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.
(View) - 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
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My congratulations to Dr RObinson for this informative discussion! I come from South Africa, and was involved a great deal in Trauma back there. We NEVER used ice for sprains. I was shocked how the Canadian mindset seems to think that “icing it” is miracle cure from Heaven!
And so another dogma takes a dive. Good advice. Encouraging direction.
Yes! Thank you! I was advised by a wise phys med rehab doctor a number of years ago that our bodies develop inflammation for a reason and it aids the healing process. Since then I’ve been telling patients that although the mantra is “RICE” I don’t see the evidence for an NSAID or ice in the healing. So good to hear this go mainstream!
Excellent piece. As a chronic pain doc, we only get a rare acute injury. When we do, in our clinic we assess for instability or catastrophic mechanical failure, then prescribe ten low level laser treatments, 3-5 grams of Vitamin C, mild compression (15 mmHg) and graded excercise titrated to tolerable discomfort. If analgesia is required and there is a low opoid risk score and no other issue we use tramadol for analgesic in the rare event the LLLT is inadequate. RICE is not nice and is poor advice. Thank you. Now it is time for you to bring some sensibility to the overuse of stretching.
Very interesting and worth reviewing our current practice. Suspect most doctors were not comfortable with ice and NSAID. However rest and elavation especially when there was swelling and pain seems sensible..
However what about when there is ligament injury suspected that is neither ‘a fracture’ nor ‘catastrophic’ (eg at the ankle or knee), is MOVE still better than RICE.
Regarding Dr Behroozi’s comment for ligamentous knee injuries:
I recommend patients get on an exercise bike as soon as they can tolerate it with knee injuries, including ACL tears. I have found it actually helps reduce swelling, increases mobility and starts the rehab process more quickly. Our local orthopedic surgeons support this approach. I tell patients to start with 10 minutes a day and then build up, and to use a stationary bike rather than a real bike to reduce the risk of re-injury by being in a controlled setting.
Overall I think we are recognizing more and more than rest, and immobilizing anything, is not good for recovery. To think we used to tell people to stay in bed for back pain!
Dr Dara Behroozi:
Thank you for your comment, you do bring up excellent points.
Yes. This principle particularly applies to ligament injuries including ankle sprain and knee sprain injuries.
• The Wharton’s in proposing movement rather than rest, highlighted a case of a track athlete with an ankle sprain injury. Active range of motion movement was promoted right away, and their patient actually returned to sprinting in a track meet two days later. (The Wharton’s stretch book). They do point out that the movement is the patient’s own active range, not any passive pressure applied by the treating practitioner.
• A 2002 Cochrane review also supported this notion (Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults, Cochrane Database Syst Rev, 2002, vol. 3 pg. CD003762), although an update is currently in progress.
• What I currently do: I recommend applying the Ottawa Ankle rules, and if fracture is excluded, I don’t believe a patient with a grade III (complete tear) ligament injury or a high ankle sprain (syndesmosis injury) is harmed by allowing active range of motion. The forthcoming Cochrane review may provide more information on this precise injury once completed.
• With regard to knee ligament injuries: Frobell’s group in their randomized trial to compare surgical treatment of ACL tears versus conservative treatment, endorsed unloaded range of motion in the early post injury phase. They encouraged walking “as soon as tolerated”, with crutches initially if needed. Unloaded biking was similarly started within weeks zero to 4. There was no immobilization.
(Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 2010;363:331-42: Supplementary data).
• What I currently recommend: If the patient’s knee is quite swollen, I’ll suggest just rocking on a stationary bike, letting the pedal go back and forth without forcing a full pedal rotation. But it does not take very long for the patient to be able to rotate the pedal fully, if the tension is set very low. I do not believe the ACL is placed under stress through straight forward walking, but I do caution care be taken when pivoting, twisting, turning or crouching.
With regard to examples of catastrophic injuries where caution is more important than movement in the early post injury period, I think of the following diagnoses:
• Total knee dislocation (multiple ligament disruption) with concern for vascular compromise.
• Hypothermia or frost bite. an example is: Marko Cheseto: Bilateral leg amputee due to Frostbite, now Paralympic track athlete.
• Electrocution. an example is: Eduardo Garcia: Left arm amputee due to Electrocution burns.
• Heart stopping blow to the chest. an example is: Chris Pronger: cardiac arrest, ice hockey puck to the chest.
• Vascular laceration. Examples are: Clint Malarchuk: Ice hockey, carotid artery laceration; Jordan Rapp: Triathlete: Jugular vein laceration.
