1978 – a year in which average gas price was $0.63, Jimmy Carter was president of the United States, Kobe Bryant was born and Pete Rose hit his 3000th hit. You are most likely thinking what in the world does any of that have to do with injury management? Well, something else significant occurred in the sports medicine field in 1978, which was the coining of the acronym “RICE,” which is short for Rest, Ice, Compression and Elevation. A seemingly simple and well-received injury management method, coined by Dr. Gabe Mirkin caught on very quickly. Let’s fast forward 39 years. In 2017, the sports medicine field is conducting ground-breaking research and making advances in athlete and patient care every single day. But in terms of injury management, we have been stuck in a time capsule. Do you know what that time capsule was filled with? A whole lot of RICE (see what I did there).
In all seriousness, the way we have been handling injuries has been subpar, and because of our lack of efficiency in the management process, athletes have been on the sidelines longer than needed. It should be noted as well that this problem is multifaceted and isn’t entirely on clinicians. The RICE technique and its core components are still being taught in classrooms today. My goal is to help you understand what we can do better. In this article, I will dive into what we have been doing wrong for so long, why it isn’t working and what we can do moving forward to facilitate the healing process more efficiently.
To start, I will give you a new acronym, yes I realize it seems like we throw many of these at you, but this one needs to stick and it is easy to remember. It is coined as the “POLICE” method.
P – Protect the Injury
OL – Optimal Loading
I – Ice
C – Compression
E – Elevation
You may notice there are still aspects of the POLICE method that overlap from RICE, and that is purposeful, but these aspects are modified from how they’ve been used, and it’s been proven to be much more effective in how injuries are managed.
When we talk about protecting the injury, this has not changed much from the initial response during the RICE method. The most important thing initially is to rule out a severe injury. The likes of a fracture, dislocation, severe sprain or strain should be referred on to a sports medicine physician. In the absence of those injuries, (that is not an exhaustive list) the next course of action is extremely essential. When we look at the initial action in the RICE technique, we know the “R” represents rest. Let’s take a basic lateral ankle sprain for example. In the past, if an athlete came off of the field after rolling their ankle, many times we would let them rest until the pain wasn’t as severe, at times this could take 2,3,4 days. Well, in that time period what have we accomplished? Wasted time. During that rest period, the athlete has not made any useful steps towards recovery. Additionally, the injured joint, in this case the ankle, will become much stiffer, due to lack of activity and the athlete will lose joint mobility and surrounding soft tissue flexibility. So, after that initial resting period you then must address these mobility/flexibility issues, which can take another few days to fully restore proper function. By this time, a week has been lost. See the problem here? Instead of wasting all of that time and losing precious seconds during the acute inflammatory process, begin gentle early range of motion, (ROM) or optimal loading.
This idea of optimal loading is essentially early ROM exercises that aim to keep and restore full function of the injured joint post-injury. To give an example of this, let’s revisit the ankle sprain. When the athlete comes off the field and a severe injury has been ruled out, immediately begin gentle ROM exercise and progressively make it more difficult. Have the athlete prop the foot up on a wall or even a coach’s hip. From there, the athletic trainer or coach can begin to take the ankle through dorsiflexion and plantar flexion passively for 5 minutes while the athlete is just relaxing and not actively contracting. Once this has gotten comfortable for the athlete, the athlete can then begin active ROM in the same position as before for another 5 or so minutes. This is fully active by the athlete with the idea that the combination of the muscle contractions and elevation will help again restore the full ROM of the ankle, but also assist in reducing the swelling that will occur. The final step of the optimal loading is to add resistance to the ROM exercises to really facilitation strong muscle contractions. Keep in mind, this is immediately post-injury, so you don’t need to be cranking on the foot, just providing some solid resistance. This is should be completed for another 5 or so minutes and this can be completed with all directions of the ankle in addition to clockwise and counter-clockwise circles, ABC’s and so-on.
The elevation aspect allows gravity to assist in the prevention of swelling. Gravity itself is constantly pulling us towards the earth, so why not use that to our advantage? When the ankle is elevated in that position it assists with the help of the muscle contractions of pulling that swelling away from the injured structure. The swelling is the biggest detriment in the healing process. The inflammatory response is essential in healing, but the swelling itself is harmful to the tissue. It compresses nerves, ligaments and other structures and essentially chokes the injured area and does not allow proper function, leading to more dysfunction and a longer recovery process.
The compression aspect is extremely important as well and should be coupled with optimal loading and elevation. Compression should be used as commonly and as without thought like ice is used now. This mechanical compression of the injured area allows further prevention of swelling in the injured joint area. When wrapping a compression sleeve onto an injured ankle for example, you need to keep in mind you want the swelling to be pushed away from the foot. To do this, you must begin your wrap at the base of the toes with a healthy amount of pressure and as you progress up the foot over the prominent ankle bones (lateral and medial malleoli) you begin to ease that pressure to allow the swelling to be pushed in that direction………… So, at this point you may be asking yourself, “Well what about ice?”
Ice is the most overused and misused injury modality. It is widely used for its “ability to reduce swelling and increase the speed of the healing process.” To put it bluntly it does not do either of those things, and it actually causes healing to slow down. When an injury occurs, your body sends inflammatory cells in the blood to begin the promotion of healing by secreting or releasing certain substances. When you apply ice to the injured area, it slows and prevents the release of these beneficial inflammatory substances. Additionally, when you add ice to an injured area, the ice will constrict your blood vessels and slow blood flow needed to that area. This can cause delayed healing and in severe cases irreversible damage to blood cells and other structures essential to the healing process. Ice is beneficial in reducing perception of pain, so it can be beneficial before rehabs or simple pain management, but beyond that, we really need to get away from the very common practice of “ice and elevate.” IF YOU ARE GOING TO USE ICE, here are a few recommendations:
*Apply ice directly to skin or else you will never reach desired cooling of target tissue
*Be conscious of the tissue depth you are trying to target (not 20 minutes on/20 minutes off)
*Again, you need to achieve proper cooling of target tissue
*Ex: Ice application to the quadriceps compared to an ankle will drastically differ
I hope this has been somewhat informative and hopefully has you questioning some things you have learned in the past, or even questioning things that I have stated in this article, which is great because discussion breeds learning. Please reach out if you have any questions regarding this article and look forward to an article soon about the use of heat or lack thereof during the injury management process. Have a great day and ALWAYS REMEMBER to #HealByMoving.
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