Orthopedic Research. 2003;21(4):716-722.

6 Thornton G, et al. Strength of medial structures of the knee joint are decreased by isolated injury to the medial collateral ligament and subsequent joint immobilization. Journal of Orthopedic Research. 2005;23(5):1191-8.

7 Eiff, M. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of Sports Medicine. 1994; February: 83-88.

8 Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot Ankle. 1991;12(2):69-73.

9 Pettengill K. The evolution of early mobilization of the repaired flexor tendon. Journal of Hand Therapy.2005:18(2):157-168.

10 Yelamarthi T. Static and dynamic Characterization of the ligament subjected to alternative wound healing. Faculty of the Department of Mechanical Engineering University of Houston. May 2012, 1-96.

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