Dr. Jennifer Robinson (biography and disclosures) Disclosures: Received fees from WorkSafeBC. Mitigating statement: There is no bias. The article is related to sports injury with no mention of work injury or WorkSafeBC.
What I did before
Rest, Ice, Compression, and Elevation (RICE) is a popular method of dealing with physical injury (1). However, this treatment might not be the best recovery method for all injuries.
What changed my practice
1996, the year I started my fellowship with Drs. Doug Clement and Jack Taunton at the UBC Sports Medicine Centre, was a memorable year for sports medicine. Firstly, Canadian Donovan Bailey won gold in the Atlanta Olympic men’s 100 meter sprint. It was a thrilling race: three false starts, the defending champion disqualified and a world record time.
Just as extraordinary was Canuck Pavel Bure’s early recovery from knee reconstruction surgery. Dr. Clement, the team doctor, expressed no surprise at Bure’s determined recovery (2). His rehab had begun with swimming, adding in light weight training, followed by easy skating three months post-surgery. Dr. Clement, a seasoned expert in injury rehabilitation, was familiar with success years earlier, when track athlete Lynn Williams won a bronze medal in the 1984 Olympics despite suffering a foot stress fracture in the Olympic build up. Dr. Clement had advised Lynn to run in water, and then to gradually transition back to running on land six weeks before the games. This was the same rehabilitation prescribed to Donovan Bailey in 1998 when he was recovering from a repaired Achilles tendon rupture. His surgeon Dr. Galea is quoted: “We had him in the water right away, and by ten weeks he was jogging” (3). A year later, Bailey surprised the world running 100 meters, yet again, in under ten seconds.
Movement, not rest
That recovery after injury is improved with movement, not rest, was published in that banner year, 1996, by Dr. Jim and Phil Wharton in The Wharton’s Stretch Book (4). They suggested the acronym MICE to replace RICE, where Rest is replaced with Movement. The Whartons advocated that once fracture or catastrophic injury is excluded: movement is best, not rest, to treat an injury. They encourage immediate but gentle restoration of active range of motion with gradual introduction of functional activities. They note that inactivity shuts the muscle down. Blood flow is restricted and tissue atrophy follows. In contrast, activity improves blood flow, which brings oxygen and removes metabolic waste.
That movement also directly stimulates tissue healing was clarified by Dr. Khan (Editor of the British Journal of Sports Medicine) and Dr. Scott (Director of Vancouver Hospital’s Tendon Laboratory) (5). Called mechanotransduction, the actual physical deformation of tissue by mechanical load of movement leads to release of chemical growth factors from cells. These enhance synthesis of protein and structural scaffolds, which maintain, repair and strengthen bone, cartilage, tendon and muscle. Even Dr. Gabe Mirkin, who coined the acronym RICE, now agrees rest may delay healing (6).
Inflammation exonerated: don’t ice
But even “MICE” needs reconsideration. Gary Reinl has written forcefully that Ice is also wrong, and delays healing (7). Dr. Mirkin has also conceded that ice also delays recovery. The resulting vasoconstriction from cooling, not only reduces tissue oxygenation with necrosis if extreme, but inhibits the inflammatory response needed to initiate healing. 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.
Anti-inflammatory medications deserve equal caution. Professor James McCormack (8) confirms there is no evidence non-steroidal anti-inflammatories (NSAID) improve the outcome of acute sports injuries or reduce swelling (listen to the podcast). Steroidal anti-inflammatories, such as cortisone, inhibit the production of collagen and granulation tissue (9). Tendon surgeon Prof Alfredson describes observing nectrotic tissue, reduced healing and wound breakdown after multiple cortisone injections (10).
Compression and elevation
Evidence to confirm or refute benefit on injury recovery is scanty and difficult to perform. Influence of a placebo effect is suspected. A pilot study on the effect of compression socks on recovery from a five kilometer sprint, did confirm that those who believed the socks would help, did do better than those who were sceptical of their benefit (11). My preference is to utilize the calf muscle pump or contraction of upper extremity muscles for swelling (12,13). Walk as soon as able.
