RICE: Rest, Ice, Compress, & Elevate?
…Or Reintegrate, Isometrically Challenge, and Eccentrically load?
Hint: enough with the ice already!
All day long in my Austin clinic I hear the four-letter word (welllll, lots of four-letter words actually, but one that stands out)…pain.
Most of us are afraid of it. We avoid it at all costs and consider pain a big red-flag that we are doing damage to something and need to stop. This aversion to pain is one of the biggest limiters I see both from a rehab standpoint as well as a performance development perspective, and the rehab world continues to grasp onto this “avoid painful activity” paradigm for fear of aggravating a patient’s symptoms.
Don’t get me wrong, it’s not advisable to run immediately following a hamstring avulsion, tibial stress fracture, or other severe injury, but it’s also not advisable to stop loading those structures altogether, even if it causes pain!
Most injuries are much less severe than those mentioned above, and yet the medical community’s standard advice is typically to:
- Stop running
- Rest, Ice, Compress, Elevate (RICE)
- Tape it up
- Manage the injury (and of course the pain) with analgesics, anti-inflammatories, muscle-relaxers, and cortisone shots
But is this working? Should you keep sticking an ice pack on everything that hurts?
At RunLab, we have always taken an active care approach to rehab, at the risk of increasing a patient’s symptoms for the greater good. I almost never tell someone to stop running unless the injury is extremely severe, and even then I advocate for a rehab plan that includes loading.
More and more research is coming out that shows our old way of doing things in the rehab world just doesn’t work. Even Dr Gabe Mirkin, who first coined the RICE acronym in 1978 recanted his position on rest and ice in light of an onslaught of evidence showing that it actually causes a delay in healing. Research shows ice can cause decreased release of IGF-1 (a growth factor released by macrophages to help “clean up” damaged tissue), constriction of blood flow to the injured area (the effect we THOUGHT we wanted but now realize can be damaging, especially if ice is used on an area for more than 20 minutes), and a reduction in strength, speed, power, and agility immediately after use. Food for thought: consider how this affects an injured athlete trying to get back on the field as they sit on the sidelines with a huge ice pack on their knee until it’s numb enough to get back in the game. Now they have just entered back into a match with decreased coordination and agility, which is a recipe for disaster when it comes to sports like soccer, rugby, and pretty much everything else involving lateral movement.
Many of the most frustrating injuries are those that occur in areas with poor vascular supply: high-hamstring strains, Achilles tendinopathy, ITB syndrome, etc. Many patients end up spinning their wheels on the massage table, foam roller, etc. to find only temporary relief with these passive modalities. Slow progress in healing these injuries is often multifactorial.
Let’s look at a case study. A patient, we’ll call him John, is an avid marathon runner who has recently read that he may want to occasionally actually work on speed instead of just slogging through the miles day in and day out. Like any good runner, he takes this to mean he should do speedwork every day…and lots of it. Shockingly, he injures his hamstring at the insertion point (sit-bone) while at the track one day. John tries to keep up his training, but develops pain with both walking and running. Eager to solve the issue, he visits his doctor and is told that he should take time off of running and all weight bearing exercise until the pain is gone. He complies with his doctor’s order, ices the area a couple of times per day, downs a few Ibuprofen each morning, foam rolls the area like crazy, and sits around thinking about running, how fat he is getting, and the marathon he has in 8 weeks. Note: you don’t in fact get FAT by taking one day off of running…I’m looking at you every runner in the history of ever.
Since John’s doctor told him to take two weeks off, he waits 4 full days before deciding to “test it out”. It feels ok for the first few steps as he gingerly shuffles along, but then the familiar tugging starts as soon as he tries to up his pace. He tries to shorten his stride so it doesn’t hurt. This helps a little and he is able to shuffle along for a couple of miles before his calf starts giving him trouble. He stops and walks back home frustrated.
John takes a couple more days off but can’t stand it anymore and tries to run again on his next day off of work (where he spends all day sitting at a computer). As soon as he begins running he feels pain in the hamstring, but he is able to shift his gait again and get a little further this time. Progress! He comes back from a 3-mile run and is finally happier mentally, already looking at his calendar and counting how many runs he can get in before his marathon. He continues to foam roll, starts stretching the hamstring a billion times a day, and continues to increase his mileage as he keeps his stride super short so as not to irritate the hamstring.
He limps along like this for another month, and races the marathon with a disappointing slide into run/walking by mile 16. By the end of the race his hamstring is worse than ever and his Achilles tendon is now aching considerably.
He ends up back in the MD’s office, who sends him to physical therapy where they focus on stretching, foam rolling, clamshell and other antiquated hip exercises to strengthen the “glutes that aren’t firing” (an entire blog post for another day…). He is told to avoid all exercises that increase his pain, including running.
