It’s the most famous acronym in sports medicine, a household term as familiar to athletes as the physicians who treat them: R.I.C.E., for rest, ice, compression, and elevation.
Legendary sports doc, Gabe Mirkin, M.D., coined R.I.C.E. in his 1978 bestseller, The Sportsmedicine Book. In the four decades since, his memorable protocol—especially the ice and rest components—have become an article of faith among wounded warriors everywhere.
PUT DOWN THE ICE PACK. STEP AWAY FROM THE BAG OF FROZEN PEAS. TURNS OUT, WE’VE BEEN TREATING OUR INJURIES ALL WRONG FOR DECADES.
Tweak your ankle, throw out your back, strain your rotator cuff, or upset any other soft tissue during exercise? R.I.C.E. it right away! If no ice bag is available, slap a bag of frozen vegetables onto your aggrieved part. By icing an injury within the first golden hour of sustaining it, you’re virtually guaranteed of not only reducing pain but speeding recovery. Ditto for rest—taking time off to let things settle down will prevent further damage and also expedite healing. Everybody knows this, right?
But what if R.I.C.E. is wrong?
“Nearly everyone who ices today,” says veteran athletic trainer Gary Reinl, “believes they’re doing it to prevent inflammation, reduce swelling, and control pain. But here’s the problem: Icing doesn’t prevent inflammation or swelling; it only delays it. Once tissues rewarm, the inflammatory process resumes and your body’s innate intelligence sends the correct amount of fluid to the damage site. Although icing can provide temporary pain relief, numbing just shuts off protective signals that alert you to harmful movement. And the Journal of Athletic Medicine Research recently showed that icing actually kills muscle cells.”
The latter study is hardly the only one to raise questions about icing. Reinl, for his part, says he used to be a true believer in the healing properties of the big chill, but he became skeptical after searching the medical literature for the best ways to ice different injuries.
What he discovered shocked him. A meta-analysis in the British Journal of Sports Medicine, for example, investigated 22 separate studies and concluded that “ice is commonly used after acute muscle strains, but there are no clinical studies of its effectiveness.” A report in the Journal of Strength and Conditioning Research was even more alarming. Not only does icing fail to help injuries heal, the authors found, it may well delay recovery from injury.
And subsequent research at the University of Pittsburgh Medical Center found evidence that icing sore muscles may be detrimental to recovery. Researchers at the Cleveland Clinic have even identified a likely reason: Icing an injury delays the release of IGF-1 (insulin-like growth factor-1), a key hormone unleashed by immune cells to repair damaged tissues.
“Icing just doesn’t work—it actually screws things up,” says Reinl, whose new book, Iced! The Illusionary Treatment Option, is dedicated to encouraging doctors and athletes to move out of the ice age.
You might think that Dr. Mirkin would bristle at this blow to his erstwhile recommendations. Not so—he now openly rejects at least half of the R.I.C.E. advice that helped make him famous. “I do not believe in cooling anymore,” he explained via email. Nor does he believe in the “R” component of his famous prescription either.
In a foreword to the second edition of Iced!, Dr. Mirkin says most athletes are far more concerned with long-term healing than transient pain relief. “And research,” he writes, “now shows that both ice and prolonged rest actually delay recovery.”
As for why keeping injured tissues moving works better than immobilizing them, the exact mechanisms await further research. “We don’t understand everything about this yet,” Reinl concedes, “but we do know that stillness is the enemy. If you remain still, everything shrinks and atrophies—your muscles, bones, ligaments, everything.”
Careful muscle activation, by contrast, has the opposite effect. Contractions around lymphatic vessels clear waste and increase blood circulation to damaged tissues. This, in turn, increases deposition of replacement collagen and boosts the “remodeling” process that pulls apart scar tissue and makes it functional.
A growing cadre of sports medicine specialists now agrees: Trying to interrupt the body’s innate healing mechanisms can backfire. Humans have been evolving for hundreds of thousands of years, and neither cryotherapy nor prolonged bedrest were viable options for our ancestors. They depended instead on natural healing.
“The human body is absolutely remarkable,” acknowledges Nick DiNubile, M.D., an orthopedic surgeon and former team physician for the Philadelphia 76ers. “Most of the time it knows what it’s doing. I still believe there’s an occasional place in the medical bag for ice—for acute pain, for instance, it’s certainly preferable to Percocet or Vicodin. But you really have to be mindful of what you’re trying to accomplish before you throw in the ice pack.”
So if R.I.C.E. is no longer the answer, what’s a better strategy for expediting your return to the field of play? Reinl, for his part, believes the answer lies in a new acronym: A.R.I.T.A.—active recovery is the answer.
There are exceptions, of course—you may have no choice but to immobilize a limb, say, with a compound fracture. But for most garden-variety sports injuries, Reinl suggests resisting the urge to ice away your pain and plop down on the couch for days. Instead, let your pain level be your guide and keep on moving as much or as little as your mending body allows.
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