Rest. Ice. Compression. Elevation.
It’s the famous acronym that’s been wired into our brains for decades. The perfected plan for injury recovery. The battle-tested solution to every ache and pain. Whether it was a doctor, school nurse, or your very own mother, we’ve been instructed that these 4 words should be our first thought after an acute injury strikes. Ever since Dr. Gabe Mirkin coined the acronym back in 1978, we’ve hopped on the RICE train and many have yet to jump off.
Well, it’s time to flip all of that history on its head.
Despite our faith in Dr. Mirkin’s work, the concrete evidence to support his original thesis is jaw-droppingly low. What’s even more shocking is the proof that RICE actually delays recovery and can lead to lasting damage to the body. This evidence is so overwhelming that Mirkin himself retracted his statement in a 2013 book called “Iced! The Illusionary Treatment Option”. Here’s what he had to say:
“Subsequent research shows that ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury.”
Crazy, right? The very author of our most heavily used acronym for injury management has abandoned it. I think it’s about damn time we do as well. To be fair, you probably have a few questions before making the leap for yourself. You may be thinking…
Doesn’t RICE help with inflammation?
It feels good, so why should I stop?
My doctor says I need to do it, who are you to tell me otherwise?!?
These are all great questions, but I believe there is a logical answer to every single one of them that still points to RICE being a faulty rehab strategy. Without further ado, let’s take a deep dive into the science behind this defective strategy to appreciate just how wrong we’ve been all along.
Why RICE in the First Place?
In 1978 Harvard physician Dr. Gabe Mirkin coined the term RICE as the recommended treatment for sports injuries in ‘The Sports Medicine Book’. The main thesis, and the one that is commonly carried today, is that ice can attenuate pain, lower swelling, and reduce inflammation. To your average Joe, this sounds like a pretty sweet deal.
The tricky thing about RICE is that it’s disturbingly good at disguising just how bad it is. In a near comedic fashion, every letter in Mirkin’s acronym is virtually the opposite of what we should be doing after an injury. Let’s take a look, shall we?
REST — Staying still is one of the worst things you can be doing post-injury in almost every musculoskeletal case.
ICE — While it may feel good temporarily, this merely delays healing and recovery in the long term.
COMPRESSION — Tight compression can greatly inhibit our ability to contract localized muscles at the site of injury and move through a range of motion — 2 keys to a speedy recovery!
ELEVATION — Again, this means that we’re likely holding a sedentary position which will do more harm than good. The main rationale for elevating an injured site is to restrict blood flow, but we actually want to be encouraging flow to the area from a rehabilitation perspective.
Just like that, everything that we once thought to be the gold-standard of acute injury rehab is completely dismantled in a few sentences.
The Robust Case Against RICE
You just got a brief glimpse at RICE’s many shortcomings, but I’m assuming you want to go deeper before you’re fully convinced. As rest, compression, and elevation are all working towards immobilizing the injured area, I’ve divided this next section into two main parts: rest and ice. Yes, this may be a slight oversimplification, but just stick with me here. It’s time we bring out the big guns and dismantle the rationale for RICE by looking at the science. Of course, we’ll be calling on a little help from some well-respected research.
Swelling is a natural process within the body after injury. It contains the waste products of damaged tissues. Unfortunately, this waste cannot simply leave through your circulatory system, it must utilize a different network. This group of pathways is called the lymphatic system, and unlike the circulatory system, it is completely passive. You can’t rely on it to beat like a heart for you…a little bit more work is required.
When you contract your muscles, the lymphatic vessels deep inside your body are squeezed and the fluid within is forced to move. As long as these byproducts have a place to evacuate, swelling is not an issue and will gradually dissipate as healing takes place. The problem we often face, however, is experiencing a ginormous accumulation of fluid post-injury.
When you see an athlete after a sprained ankle whose leg has ballooned two to three sizes the following day, they don’t have a swelling problem…they have an evacuation problem. — Squat University
The main cause of this accumulation? Rest and immobilization. If we aren’t being active (literally) in our recovery, the lymphatic system won’t do its job of draining excess fluid. An equally large threat in this area just so happens to be ice, but we’ll get there in a moment. With physical activity comes a plethora of benefits including…
Enhanced macrophage function
Hastened waste removal
Boosted muscle repair and regeneration
Improved overall mental and physical health
By resting and immobilizing the injured site, we are missing out on all of these benefits that movement brings. This will severely delay the recovery process, and can even impact long-term outcomes.
The big draw to icing an injury is that it can temporarily numb the pain. Unfortunately, this is doing us far more harm than good. By stifling inflammation through the use of ice, we’re blunting the healing process which will contribute to slow tissue regeneration. This is a classic case of throwing a band-aid on a situation that requires much more than a band-aid.