After 3 months of physical therapy, daily foam rolling, a few chiropractic adjustments to “realign his hips and pelvis”, several rounds of kinesiotaping, daily ice packs, and a few hundred miles on the spin bike to kill the demons, he tries his first run.
He feels great for about 2 miles and then guess what? Yep, you guessed it. More of the same.
Sound familiar? Most runners have struggled with something like this, whether it’s a hamstring, patellar tendon, plantar fascia, the IT Band, or any number of other problem areas.
So what are we doing wrong in the rehab world?
Many will disagree with me and that’s okay. But after treating thousands of runners over the last ten years, here’s what I have found to be true:
Tendons are meant to be loaded.
Is it going to cause pain if the tendon is injured? You betcha. Is that a bad thing? Not necessarily. A systematic review just published in the British Journal of Sports Medicine reiterated what many forward thinkers in the rehab world have suspected for years: pain-inducing exercise can actually speed reduction in symptoms over non pain-inducing exercise as it relates to chronic musculoskeletal injury.
More research is warranted in this area but evidence is starting to solidify the idea that pain should not always be used as the overarching guideline for rehab, strength training, or injury management.
Should this knowledge be exercised with caution and under guidance from someone who is going to make sure you crazy runners don’t all go out there and rupture your Achilles tendons because “if a little pain is good, then a lot is REALLY good”? Yes. Obviously.
Fear-avoidance behavior can be more damaging to movement patterns than the injury itself.
I have seen many runners who end up sidelined 2 years after a minor injury because they are so afraid of doing more damage to the area that they avoid any movement or activity that increases their symptoms even temporarily. This leads them down the biomechanics corridor of death in terms of movement patterns. Compensation pattern after compensation pattern is developed and a snarled mess is created that can be extremely difficult to unravel years later.
The body is meant to run.
Running is an activity of daily living. If you can’t sprint to catch the bus because your knee will hurt for 3 days, then that is a serious problem. Wait…is riding the bus still a thing? I should say if you can’t sprint to catch your Uber driver when you realize you weren’t paying attention and had gotten into some random person’s car, then THAT is a problem. Not saying that that has ever happened to me…
R.I.C.E is a load of crap.
REST? Completely resting an injured area for any length of time is a sure-fire way to decondition the entire kinetic chain and create long-term problems. Reintegrating injured muscles into their normal functional movements should begin immediately following injury.
ICE? Ice doesn’t help healing in most circumstances, it delays healing, decreases coordination, agility, strength, and endurance. What’s a better “I”? Start the isometrics as soon as possible.
COMPRESSION? Sure. Doesn’t seem to hurt but more research is certainly needed on whether those really cool looking compression sleeves actually do anything significant beyond covering up your GIANT Ironman tattoo. I jest, I jest! I did triathlon for years, and as an official drinker of the Ironman Kool-Aid I never miss a chance to tease my fellow triathletes about the tattoo obsession.
ELEVATION? Sure. Ok. Assuming you have so much swelling that you need that edema to be flushed back towards the heart and stop pooling in the extremities. Otherwise, once you can tolerate isometric exercise and loading, start with eccentric exercise to strengthen muscular control during the gait cycle.
Running through injuries is often ok.
Assuming the injury does not involve, say, a fractured bone, running can often be incorporated into a rehab program. Even a fractured bone needs loading or it will end up deconditioned AND osteopenic, it just needs to be loaded carefully and under the guidance of someone who understands biomechanics at a high level. Familiar with Wolff’s Law? Pressure on bone builds more bone. Active recovery in a functional environment is, in my opinion, the best thing that can be done for an injury. The sooner the injured tissue can get reintegrated to do its job within the context of the kinetic chain, the less chance there will be for developing scar tissue and compensation patterns. Also, if you have a fractured bone but a bull is chasing you? Probably still ok to run.
- Pain is not always bad and can often be beneficial
- Loading is good for muscles, tendons, and bones and it should be an integral part of all rehab
- For the love of God, stop “RICE”ing everything
- If a doctor tells you running is bad for you, find another doctor
- When you injure yourself, get guidance from someone who looks at the whole kinetic chain within the context of functional movements. There are a lot of good therapists and trainers out there but you have to do your research!
Based in Austin Texas, RunLab is a sports medicine, gait training and education facility built entirely for runners. We treat runners of all shapes, sizes and experience levels who want to work on running technique, injury prevention, rehab of a current injury, and performance development.
RunLab Training is the education arm of RunLab, with educational seminars and gait evaluation courses throughout the United States.
To book an appointment in Austin, you can reach us at 512-266-1000 ext 1 or Info@RunLabAustin.com.