We must always treat, train, and move with purpose. So why should the way we manage musculoskeletal injuries be any different?

True or false: you use and trust the mnemonic RICE (rest, ice, compression, elevation) when dealing with injuries?

True or false: after a hamstring strain or ankle sprain, ibuprofen or aspirin (common NSAIDs – non-steroidal anti-inflammatory drugs) are popped like Skittles?

The truth of the matter is, despite what we all have learned, RICE may not be such a good idea if the goal is promoting adaptation and tissue recovery following injury and/or intense muscle soreness.

In a healthy person with a normal functioning system, the Inflammatory stage is paramount to healing. In fact, the inflammatory process must be initiated for the body to progress to the Repair stage (collagen is laid down and scar tissue begins to form) and finally the Remodeling stage (collagen is realigned and strengthened).

Now, the inflammatory stage does create swelling which causes fluid pressure to build. The pressure from swelling blows out free nerve endings causing pain and inhibiting muscle contraction. So swelling, NOT inflammation, is the real problem here. By icing or taking NSAIDs we are retarding, and potentially eliminating, the natural inflammatory response and not letting the body go through the necessary steps for tissue repair. The body does a great job of healing itself if we quit being bozos and get out of the way! Our GOAL is to promote tissue repair and create the perfect healing environment, not just numb the area with ice and ibuprofen – which does nothing to reduce the swelling, by the way.  Don’t get me wrong, we take injuries seriously and continuing to irritate a hot and inflamed joint will stall the healing process but we have to look beyond ice and ibuprofen to promote repair.

I know this is tough to deal with considering everything you’ve been told about the benefits of ice and NSAIDs so below is some hardcore evidence (the peer-reviewed kind – NERD ALERT):

“Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?”
Abstract: Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practiced. This review was conducted to examine the medical literature to investigate if there is evidence  to support an improvement in clinical outcome following the use of ice or cryotherapy.  Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.
    Journal of Emergency Medicine, Feb. 2008; 65-68

“Does Cryotherapy Improve Outcomes With Soft Tissue Injury?
Results: The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain.
    J Athl Train. 2004 Jul-Sep; 39(3): 278–279

“The Use of Ice in the Treatment of Acute Soft-Tissue Injury A Systematic Review of Randomized Controlled Trials
Results: There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.
    Am J Sports Med January 2004 vol. 32 no. 1 251-261.

“A Randomized Controlled Trial of Piroxicam in the Management of Acute Ankle Sprain in Australian Regular Army Recruits”
Results: Interestingly, subjects treated with piroxicam showed some evidence of local abnormalities such as instability and reduced range of movement.’
    Am J Sports Med July 1997 vol. 25 no. 4 544-553

Check out this New York Times article on NSAIDs. Not to mention the side effects – read your ibuprofen warning label if you want to get freaked out.

There’s even more out there on this but here’s the point:
We have to improve circulation and promote healing and tissue recovery through improving venous and lymphatic drainage (passive circulatory system that returns proteins too large for the veins – stuff like swelling/waste). The BEST way to do this is through compression such as active muscle contraction, compression gear/clothing, etc. to squeeze the passive tubes and get the swelling out of the system to restore homeostasis – not just stop it in its tracks. Now, don’t be ridiculous and flex a broken bone or start contracting your newly-repaired rotator cuff but even gentle muscle contractions in uninjured, regional muscles will do the trick. This benefit is amplified when combined with compression. Elevate as much as possible.
*Check with your physician if this freaks you out or if you have an out-of-control immune/inflammatory system (like RA) – NSAIDs may be warranted in some, typically non-musculoskeletal conditions. Seriously though, look at this evidence with an Eagle eye.

Bottomline:
Rest: not really an option, we need to move safely when we can. And don’t even get me started on the horrors of immobilization
Ice: not nice, kick it to the curb – no thanks I’d like to heal
Compression: absolutely, check this out for more ideas
Elevation: yes
Movement: yes, safely

People, we have to kick our habit of ice and ibuprofen post-injury/post-surgery. Do NOT let the drag of orthodoxy rear its swollen, ugly head! Just because have always done it doesn’t mean we always should.

-Seth

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