Emotional cost of injury
While Pavel Bure’s rapid return to hockey after the ACL surgery was accredited to his conditioning, his own explanation related more to his mental fortitude. He reports he reset his goals from scoring to recovering, and is quoted saying: “From the start, you can’t get down on yourself”. I believe the emotional cost of injury may be moderated by permission to move immediately. It starts with range of motion and walking. Cross training can maintain fitness and supplement strengthening drills. Low intensity practices start soon, with a gradual progression to full participation when sufficient strength and agility is realised (14).
What I do now
Excluding fractures, cord, or catastrophic injuries, I get patients moving post injury and doing range of motion exercises as soon as possible.
- For foot and ankle injuries I recommend drawing the alphabet with the toes.
- For knees: stationary biking with low tension.
- For shoulder injuries: pendulums, pole walking, and Nordic ski.
- For neck pain: rows and ellipse.
- For back pain: walking, swimming, and yoga.
- For lower limb fractures: water running and seated weights.
- For upper limb fractures: walking and the recumbent bike.
I minimize use of braces, splints or shoulder slings and encourage physiotherapy to maintain range of motion of surrounding joints for casted fractures.
Ice is out. I reserve anti-inflammatories for inflammatory arthropathies. Patients can choose. Use compression if you believe it works, and elevate if you like, but I prefer calf pump exercises, walking and cross training. Light strength and agility exercises can start right away. I permit resumption of training and practices as soon as the patient is strong enough, with gradual easing back to full participation.
Let’s call it MOVE:
Movement, not rest.
Options: offer other options for cross training.
Vary rehabilitation with strength, balance and agility drills.
Ease back to activity early for emotional strength.
References and resources:
- Mirkin G, Hoffman M. The Sports Medicine Book. Sydney: Landstowne; 1978.
- Jamieson, J. Quick fix possible: Bure could set rehab record.The Province. 1996, Jan 12. Vancouver, BC.
- Rutherford K. Doctor to the star athletes. Burlington Post. https://www.insidehalton.com/news-story/2946463-doctor-to-the-star-athletes/. 2007.
- Wharton J, Wharton P. The Whartons’ stretch book: featuring the breakthrough method of active-Isolated stretching. New York: Times Books; 1996.
- Khan K, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. J. Sports. Med. 2009;43:247-251. (Request with CPSBC or view UBC) DOI: 10.1136/bjsm.2008.054239
- Mirkin G. Why Ice Delays Recovery. Dr. Gabe Mirkin on Health, Fitness and Nutrition blog. Updated October 13, 2016. (View)
- Gary Reinl: Iced! The Illusionary Treatment Option, 2nd edition, 2014.
- McCormack J. “Mythbuster” on NSAIDs in sports medicine, challenging nutrition dogma, and evidence-based practice. BMJ Talk Medicine. 2014. https://soundcloud.com/bmjpodcasts/mythbuster-on-nsaids-in-sports. Accessed May 24, 2017. (Listen)
- Lorenzen I. The Effects of the Glucocorticoids On Connective Tissue. Medica. Scandinavica. 1969;185:17-20. (View with UBC) DOI: 10.1111/j.0954-6820.1969.tb16718.x
- Alfredson H. Treating tendinopathy with Professor Hakan Alfredson. BMJ Talk Medicine. 2013. https://soundcloud.com/bmjpodcasts/treating-tendinopathy-with. Accessed May 11, 2017.
- Brophy-Williams N, Driller MW, Shing CM, Halson SL, Fell JW. Physiological, Perceptual And Performance-based Effects Of Compression Socks – Are They Just A Placebo? Sci. Sports Exerc. 2015;47:779. (View with UBC) DOI: 10.1249/01.mss.0000478861.39685.d1 Not available locally
- Recek C. Calf Pump Activity Influencing Venous Hemodynamics in the Lower Extremity. J. Angiol. 2013;22:023-030. (Request with CPSBC or view UBC) DOI: 10.1055/s-0033-1334092
- Goddard AA, Pierce CS, McLeod KJ. Reversal of Lower Limb Edema by Calf Muscle Pump Stimulation. Cardiopulm. Rehabil. Prev. 2008;28:174-179. (View with CPSBC or UBC) DOI: 10.1097/01.HCR.0000320067.58599.ac
- Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-Play in Sport: A Decision-based Model. J. Sports Med. 2010;20:379-385. (View with CPSBC or UBC) DOI: 10.1097/JSM.0b013e3181f3c0fe