Sports Injuries – RICE: Why We Do Not Recommend It
At Caring Medical, we treat athletes of all levels, every day. We recommend that to treat acute sports injuries, not with RICE, but with MEAT. The R.I.C.E. treatment is the conventional method of pain management and sports injuries today. Just go to any emergency room or sports trainer with an acute ankle sprain or other ligament injury, and the injured person will be given these instructions: Rest, Ice, Compression, and Elevation.
Most people would also receive instructions to take anti-inflammatory medications. This treatment is recommended because ligament sprains are sometimes accompanied by quite a bit of swelling, called edema. The premise with the RICE treatment is that the swelling and edema is harmful to the tissue. Where did such a preposterous idea originate?
Unfortunately, sports medicine specialists and athletic trainers fell into the trap that muscles were like tendons and that tendons were like ligaments. Muscles, unlike ligaments and tendons, are encapsulated within a tight, compartmental, special tissue called fascia. These fascial sheaths only have a limited amount of space and in high-energy trauma, as can occur in sports, this limited space can be encroached upon by a hematoma (blood clot in the muscle) or be externally compressed by a hematoma in another compartment (or broken bone, etc.).
This increased tissue pressure within the fascial sheath that contains the muscle causes a decrease in the blood circulation (malperfusion), causing further tissue damage. This further tissue damage causes an increase in the edema, which increases the pressure in the space even more, causing even less oxygen to get to the injured tissues (hypoxia), which causes the pH in the tissue to be decreased (acidosis) and a vicious cycle is set up. This continued increase in a specific muscle facial sheath is called compartment syndrome.
Compartment syndrome, if not immediately taken care of, quickly progresses to permanent muscle, nerve, or circulation damage. RICE treatment is very effective at eliminating edema, so it could, theoretically, prevent a compartment syndrome situation from occurring. What occurred in the early 1970s, unfortunately for the athletes of the world, is that sports medicine doctors and trainers started treating every injury as if it was going to turn into compartment syndrome.
A muscle, tendon, or ligament injury is very easy to identify on physical examination. The first thing to do is ask the athlete to point to the injured or painful area. The very astute clinicians would also inquire if the big black and blue area on the skin was the area of the injury. Since muscles are completely different than ligaments and tendons, the treatment regime for muscles does not apply in any way to ligament and tendon injuries.
The main difference between muscles and ligaments is that muscles are massively strong structures with a tremendous blood supply, both outside and inside the muscle (this is why steak is red). Ligaments, on the other hand, are small tissues that have a poor blood supply both inside and outside of the ligament (why they appear white). Muscles, because of their good circulation, heal quickly and rarely cause a long-term problem, whereas ligaments, due to their poor blood supply, often heal incompletely and are the cause of most chronic sports injuries and pain. It is our opinion that nonhealing ligaments are the number one cause of early retirement in athletes.
Understanding the difference between ligaments and muscles is crucial to understanding why the RICE treatment is totally inappropriate for healing ligaments. One of the main protective mechanisms of the body is the fight-or-flight response. During the fight-or-flight response, the blood flow to the muscles may increase a dramatic 25-fold during strenuous exercise. Exercise also has specific, direct effects on muscles themselves. Muscles may hypertrophy (get bigger) by up to 60 percent. This hypertrophy occurs because of an increased diameter of the muscle fibers. The energy storing and releasing capability of the muscles then becomes much greater. The person manifests this by becoming stronger and faster. More weight can be lifted and longer distances run before exhaustion. Contrast this to the effect of exercise on ligaments. Exercise does not notably increase the blood supply to ligaments. (Akeson, W. et al. The Chemical Basis of Tissue Repair. Chapter 6 in Rehabilitation of the Injured Knee. Hunter, L., editor, 1984, St. Louis, MO: Mosby, pp 93-148.)
This is probably because the ligament is not important in the fight-or-flight response. It is not involved in the defense of the body if attacked. The ligaments are always strong and on alert (unless injured). The strength of the ligament is dependent on stress to the joints to maintain ligament strength. Exercise does not have the profound stimulatory effect on ligaments that it has on muscles.
Why Say No to Rest, Immobilization, and Ice?
Ligaments are made up primarily of type I collagen. This particular type of collagen is very resistant to stretching (has a high tensile strength). Collagen is a type of protein, therefore the collagen is made up of amino acids, building blocks of protein. What most people do not know is that the collagen in ligaments is thought to remain relatively metabolically inert, with a half-life on the order of 300 to 500 days. This means that the metabolism of collagen is very, very slow. It is a good thing this is true, because blood supply to ligaments is so poor. This is another reason ligaments heal so slowly and are so prone to injury. Muscles, on the other hand, have a tremendous blood supply that can increase 25-fold during strenuous exercise. Anything that decreases the metabolic rate or blood supply to the ligaments will further promote the decline of the ligaments, and profoundly delay their healing.