In one 2011 study, muscle injury rehabilitation was examined between an ‘icing’ and ‘no-icing’ group. It was discovered that the ‘no-icing’ group had a significantly better macrophage response during the initial recovery phase. After a few days post-injury, there was a noticeable difference in muscle regeneration between the two groups. Several weeks into the study and the regenerating muscle of the “no-icing” group jumped to 65% larger than those who were using ice.
Please keep in mind that research always has its limitations, but there is still no denying the significance of discoveries like this one.
To hit the nail on the head, the National Athletic Trainers’ Association (NATA) released a statement that, “strong clinical evidence for advocating cryotherapy is limited.” This is a group of experts who review the top research in the world of acute injury management every year. For each recovery modality covered, they assign an efficacy rating from A to C (best to worst). Can you guess what score ice got?
Peeling Back the Band-Aid
If we look at the root for why we have believed in RICE for so long, it can be broken down into 3 faulty paradigms that we’ve been fed. If you can begin to rewire your brain into this new way of thinking, you’ll be far better off when pain comes knocking at your door.
Lie #1 —Inflammation is bad! We should be avoiding it at all costs by numbing the area.
Response: Inflammation is a completely normal process within healing. We absolutely need it to make a full recovery!
Lie #2 — Swelling is a horrible sign, but icing it will help.
Response: Swelling is another natural process within the body. Icing an injury will stunt recovery, but encouraging muscular contraction will greatly improve outcomes.
Lie #3 — We should be resting after an injury to assist in recovery.
Response: No, no, and no. Loading damaged tissue with proper exercises as soon as possible following an injury actually accelerates the healing of muscle and bone.
So, it’s clear that RICE is not the way to go. But that leaves us with a critical question: “What is the optimal recovery strategy?”.
**Quick note: The evidence for icing muscles post-workout isn’t great either. The only scenario where it may be appropriate is if you’re a high-performance athlete who is looking to recover for a same-day competition or event. For the majority of us, we’ll do far better by maintaining light activity, eating well, and prioritizing sleep hygiene. No need for ice baths!
Well, Now What?
Before continuing, it should be noted that there is no ‘one-size-fits-all’ approach to rehabilitation. Everyone’s biology and circumstances are different, so I’m by no means stating the advice below is relevant to 100% of cases. If you have a broken bone or are severely immobilized for an array of reasons, obviously there is going to be a level of rest required. For the vast majority of our aches, pains, sprains, and other acute injuries of that nature, however, the evidence is clear that we should ditch RICE and realize that movement is the way to go.
The first step is seeking professional help. Finding someone who knows when and why to begin loading up an injured site will work wonders for your recovery. The reality is, there is a right and wrong way to utilize active rehab for injuries. If you rush it, you will likely turn out worse than when you started. If you can nail a graded exposure program in a way that challenges you but doesn’t exacerbate anything, you’ll be well on your way to a full recovery. It may seem counterintuitive, but exercise is the best medicine for nearly every musculoskeletal injury.
Discerning what exercises, volume, and progressions are right for you is not easy. This is why I highly recommend you see a health professional who knows what they're doing to give you the best results.
If for whatever reason you can’t afford or access help, here’s some simple advice — move more than you think you should. Avoid long bouts of sedentary behavior, do your best to move through a pain-free range of motion, and load up the area with light resistance activities as soon as it is bearable.
Even if you’re in the initial stages of recovery (wearing a cast for instance), the simple act of isometrically contracting your muscles can work wonders to boost recovery. This may seem intimidating, but your body will tell you what it needs. As long as you’re being patient and persistent, it’s highly likely that your body will want more of the movement you’re giving it. Keep this up, and you’ll be back to feeling like yourself!
From improving macrophage function to attenuating scarring and muscle regeneration, exercise is the ultimate key to not only recover but prevent future injuries down the road.
In more ways than one, movement is truly medicine.
It’s time to let decades of history wash away. The evidence is just too strong against RICE as a rehab strategy. Not only is it delaying recovery, but it’s flat-out damaging the body’s natural responses that are required for our health and wellbeing.
I know that this is a challenging pill to swallow as this acronym has been ingrained in us for so many years. I want to encourage you in this moment, however. You now have the knowledge and tools to begin approaching pain in the right way. Celebrate that! We’ve been ignoring the life-changing effects of active rehabilitation for far too long. More than ever, we must advocate the message that movement is medicine. This has the potential to drastically change the way our society handles pain and injury management for the better.
Here’s to transforming health care as we know it.
Here’s to a speedy recovery!