Acute Pain & Swelling - R.I.C.E. Reconsidered

If you Google or ask your doctor what to do for acute pain & swelling, R.I.C.E. is often the universally accepted answer. It’s automatic; you get an injury, you ice the injury, you get back to it? Or do you? 

Since the late 70’s, the field of sports medicine has advanced greatly in how acute injury is managed, however many healthcare practitioners continue to provide outdated advice. With advanced exercise concepts and evidence based methods at our fingertips, it’s time we all catch up! 

“Do the best you can until you know better. Then when you know better, do better.”

-Maya Angelo

Today, I want to help you know better when it comes to managing acute injury. In this article, I’ll explore what actually happens when you have an acute injury and answer commonly asked questions about icing, injury management, and return to activity.  You’ll learn about the history of the R.I.C.E. method and what it’s being replaced with in current sports medicine as well as how to put these concepts into practice next time you get sidelined. 

Meet Gabe Mirkin, the American sports doctor who coined R.I.C.E. in 1978. This acronym was simple and well received throughout the sports community.  Unfortunately it is still widely taught and recommended by medical professionals and popular online sources. 

Let’s take a step back and do some simple math. The R.I.C.E. recommendation was made over 40 years ago!  Think about what you do the same, from even 20 years ago... What did you think was healthy eating? What type of exercise did you think you needed to get fit? What clothes did you think were cool? It’s likely quite different than what you know now. Even Dr. Mirkin himself retracted on his initial hypothesis back in 2015, writing that ice “may delay healing, instead of helping.”

Let’s start with breaking down what happens in our bodies/muscle tissues/cells with an acute injury. I’ll use the common ankle sprain to illustrate my points. Let’s say you’re in the middle of a trail run and lose your footing around some tree roots, ankle rolls inward and immediately you notice increased pain and swelling. No pop was felt. Whew, but it hurts to bear weight. You’re limping. It hurts and swelling is in full effect...

Now let’s take a field trip to the inside of your ankle to learn more about the phases of the inflammatory process.

Phase 1 | Inflammatory Response

Inflammation has ensued, this is your body’s way of trying to stabilize the injury. This process is initiated by your immune system, blood clots and vessel constriction occurs naturally to reduce stress on the injured area. Conversely, vessels around (above + below) the injured ankle are dilating to allow the body’s “clean up crew” to come in and do its job. These are the cells that facilitate cellular repair and removal of damaged tissue.  Pain is common during this phase. It’s likely that you’re experiencing pain in and around your ankle, which increases if you bear weight or use the muscles around the foot and leg. One other thing, it’s likely that your pain will move during the course of a day or from one day to the next.  This coincides with the swelling fluctuation as well as the movement compensations that you’ll adopt to avoid further injury. This phase usually lasts 2-7 days.

What to do instead of R.I.C.E. ? 

The goal of this treatment phase is to reduce pain, reduce swelling, and protect the area with a minimum effective dose of gentle movement & stretching as prescribed by your physical therapist. If you were to ice, compress, and elevate without utilizing ROM and stretching, you are missing the boat and delaying recovery. The ice will not only constrict the blood flow, but the numbing effect it has on your skin will impair the “clean up crew” to know where to go to do its job. 

Phase 2 | Proliferation

Once inflammation has been reduced, you enter the proliferation phase. This is when your body begins laying down new tissue as well as scar tissue (which is less organized than skeletal muscle tissue.) During this phase, your ankle swelling is minimal and usually swells in response to doing too much too soon. Because the injured area is still undergoing internal repairs, the strength and resilience of the tissue is not structurally sound so caution is taken as you introduce advanced range of motion drills, balance work, and strengthening exercises. This stage lasts 4-6 weeks. 

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What to do instead of R.I.C.E.?

The goal of this treatment phase is maintaining pain and swelling reduction while restoring normal range of motion, strength, stability, and balance. By working with a physical therapist, you can map out your return to activity with appropriate progressions and modifications. For an ankle, we start with gentle mobility and resistance training paired with balance exercises. Getting back to running requires significant balance, single leg strength, and impact tolerance which is built through gradual progression of exercise difficulty and number of foot contacts/repetitions.  

Phase 3 | Remodeling 

This phase is long, lasting from 6 weeks to several months. This phase is highly dependent on the measures taken in phase I & II. At this stage, your range of motion has been restored to 80-90% and swelling is controlled- if you’re swelling in this stage, it’s likely because you’re prematurely loading the structures, otherwise known as “doing too much too soon”. During this phase the collagen fibers of your muscles, tendons, and ligaments are remodeling and becoming organized in response to gradual loading.  (Loading refers to exercises, stretch & mobility drills, strengthening, balance, plyometrics, and a guided return to run program). 

As you stress the tissue with a progressive exercise program, these structures become stronger to meet these new demands, in turn decreasing your risk for re-injury. As you can imagine, there is a sweet spot of maintaining an appropriate challenge while not exceeding the capacity of the healing tissues. Another reason that working with a physical therapist is key in achieving complete recovery!

Now, let’s circle back to the R.I.C.E. theory.  The drawbacks of utilizing this method come down to it being inherently passive. Think about what you do if your vehicle's engine light comes on. Ignoring it doesn’t make the problem go away. Parking it in your garage and not using it- also will not fix the issue. Similarly, your ankle will only experience temporary relief with sole use of the RICE method. Rest, ice, compression, and elevation aren’t bad- it’s just that in most cases, there is a smarter, better way to manage these injuries and that’s using the M.E.A.T.  protocol. 

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M: movement
E: exercise
A: analgesics
T: treatment

Movement | Controlled movement of the affected area and surrounding joints. Movement should be controlled and within the limits of pain. The result of gentle movement during phase I has been shown to promote blood flow to the affected are and helps stimulate organized growth of new tissue

Exercise | Exercising through an acute injury takes patience and creativity.  I tell my patients (and myself!) that this time of recovery is an opportunity to work on areas that need more attention. Make the most of this time! It’s important to maintain your activity level while respecting the affected area. The exercises you choose should not require one side/non injured side to work harder. (i.e. Squats, lunges, deadlift type movements are not recommended as you will push dominantly on the non injured side, potentially leading to back and hip injuries.) 

In our ankle sprain case, during Phase I and possibly part of Phase II, use of a stationary bike, upper body bike, or ski erg may be appropriate. Weight training and HIIT style workouts are incorporated without compromising the ankle. At Sergent Wellness, your physical therapist works alongside a ReIntegration specialist to develop workouts that keep you moving at your highest level. 

Analgesia | Also known as pain relief, I recommend natural methods to achieve reduced pain and swelling. Doterra’s Deep Blue rub is a blend of therapeutic grade essential oils that offers a soothing, cooling sensation to the affected area. Nutrition plays a powerful role in injury recovery. Eating nutrient dense, whole foods, drinking water, and use of inflammation managing herbs and spices creates an internal environment fit for healing. Check out this infographic for more info.

Treatment | Treatment refers to techniques administered by your physical therapist that facilitate a safe and efficient progression through each phase of your recovery.  Some examples of treatments include dry needling with electrical stimulation, deep tissue massage, joint mobilizations (these are like stretches for your joints),  and exercise prescription.  At Sergent Wellness, treatment programs are comprehensive and individualized, designed with consideration of the patient's history, activity level, job/sport requirements, and goals. 

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If your goal is to lead an active lifestyle, having a baseline understanding of what to do if when you get injured will largely impact how well you can sustain the active lifestyle through all your years. 

Feel free to share this information with your favorite workout partner, athlete, and friend. Now get moving!!