I can’t remember the first time that I heard the acronym R.I.C.E. I’m sure it was at some point during elementary school when I suffered an injury. The prescription was simple. The ‘R’ stood for Rest, the ‘I’ for Ice, the ‘C’ for Compression and the ‘E’ for Elevate. I can tell you that my Mom would recommend that we “just put some ice on it” for all injures that my brothers and I suffered as kids. We still joke about this.
Through most of our lives, if you sustained an injury, let’s say a sprained ankle, you were told to stay off if it (Rest), get an ice pack on it immediately (Ice), wrap it up (Compression) and prop it up (Elevation).
The term RICE first appeared in a book written by Gabe Mirkin called Sportsmedicine back in 1978. So we’ve been doing this for nearly forty years. Coaches and trainers have been grabbing ice packs for in-game or practice injuries for a LONG time. Even today, if you watch professional sports like basketball or soccer, you will see ice immediately applied to injuries even right on the sidelines.
My thoughts on this method came into question last summer when I severely sprain my left ankle while running. My trusted Chinese Medicine practitioner, Patrick at Meridian Acupuncture told me to put heat on the injury and not ice! I took his advice, as I always do. The heat, along with some Physical Therapy at Rudy Ellis Sports Medicine Clinic (lots of sponsor plugs here), got me ready to run a Half Ironman (including a 13.1 mile run) just 10 days after I couldn’t even put weight on my foot.
So what’s the deal? Ice is supposed to reduce inflammation and speed up the healing process, right? Recent findings are showing that both ice and complete rest may delay healing, instead of help it. This has been known for a long time by those that practice Eastern Medicine, but like most things we are slow to catch on here in the Western world.
Cold does reduce inflammation and alleviate pain. But it does that by vasoconstriction, denying blood into and out of the area. This prohibits immunoglobulin (an antibody used by the immune system to neutralize pathogens such as bacteria and viruses) to the injury, prohibiting healing. Heat speeds and aids the healing process but doesn't do anything for pain.
After ice restricts the blood flow, the blood vessels do not open again for many hours. This decreased blood flow can cause the tissue to die and can even cause permanent nerve damage. So, if you can deal with the initial pain related to an injury, don’t use ice at all. By doing so, you are causing lasting damage to the area.
While the cooling through ice decrease pain, it will also negatively affect an athlete's strength, speed, endurance and coordination. In this review by Sports Med, Nov 28, 2011, a search found 35 studies on the effects of cooling. Most reported that immediately after 20+ minutes of cooling, there was a decrease in strength, speed, power and agility-based running. However, a short re-warming period returned the strength, speed and coordination. The authors of the review recommend that if cooling is done at all to limit swelling or decrease pain, it should be done for less than five minutes, followed by progressive warming prior to returning to play. So keep this in mind if you are injured playing a sport and want to get back in the action quickly.
The inflammation process is evolution’s way of putting a "cast" over the specific muscle and tendon fibers that are damaged - signaling a reaction for the body’s natural repair mechanism to go to a specific location.
In a study by The American Journal of Sports Medicine in June 2013, it was found that cooling delayed swelling, but it did not speed recovery from muscle damage.
Anything that reduces your immune response (inflammation) will also delay muscle healing. Thus, healing is delayed by things other than just ice. For instance, cortisone-type drugs, pain-relieving medicines (such as non-steroidal anti-inflammatory drugs like ibuprofen) and immune suppressants that are often used to treat arthritis, cancer or psoriasis.
I feel like I need to take a quick side-bar on the inflammation topic. With an injury, we are talking about acute inflammation. It arrives suddenly and leaves after its job is done. Acute inflammation is a healthy, localized, deliberate response that you don’t want to mess with too much.
Chronic inflammation is a different story. This is the bad kind of inflammation. It usually results from a poor diet and prolonged stress. Chronic inflammation (sometimes called systemic inflammation) takes months and years to accumulate and can be very difficult to get rid of. Examples include arthritis, cancer, diabetes, Alzheimer’s disease, and ulcers. It’s important not to get the two kinds of inflammation confused.
If after absorbing all of this information, you agree that the R.I.C.E. method is no longer the best way to get you back in the game or sport, what should you do next time you have an injury?
Step one is to elevate the injured part to use gravity to help minimize swelling. You elevate your injury because the swelling causes an increase in resistance of blood flow to your blood vessels. The arteries delivering the blood are fine, they have plenty of pressure from the heart. The blood pressure in veins on the other hand is a lot lower, and the force of gravity from an elevated extremity helps the blood not pool in the veins.
Step two, once it’s determined that the injury is limited to muscles or other soft tissue, have a doctor, trainer or coach may apply a compression bandage. If you have been trained on how to properly apply a bandage or other compression clothing, you can do this yourself. Compression keeps excess fluid from building up, which can slow down the healing process and inhibit range of motion if the injury is at or near a joint. Active compression also helps stimulate the flow of lymph fluid, which carries vital nutrients to the damaged tissues surrounding the injury. Lymph fluid is also important for removing waste from cells and body tissues, an important function during the tissue regeneration process.
Step three is only if you are in severe pain. Since applying ice to an injury has been shown to reduce pain, you can cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10-minute application once or twice. There is no reason to apply ice more than a few hours after you have injured yourself. If the pain is still consistent beyond a few hours, you have likely done enough damage to have it looked at by a medical professional.
Step four is to apply heat. Modern science is validating what traditional Chinese medicine has recommended for thousands of years, that healing requires warmth. The principle is simple - heat encourages circulation while cold restricts it, and circulation is what is needed for tissue repair. Continue to apply heat a few times a day until the injury is completely healed. A simple heating pad is the easiest way to get heat on an injury.
Step five is rehabilitation. Based on a doctor or physical therapist’s instructions, with most minor injuries, you can usually start to move and use the injured part within a few days. As long you do not feel an increase in pain or discomfort, get back to your sport as soon as you can.
So instead of R.I.C.E., we need to start promoting E.C.H.R. (Elevation, Compression, Heat, Rehab). I guess that doesn’t quite roll off the tongue or is as easy to remember, but it will work.
Next time you roll your ankle or tweak your knee, give this method a try. In my experience, it will work to get you back on the road or in the game much faster!
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Wishing you optimal health and peak performance,