Bad news. It’s time to say goodbye to RICE. Not the grain. We still love rice. Keep eating it, no stress. We’re talking about following the acronym RICE: Rest, Ice, Compression, Elevation after an acute injury. If you ask anyone on the streets what to do for an acute injury (think sprains and strains), I’d bet they’d tell you “Rest, Ice, Compression, Elevation.” I’ve heard so many stories of people having a hamstring strain or ankle sprain and literally cancelling their gym membership, avoiding all movement, taking some sick days off work, and then the injury never fully heals. Then… they go back to their sport or gym routine a few weeks later and get re-injured. Why is that? Let’s find out.
History of RICE
Since 1978, the acronym RICE has been the go-to way to treat acute injuries, BUT it actually may be blunting your overall recovery and delaying healing. Dr. Gabe Mirkin coined the term RICE but actually recanted his original statement in 2014 due to a lack of concrete evidence and recognition that inflammation is a natural part of the healing process. OOPS! Just like our jeans, trends change, and it’s always best to stay up to date with the latest research as we learn and gather more long term data.
Ice (I in RICE) was originally claimed to "reduce inflammation" and speed up recovery in the short term, BUT inflammation is a part of our body’s natural healing process, and we don’t want to halt it. That would be like preventing EMS and First Responders from rushing to the scene when there’s a wreck on 526- not ideal.
Additionally, long periods of rest (R in RICE) for soft tissue injuries (strains and sprains) are also shown to delay recovery AND set you up for re-injury, as rest weakens tissues and can lead to problems down the road. Definitely don’t want to get trapped in this frustrating cycle.
Why Might RICE Delay Healing?
There is a TON of evidence that loading and moving injured tissues ASAP actually accelerates healing. In fact, there was research by two doctors as early as 1996 in which they tried to replace RICE with MICE, the M meaning MOVE. These doctors noted in their book that patients should start initiating movement as tolerated post-injury. Their take? “Once fracture or catastrophic injury is excluded: movement is best, not rest, to treat an injury...[including] immediate but gentle restoration of active range of motion with gradual introduction of functional activities”(Robinson 2017).
What does this look like in real time? Let’s say an athlete sprains their ankle and have been cleared from a fracture. Instead of elevating and icing that ankle for two weeks, let’s start moving that ankle around (gentle active range of motion) and putting weight through it (functional activities) as much as pain allows. This will help us normalize gait patterns early and gradually expose tissues to load, both of which help to desensitive the brain to the injury.
Ice leads to vasoconstriction, ie. it makes your blood vessels smaller. Decreasing the size of these blood vessels decreases the efficiency of our body’s natural inflammatory processes that expedites healing. How so? “The release of kinins and cytokines from damaged tissue is meant to increase vascular influx, which brings fibrinogen and platelets for hemostatis, leukocytes and monocytes to phagocytose necrotic debris, and fibroblasts for collagen and protein synthesis” (Robinson 2017).
Okay that was a bunch of very sciencey words so here is a VERY basic rundown here is what the above tells us:
The release of inflammatory cells (kinins and cytokines) after injury stimulates blood flow (vascular influx). Blood flow brings the blood cells (platelets and fibrinogen) which are the cells that help clots (hemostasis) form when we get a cut or scrape so that we don’t bleed out.
More cells (leukocytes and monocytes) then come in to help clear out (phagocytose) the bad stuff (necrotic debris).
Now time for the repair! Fibroblasts and collagen come in to help with protein synthesis. Macrophages also come in during this time and release insulin like growth factor (IGF-1), which is another “building” hormone.
Icing simply constricts blood vessels, slowing this whole process down. We WANT blood flow and vasodilation (blood vessels enlarging) after injury in order to let this whole cascade of events do their magic.
Loading, movement, and muscle activation helps your body with the above inflammator process in order to repair, reduce stiffness and pain, and prevent tissues from getting weaker or sensitized. Of course, the amount of movement and loading is going to be dependent on the injury and the person. This is where working with your PT at Made 2 Move can be helpful in monitoring and applying appropriate loads based on your body’s responses and stages of healing.
Our bodies are smart. Let’s stop searching for quick fixes as the solution to injury. Injury is a part of life, and our bodies have built in machinery to help us bounce back from them- inflammation and movement are just two of them. Let’s use ‘em!
When to Ice?
NEVER! Okay, we’re kidding. Stated more beautifully than we could ever summarize,“We have to keep in mind that anything that reduces inflammation [ice] also delays healing since the process of inflammation is an essential aspect of recovery itself. Although cold therapy typically slows the soft tissue swelling to some extent, it does not hasten the recovery process” (Wang et al. 2021).
After an acute muscle strain or tissue sprain, don’t completely stop moving (R) and don’t reach for the ice (I). Instead, find safe and manageable ways to move the injured area and then progressively load. Start slowly and build.
Here’s what this means for you
A 2013 book titled, “Iced! The Illusionary Treatment Option” noted, “ Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury” (Reinl 2013). Here’s the gist:
Inflammation is a natural part of the healing process.
Rest and ice may not be helping your recovery from acute injuries - they actually may be delaying it!
Continue to move and load in a tolerable range after acute injury. Motion is your friend!
Feel free to ice in 20 minute increments in the initial 12 hours after injury IF your pain is unbearable and ice is helpful in minimzing it. If you don’t ice, you will be just fine as your body will take care of it.
Does all of this mean that icing is going to make or break your recovery? No. Most of the studies that have been done on icing have been in animal models, so way more research is warranted before we can definitively come to any conclusions about it’s use in humans. The gist on ice thus far? There are likely just better uses of your time than resting, icing, compressing, and elevating for extended periods of time, and at Made 2 Move we are all about optimizing your time, recovery, and movement capabilities. Here’s what you can do:
Ankle injury? ➡️ ankle ABCs, weight shifts.
Knee injury? ➡️ gentle biking, box squats or deadlifts (if deep knee flexion is the aggravator).
Back injury? ➡️ walking, swiming, squatting without axial load (ie. without the barbell on the back). This could look like belt squats or Hatfield squats, as these options help to decrease load through the back.
Lower body fractures? ➡️do upper body (Benching? This naturally puts the hip in a little bit of extension so you’re MOVING through without even recognizing it. Sneaky! Movement (walking or running) in the water can also be helpful with injuries like stress fractures, as it offsets the effects of gravity and thus, decreases the amount of load through the fracture.
Neck pain? ➡️ let’s work the mid back with some rows!
Shoulder pain? ➡️ Isometrics and movement in a tolerable range, progressing to more range and load as pain allows.
If you’re in a ton of pain and ice helps with that, go for it, but use it sparingly. This will be dependent on the injury, and if you’re unsure, consult your friendly neighborhood physical therapist: firstname.lastname@example.org. Research has come up with a new acronym, of course - PEACE & LOVE. Stay tuned for next week’s newsletter to learn what PEACE ☮️& LOVE is all about!