The Detrimental Effects of Ice on Sports Injuries
The cells that make up ligaments, tendons, and organs are extremely temperature-sensitive. The metabolic rate at which these cells function is directly proportional to the temperature in their environment. For each 10 degree Celsius change in the temperature, there is a more than two-fold increase in the cell metabolism. (Guyton, A. et al. Textbook of Medical Physiology. Philadelphia, PA: W. B. Saunders, 1996, p. 620.) In other words, in order to increase cell metabolic rate by more than 100 percent, the temperature of the tissue must increase by 10 degrees. Conversely, cooling tissue will decrease that cell’s metabolism.
It is obvious that ligaments require improved circulation to the area in order to heal after an injury, since the blood supply to ligaments is normally so poor. Yet ice is arguably the most widely used therapeutic agent in medicine today, which most definitely decreases circulation. Ice has been shown to be one of the most efficient forms of cryotherapy, and is often the first line of treatment for traumatic injuries. As with many common and time-honored remedies, the use of ice has developed over time. The effect of ice on the tissues and their healing has not been studied in depth until recently.
Research on the negative effects of icing injuries
In one landmark study done at the University of Hawaii, Dr. Sherwin Ho and associates, put a commercially-available ice wrap on one knee for 20 minutes, and on the opposite knee a wrap was placed at room temperature. The knees were then injected with dye and scanned for blood flow. The study showed that all iced knees demonstrated a decrease in arterial and soft tissue blood flow, as well as decreased bone uptake of the dye, which is a reflection of changes in both the bone blood flow and metabolic rate. The average decrease in arterial blood flow was 38 percent, 26 percent in soft tissue blood flow (ligaments), and 19 percent in bone uptake. In the 21 people studied, the “ice effect” was not related to age, sex, knee circumference, or skin temperature after cooling. The authors go on to conclude that these findings provide a scientific rationale for the use of ice in limiting further hemorrhage and cell injury after traumatic musculoskeletal injuries and surgical procedures.
See the thinking in modern medicine? The last statement would only apply if swelling were occurring in a closed space, leading to the development of a compartment syndrome. This only occurs in muscles (and only those with a lot of damage) and never occurs in ligaments. The last statement would, therefore, not apply around the knee which is full of ligaments. The last statement in the article should read, “The findings provide a scientific rationale as to why ice should not be used in acute ligament injuries because ice has a dramatically negative effect on circulation and cell metabolism.” The net effect would be impaired or at best, delayed, soft tissue healing. The decrease in bone was measured a full two hours after the ice wrap was removed. Imagine what the decrease in blood flow to the bone was during the ice wrap? The weak link in the musculoskeletal system that is responsible for most non-healing sports injuries is at the point where the ligaments attach to the bone. These studies show that ice decreases both the soft tissue (ligament) and the bone blood flow. Realize that the blood flow decreased significantly with only a 20-minute wrap. Many athletes ice their injuries for much longer than 20 minutes. The next time the trainer comes toward you with an ice pack, tell him, “Thanks, but no thanks. I want my injury to heal.”
Dr. Ho had already published articles in 1990 on the negative effects of ice, where he showed that as little as five minutes of icing a knee can decrease both blood flow to the soft tissues and skeletal metabolism. He found that icing a knee for 25 minutes decreases blood flow and skeletal metabolism another 400 percent! (Ho, S. Comparison of various icing times in decreasing bone metabolism blood flow in the knee. American Journal of Sports Medicine. 1990; 18:376-378.)
Healing is hindered by a decrease in blood flow and metabolism to the area. Icing increases the chance of incomplete healing by decreasing blood flow to the injured ligaments and tendons. This increases the chance of re-injury or the development of chronic pain.
Did you ever wonder why almost all athletic trainers and therapists ice a limb for 20 minutes? Why not 15 or 30, but always 20? It does not matter if you are in France, Idaho, or Germany, they all ice for 20 minutes. In 1980, at the American Orthopedic Society meeting for Sports Medicine in Big Sky, Montana, and then again in American Journal of Sports Medicine, physicians from the Louisiana State University School of Medicine reported on five athletes who obtained nerve palsies (nerve injuries usually to the peroneal nerve that moves the foot up) from too much ice around the knee. The conclusion of the article was, “Applying ice for more than 30 minutes, and preferably for not more than 20 minutes, should be strictly avoided.” (Drez, D. et al. Cryotherapy and nerve palsy. American Journal of Sports Medicine. 1981; 9:256-257.) They reported that one of the athletes still had a nerve palsy at nine months. Here is our answer. You are iced for 20 minutes because the athletic trainer or therapist does not want to give you nerve palsy!
