Most runners are familiar with RICE treatment as being the number one protocol for dealing with acute injury like a strain or sprain. However, in failing to incorporate an extremely important part of rehab, many would argue R.I.C.E. now needs to be updated to P.O.L.I.C.E.
ICE – reduce pain and excess swelling by lowering muscle temperature.
COMPRESSION – restrict swelling to one area.
ELEVATION – help reduce swelling by aiding venous return.
The acronym R.I.C.E. is without doubt one of the best known and most practiced protocols for acute injury. It has come under fire lately with some folk raising the question as to whether we should actually be trying to inhibit inflammation at all, given that it is a natural reaction of the human body. Even Dr. Mirkin himself, who first introduced the acronym RICE to the world in the 1978 publication ‘The Sports Medicine Book’, has been quoted as saying ‘rest and ice could potentially delay healing instead of helping’.
Whilst the debate continues, most practitioners continue recommending ice in the first 48 hours of an acute injury as it invariably proves to be a very effective analgesic (pain reducer). With that in mind, here are some tips on using ice:
• Never place ice directly onto the skin as this can cause ice burn.
• Instead, place the ice (ideally crushed) inside a cloth as wetness of the fabric will enhance the level of pain relief.
• Ice packs are useful if no real ice is at hand but they tend to lose their low temperature quite quickly.
• Sprays and creams lack the ability to penetrate the tissues sufficiently so long term effect is normally negligible.
• If the injury has literally just occurred and you see signs of swelling, compression is also recommended to help reduce excess build up of fluid.
• This can be done by placing the crushed ice in a plastic bag against the injured area and wrapping a bandage around it to maintain compression.
• Alternating ice on / ice off (e.g. 10mins on / 10 mins off) may well help the temperature drop reach deeper tissues.
Time To Update RICE?
Various attempts have already been made to modify the acronym RICE. Some practitioners use PRICE, where the P stands for Protection. This serves as a reminder that if movement or loading is causing severe pain, protection (an ankle brace, taping or crutches) should be applied. In reality, most runners unable to place any weight at all on an injured limb will naturally seek some form of protection and don’t really need a modified acronym to remind them; maybe this is why PRICE never really caught on. Other attempts to modify RICE include ‘RICER’ (‘R’ for rehabilitation – a nice idea but never really caught on) and ‘PRINCE’ where ‘N’ stands for NSAIDS e.g. ibuprofen.
The Problem with REST
One issue that does need addressing with RICE is that first word… REST. Once upon a time, the immediate advice given to anyone with acute injury was to avoid anything that causes pain. Even today some practitioners recommend putting your leg up until you can happily walk with no pain whatsoever. However, thanks to concepts from modern neuroscience we now understand more about how pain works. Research has shown that optimal loading (putting a sensible amount weight onto the injured limb) can be a far more effective way to kick start recovery, on both a physical and psychological level.
In 2012, an article in the British Journal of Sports Medicine stated: “Progressive mechanical loading is more likely to restore the strength and morphological characteristics of collagenous tissue. Indeed, early mobilisation with accelerated rehabilitation is effective after acute ankle sprain. Early weight bearing with an external support is superior to cast immobilization for most types of sprain severity.”
In short, this means rather than avoiding any loading of the limb whatsoever, we should really be attempting as soon as possible (once protection is no longer necessary) to start applying a bearable load, i.e optimal loading. Experimenting with how much load the tissue can handle may well cause some pain production, but that does not mean that we are doing more damage. Pain is not a report of actual tissue damage; it is a warning that our system perceives danger, something that is totally reasonable when we understand that pain is our most sophisticated mechanism of defence. When playing with optimal loading, use a pain scale of 1 to 10 (where 10 is the worst pain you have ever felt) and seek loads that cause a 1 to 4/10. If a certain load or exercises causes more than 4/10, don’t worry, just reduce the load / modify the exercise and try again.
Add P for ‘Protection’ and replace ‘Rest’ with ‘Optimal Loading’. Goodbye RICE… hello P.O.L.I.C.E.
The change from RICE to POLICE is a significant one. Too many runners believe that putting their foot up for a week is the way to recover from an ankle sprain when in reality they should probably have been loading it gently and gradually increasing the load as and when possible. Just because you can not walk or run yet does not mean you cannot try shifting weight onto the injured leg whilst seated, standing on the injured one leg with the aid of a chair or window ledge, maybe add a little knee bend or shift your centre of mass by performing movements with the rest of the body. This is why it is worth seeking help from a therapist as soon as possible after an injury. The sooner a suitably graded program of optimal loading is put into place, the sooner recovery can start.
So go forth and spread the word: forget R.I.C.E… call the P.O.L.I.C.E!