Sprain your ankle playing sports? Strain your wrist in a throw?  It’s likely you will be told to RICE your injury by your coach, your well meaning neighbor, or your physician (and no, that’s not a reference to the grain grown in waterlogged fields in central and eastern asia).

RICE, which stands for Rest, Ice, Compression, and Elevation, is the go-to formula for treating acute inflammation following a muscle, ligament, or tendon strain. Its goal is to reduce pain and swelling during the initial stage of recovery and prevent further injury. The benefits of RICE are that it’s easy to self-administer at home, generally applicable to most injuries, and doesn’t require in-depth medical knowledge or expensive materials. You can use a variation of the formula when treating anything from a sprained ankle to a biceps strain or a stressed wrist.

However, while there is logical reasoning behind each stage of the RICE formula, clinical research supporting its benefits is not well established.  Because of the number of variables involved in acute strains and sprains (severity, ligaments damaged, condition of the patient, etc) it has been difficult to for researchers to put together a conclusive study (This is not uncommon for many musculoskeletal situations - the people and the injuries are so complex as to make research difficult).  However, one study of looking at ankle sprains in adults gives us a small view into how RICE application actually works. (link study)

The logic is thus:

• Rest both reduces the demands of the afflicted tissue (reducing blood flow and swelling) and helps to avoid stress on already injured tissues
  
  
• Ice reduces swelling by lowering the energy demand of the localized area and contracting blood vessels to decrease blood flow. It also reduces pain by numbing the nerves in the stressed area.
  
  
• Compression stops the internal bleeding from damaged capillaries and helps reduce swelling.
  
  
• Elevation lowers the blood pressure in the area to limit bleeding and increase drainage. 
  

In practice, each aspect of the formula has some qualifiers that need to be addressed. As for most injuries, treatment needs to be modified for the individual and the injury in question. Also, the greatest benefit from all of these would be when implemented immediately.

Of all the steps in RICE, Rest requires the most modification. Research shows that while some rest is good for a sprained joint, exercise and manipulation help to improve muscle strains. Too much rest can become an issue if the joint is kept immobile and the muscle tone starts to degrade. The goal of resting an injured limb is to protect the stressed joint in order for rehabilitation. We want to avoid over-activity and reduce risk of further injury by a poorly performing limb, but we don’t want to increase the recovery time by losing strength and stability from prolonged immobilization. Instead of simple rest, we advocate for Protection with early activation. This can include rest, but also involves protected movement such as bracing, the use of a crutch, aircast, etc. so that graduated controlled motion is added to the recovery plan.

Ice, the next part of the RICE formula, is fairly uncontroversial. Research recommends an icepack (separated from the skin by a thin cloth or towel) or other cooling device placed on the injured joint for 12-20 minute sessions 1-3 times per day. One of the challenges of ice treatment is that it can chill the individual and cause them to tense their strained muscles. If localized ice application gives you the chills, try warming the rest of the body with a heat pack on the stomach to help you relax and enjoy the benefits of cold and heat together.

Compression and Elevation, the final two aspects of RICE, are much harder to research effectively. Their role in initial reduction of swelling by preventing further bleeding is reasonable, and there is no evidence to refute it. However, prolonged use of compression may be unnecessary and we recommend it only for the first day with most injuries. Only in serious muscle contusions and hematomas will the bleeding continue for more than a day and it is important to focus on other aspects of the recovery.

Tennis Elbow. Jumper’s knee. Pitcher’s Shoulder. Repeated actions, such as those performed during many sports, can break down the integrity of a tendon over a period of time. This type of injury is referred to as tendinosis.* 

Unfortunately, the recommended treatment for tendinosis is an exercise regime that often increases soreness in the present. Multiple studies over the past few years have shown that graded eccentric exercises (the lengthening of a muscle under stress) build muscle strength and control in ways that decrease pain and repair tendinosis. However, these types of exercises tend to be more difficult and can increase soreness in the short term.*

Think of the portion of the bicep curl following a lift in which you slowly lower the dumbbell - the eccentric portion of the exercise - and remember the muscle strain.

To ensure that our tendinosis patients aren’t aggravating sore muscles without result, we lay out a recovery plan that is patient and injury specific. We start with a passive approach that breaks down weak tissue and readies it to be replaced with stronger tissue. Then we adjust the biomechanics to decrease the stress on muscles and tendons. We want to ensure correct form so that we do not compound the pain of the injury with bad strength training technique. Next we add in progressive passive to active exercises that include both concentric (muscle contraction) and eccentric (muscle lengthening) exercise. And finally we finish the repair work by polishing off muscle control with eccentric exercises. Of course, after the tendon has been repaired and the muscle strengthened, we will still need to work on regaining the speed and coordination that may have been lost during recovery time.

Remember that exercise routines including eccentric exercise can (and are expected to) flare up symptoms and pain in the short term. As such, tendinosis recovery requires patience and long term focus.

We encourage individuals who are suffering from a long term injury such as tendonisis to consult with a specialist on the specific injury and recovery plan.

Tendinitis, an acute inflammation following tendon or muscle strain, is often confused with tendinosis and requires a very different treatment plan. If you have ever sprained an ankle, it is likely you’ve had tendinitis. However, if you sprain your ankle over and over again you could be developing tendinosis. In next week’s post we’ll address popular and research based treatment for tendintis like sprains and strains (spoiler: the Rest Ice Compression Elevation formula might not be as effective as popular treatment would have us believe).

However, if you have a tendinitis strain that hasn’t recovered (still walking around on that sprained ankle?) or that happens over and over, you may be developing tendinosis, so come see us and we’ll work together on finding a solution.

*Tendinosis can be accompanied by enthesopathies, an exquisitely tender spot on the bone happens when an enthesis (the region in which a tendon meets the bone) has been strained and requires a similar recovery schedule.

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