Immobilization and Rest Are the Worst!
Immobilization, also known as stress deprivation, is extremely detrimental to the joints and ligaments. Immobilization causes the following changes to occur inside joints:
1. Proliferation of fatty tissue within the joint
2. Cartilage damage and necrosis
3. Scar tissue formation and articular cartilage tears
4. Increased randomness of the collagen fibers within the ligaments and connective tissues
5. Ligament weakening with a decreased resistance to stretch (Laros, G. Influence of physical activity on ligaments insertions in the knees of dogs. Journal of Bone and Joint Surgery. 1971; 53:275; Arnoczky, S. Meniscal degeneration due to knee instability: an experimental study in the dog. Trans. Orthop. Res. Soc. 1979; 4:79.)
Both intra-articular and extra-articular (inside and outside, respectively) ligaments and periarticular (joint soft tissue) connective tissue are brutalized by immobility. Gross inspection of the ligaments after stress deprivation shows them to be less glistening and more “woody” on palpation. Under a microscope the collagen of the ligament is very random. Chemically, the ligaments lose water and glycosaminoglycans (which help maintain structure) so there is a net loss of mass in the ligaments. There is also more degradation of the collagen with stress deprivation. These changes translate to a much weaker structure.
In one study, knee ligaments immobilized for even a few weeks showed that the ultimate load, linear stiffness, and energy-absorbing capacity of a bone-medial collateral ligament-bone preparation is reduced to about one third of normal. (Ford, H. Physiology of Soft Tissue Healing. Chapter 4 in Rehabilitation of the Knee: A Problem Solving Approach by Bruce H. Greenfield, 1993, Philadelphia, PA, F.A: Davis Company, pp. 85-109.)
In addition to weakening of the ligaments themselves, immobilization decreases the strength of the fibro-osseous junction where the ligament attaches to the bone.
If rest and immobilization hinders ligament and tendon healing, then studies should show that early mobilization and exercise helps soft tissue healing. This is exactly what has been shown. For this reason a much better approach to healing sports injuries is the MEAT regime.
Why We Don’t Recommend NSAIDs
Non-steroidal anti-inflammatory medications.
NSAIDs Hamper Ligament and Tendon Healing
The following statement comes from a well-known sports medicine book that has gone through five printings. “In spite of the widespread use of NSAIDs there is no convincing evidence as to
their effectiveness in the treatment of acute soft tissue injuries.” (Bruckner, P. Clinical Sports Medicine. New York City, NY: McGraw-Hill Book Company, 1995, pp. 105-109.)
This is a true statement, but definitely not strong enough. More appropriate would be something like, –In spite of the widespread use of NSAIDs there is substantial evidence that they hamper soft tissue healing.–
NSAIDs have been shown to delay and hamper the healing in all the soft tissues, including muscles, ligaments, tendons, and cartilage. Anti-inflammatories can delay healing and delay it significantly, even in muscles with their tremendous blood supply. In one study on muscle strains, Piroxicam essentially wiped out the entire inflammatory proliferative phase of healing (days 0-4). At day two there were essentially no macrophages (cells that clean up the area) in the area and by day four after the muscle strain, there was very little muscle regeneration compared to the normal healing process. The muscle strength at this time was only about 40 percent of normal.(Greene, J. Cost-conscious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis. Archives of Internal Medicine. 1992; 152:1995-2002.)
The authors concluded that NSAIDs might delay muscle regeneration, when their study did in fact show delayed muscle healing. But you know politics…
Another study confirmed the above by showing that at day 28 after injury the muscle regenerative process was still delayed. The muscles of the group treated with Flurbiprofen (NSAID) were significantly weaker. The muscle fibers were shown under the microscope to have incomplete healing because of the medication. (Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123.)
The key question regarding the healing of sports injury is, “What exactly does any therapy do to the fibroblastic cells that actually grow the ligament and tendon tissue?” Treatments that stimulate fibroblast proliferation will cause ligament and tendon repair and will help the athlete heal. Therapies that kill or hamper fibroblastic growth will be detrimental to the athlete.
In 1993 at the University of North Carolina School of Medicine, Division of Orthopaedic Surgery, Sports Medicine section, Dr. Louis Almekinders and associates studied human tendon fibroblasts to determine the effect of exercise and the NSAID Indomethacin on fibroblasts. Group I was the control in which no treatment was done; Group II-the tendons were exercised; Group III-the tendons were exercised and anti-inflamed with Indomethacin; and Group IV the tendons were just anti-inflamed with the Indomethacin. All the tendons underwent injury through repetitive motion, similar to what would happen to an athlete in training. Seventy-two hours after the injury, it was noted that compared to controls the only group that showed increased levels of prostaglandins was the exercised group. The group that was exercised and received the NSAID, as well as the NSAID group, had statistically significant lower levels of prostaglandins (specifically Prostaglandin E2) in the tendons. This showed that the NSAID blocked the inflammatory healing of even the tendon injuries that were exercised or rehabilitated. The tendonitis that was treated with just the NSAID had almost no prostaglandins in the sample, signaling a complete inhibition of the inflammatory healing process. The effect was even more pronounced at 108 hours.