Even, these injured athletes embraced movement in the recovery phase. Rehabilitation was focussed on exercise and activation. All ultimately returned to sport post injury, a fitting testament to the resiliency of the human spirit.
Dr Jennifer Robinson has written an insightful and helpful article. My only criticism is that she quotes a Dr. Galea who she describes as a surgeon to Donovan Bailey. (“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).”), I believe she is referring to the family medicine/sports medicine physician Dr. Anthony Galea who is notorious for being charged with drug smuggling, conspiring to lie to federal agents, unlawful possession with intent to distribute and practicing medicine without a licence in the context of treating elite athletes; I personally don’t think he serves as a reasonable reference for this otherwise well done article.
I have always suspected that movement was preferential to rest for most soft tissue injuries. When not moving I recommend elevation of the dependent limb if there is swelling. As well, anti-inflammatory meds seemed to be counter intuitive. Good to see the change in recommendation!
Just adding to the support for MOVE after injury – I was involved when Silken Laumann (the rower) was injured 10 weeks before the 1992 Olympics – significant lower leg muscle loss and fractured fibula (bow of another boat ran into the side of her boat and pushed pieces of wood (boats made of wood back in those days) into her mid-lower leg). All athletes ended up in the water due to force of impact. 10 weeks later she won bronze medal at the Olympics.
The vasoconstrictive effects of ice always perplexed me. Thought provoking commentary.
Thank you for this insightful article Dr Robinson! Very practical and up to date, including the comments about steroid use.
Sometimes a bit of ice very initially may soothe the acute pain from the injury and help with the MOVE.
I am still not convinced that Ice is harmful to the healing of acute sports injuries. I have done a brief literature review and there are not convincing trials that ice is harmful and there are some showing benefits (Basur et al, Hocutt et al). I think that what I will take from this is that gentle movement is a good idea after acute injury. If nothing else, ice provides an effective analgesia in the first 24 hours post injury.
Curious if the same rules of movement apply to arthritis in the knee or other joints?
Thanks. I always thought RICE was just initially and up until the first 48 hours with the idea of minimising more bleeding at the injury site which does make sense. The severity, location and type of injury obviously was taken into account with how strongly each component was adhered to. Having said that I’ve always had difficulty believing the body could get it that wrong and create too much inflammation post injury, so have never been keen on overdoing the ice and definitely haven’t liked anti inflammatories for acute injuries which ‘I’ve been pleased to see has become contentious. My bigger point that i would like to make is empowering the patient to connect to and listen to their body, feeling their way with gentle movement, with the patient working out how much load for how long is OK (where appropriate), letting pain be their guide (isn’t that why we have it) and so not automatically giving painkillers. Painkillers can distort appropriate early listening to the body, thereby upsetting optimum early healing which can contribute to the problem becoming chronic. I have a saying “Listen early or listen long”. So I would suggest Move as able, let pain guide you Options find ways of not aggravating the injury while still keeping active Vary the rehab including injury specific activity Ease back to activity listening to your body
Thank you Dr Robinson for an excellent review and update on outdated and still commonly used RICE.
I would add
– high load exercises such as ‘ Stubborn heel pain: Treatment of plantar fasciitis using high-load strength training” from CFP
– eccentric exercises – better options for moving and/or applying high load
– aggressive massage to remove weaker type 2 collagen
– anything that increase inflammation eg PRP as a choice; body repairing mechanisms have to swim somewhere
– any sorts of stimulations to improve circulation
– for knee gradual inclusion of hindu situps increasing it to 60-100 daily. It does move patella and supply a lot of blood to the joint. Good for prevention of knee injuries too.
Thanks for the new approach.Just would like to know if it’s an ligament grade 2 or 3 injury how can we recommend movement of that specific joint.Won’t that aggravate it.
Thank you for your comment Sujay Bangera. If the joint is moved in it’s normal ranges of motion, and with low force to start, the ligaments are not in danger with movement. On the contrary, ligament sprains are exactly the type of injury that responds best to appropriate movement.
I could have saved a boat load of time healing a torn rota-tor cuff. Ice till the swelling went down then really light exercise of various shoulder muscles, repeat for weeks and months.
kind of knew that cold for injuries was bad, but everyone did it.
Thank you for your comment Dale.
There is no harm in asking for help in diagnosis and therapy, from a specialist in musculoskeletal injuries. Particularly if your recovery seems prolonged to you. Whether the advice is simply patience with a gradually progressing light exercise program, or whether alternate options are offered, a knowledgable specialist can be helpful.
I hope your shoulder recovers well.