The researchers also measured DNA synthesis in the fibroblasts. This showed which fibroblasts were proliferating. Again, the exercised group was the only group that exhibited elevated levels of DNA synthesis in the fibroblasts. Compared to the control group there was 100 percent more growth of fibroblasts in the exercise group. The tendons treated with Indomethacin had no DNA synthesis noted.
This showed there was no fibroblastic growth occurring. The group that exercised and took the NSAID showed a little bit of growth. The authors concluded, “Motion and prostaglandin release in Group II were associated with increased DNA synthesis. Inhibition of prostaglandin by Indomethacin also coincided with a decrease in DNA synthesis… Inhibition of prostaglandin synthesis, and thereby DNA synthesis, may not be desirable during the proliferative stage of a soft tissue injury, when DNA synthesis for cell division of fibroblasts is needed to heal the injury to the tendon.” The paper also stated a fact that many researchers in this field are wondering, “Despite the lack of scientific data, NSAIDs are widely used, often as the mainstay of treatment.” (Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123.)
Another study was done on the use of perhaps the most popular anti-inflammatory medication used in sports medicine, ibuprofen, in the treatment of tendon injuries. It was found that only thing the ibuprofen doses used in the study caused the strength of the flexor tendons to decrease. A decrease in strength of the flexor tendons of 300 percent was observed at four weeks. The peak force of the flexor tendons of controls was 12.0 newtons, whereas in the Indomethacin group it was an average of 2.5 newtons. Extensor tendon analysis showed similar results, with controls having a breaking strength of 12.0 newtons and the tendons treated with the NSAID, 3.5 newtons. The authors noted, “Examination of the data reveals a marked decrease in the breaking strength of tendons at four and six weeks in the ibuprofen-treated animals….This difference was statistically significant.” (Kulick, M. Oral ibuprofen: evaluation of its effect on peritendinous adhesions and the breaking strength of a tenorrhaphy. The Journal of Hand Surgery. 1986; 11A:100-119.)
From the above studies, it is clear that NSAIDs inhibit the fibroblastic growth process and thus diminish an athlete’s chance of healing. NSAIDs are used because they decrease pain, but they do so at the expense of hurting the healing of the injured soft tissue. A good example of this is a study on the use of Piroxicam (NSAID) in the treatment of acute ankle sprains in the Australian military. Compared with the placebo group, the subjects treated with Piroxicam had less pain, were able to resume training more rapidly, were treated at lower cost, and were found to have increased exercise endurance on resumption of activity. The conclusion of the study was that NSAIDs should form an integral part in the treatment of acute ankle sprains. (Slatyer, M. A randomized controlled trial of Piroxicam in the management of acute ankle sprain in Australian regular army recruits. American Journal of Sports Medicine. 1997; 25:544-553.) At first glance in reviewing this study, NSAIDs appear to be great, but the real question is did they help the ligament injury heal?
In reviewing the study, the answer is a resounding NO! To test ligament healing the ankles were tested via the anterior drawer test. During this test the ankle was moved forward to determine the laxity in the ligaments. This study was published in 1997, and the author stated that this was the first time the clinical measurement of the anterior drawer sign had been used in a clinical trial. It meant that all the studies done prior to this one, in assessing whether anti-inflammatories helped with ankle sprains, did not test whether the ligaments healed. In this study at every date of testing after the initial injury, days three, seven, and fourteen, the Piroxicam-treated group demonstrated greater ligament instability. At the time of the initial injury the ligament instability in the Piroxicam group and the control group were exactly the same. This study showed that the NSAID stopped ligament healing, yet the person felt better. The authors noted…”This result is of concern in that it may reflect a paradoxically adverse effect of the NSAID-derived analgesia in allowing subjects to resume activity prematurely.” (Slatyer, M. A randomized controlled trial of Piroxicam in the management of acute ankle sprain in Australian regular army recruits. American Journal of Sports Medicine. 1997; 25:544-553.)
Do you see the difference between pain relief and healing? The athlete needs healed tissue. Up until the present, too many studies were advocating NSAID use when it came to ligament injuries, because they were such great pain-relievers, when in fact they were and are stopping the healing mechanisms of the body. Any technique or medication that stops the normal inflammatory process that helps heal the body must have a long-term detrimental effect on the body.