R-I-C-E (Rest, Ice, Compression, Elevation) and REHABILITATION

First aid and recovery strategies for sprains, strains, tendonitis and more.


Consult a physician when:
• in doubt as to the severity of a traumatic joint injury.
severe pain lasts more than 24-36 hours.
• pain in the joints or bones lasts longer than 2 weeks.
an injury doesn’t appear to be healing or remains immobile.

To give yourself the best chance for a quick recovery from “pulled” muscles, “throwing your back out,” and common sprains and strains, use the immediate application of the famous RICE formula of Rest, Ice, Compression, and Elevation.

These measures minimize bleeding into the injury and reduce inflammation and swelling that otherwise cause immobilizing pain and a prolonged recovery. If everyone knew what to do when such injuries occur, there would be far fewer “down” days of missed activity.

Many people mistakenly apply heat to recent injuries. This is a counterproductive measure! When heat is used too soon, it increases internal bleeding, swelling, pain and immobility. Further along in the recovery process, the application of heat can often play a valuable role that we will discuss later in this article.

Damage control

Any injury to soft tissue – muscle, tendon, ligament, or fascia (connective tissue) – creates a cascade of reactions that result in bleeding, inflammation, swelling, and pain. Swelling further damages cells in the injured area and slows healing. It also increases pain, and pain in turn leads to muscle spasm and immobility.

If this immobility is prolonged, excess scar tissue can form adhesions. This happens when the repair fibers “glue” together previously independent structures. Joints can become stiff and muscle strength and endurance decline. All of the above contribute to the increased likelihood of re-injury in the future.

This is why the primary goal of first aid is to control the degree of initial swelling. And this is where RICE, and particularly the use of icy cold, enters the picture. By constricting blood vessels, cold slows bleeding, swelling, and inflammation. By
chilling nerve endings and decreasing muscle spasms, it also dulls the pain. For the first
24 to 48 hours (72 hours if swelling persists), cold therapy is the treatment of choice.
For a more complete analysis of this physiology, please refer to Ice Packs and the Injury Repair Process.
Let’s begin our examination of the RICE formula by not overlooking the “R” which stands for Rest. What this initially means is to cease the offending activity immediately. While this may seem obvious, some of us may not see the glory in quitting at that moment. However, continued stress on damaged tissues could extend the injury. It’s safest to stop the activity and head for the ice packs.

How to use ICE THERAPY

There are many ways to apply it. My top recommendation is to pick up the inexpensive and reusable gel packs to store in your freezer, ready for action. You can find these at any drug or grocery store. An ice pack is most effective when applied directly to the skin – it’s worth getting past the initial jolt for this anesthetizing therapy of deep cold — but more delicate people may prefer their ice pack wrapped in a towel.

If you don’t have an ice pack ready in the freezer, you can fill a plastic bag or hot water bottle with ice cubes or crushed ice or you can even grab a bag of frozen vegetables! Ice massage can be applied by stroking the injured area with an ice cup made by pre-freezing a water-filled paper cup, peeling back the paper as needed. For trauma to hands or feet, you can submerge the injured part in a bucket of ice and water. If you know you’ll be in the field or away from refrigeration, you can bring chemical cold packs that when squeezed produce cold for 30 minutes.

Ice can be applied hourly, with the length of each application determined by the size of the injured area and its percentage of body fat. For a knee or ankle, icings of 10 to 20 minutes per hour are beneficial, but a hamstring (the large muscle in the back of the thigh) will need twice that time. A good general rule for when you’re motivated to take your cryotherapy a little more earnestly is: 20 minutes ON – 20 minutes OFF.

Do not leave ice directly on your skin for more than about 20 minutes lest you risk frostbite, and never leave unwrapped ice for more than about 5 minutes on the outer sides/back of your knees, wrists, or on your elbows, where nerves near the surface could be damaged.

Consider, too, the benefits of ice in treating various long-term (chronic), nagging injuries like tennis elbow or a troublesome knee. It can be useful for superficial muscle strains after vigorous work or exercise. You may have observed how professional athletes routinely apply ice after workouts and games. We may safely assume that these highly paid stars get the best of everything, including sound medical advice and appropriate therapies.

If at all possible, the injured area should be compressed at the same time as it is being iced, for example, by securing the ice pack with an elastic bandage. Also, keep the injured part elevated, if possible above the level of your heart. Between icings or if ice is unavailable, it’s helpful to wrap the injury with an elastic bandage and elevate if feasible.

The application of HEAT

Heat has its place in your program of pain free activity. It can be helpful when treating chronic discomfort and stiffness that may result from previous sprains, strains, and overuse. Heat can be used effectively to warm stiff, recovering muscles before activity, with ice used to cool them afterward. Heat diminishes pain and promotes healing by increasing blood flow, bringing oxygen and enzymes to the injured area.

The trick is to recognize when inflammation is present and use heat only after inflammation has subsided. Always give the injury at least 48 hours after the initial trauma; if the area is still swollen, red and warm, do not apply heat, because it will aggravate inflammation.

Heat may also be alternated with cold (contrast therapy) to gain the advantages of each. While this is time intensive, it can help improve the range of motion of stiff, aching, mildly inflamed joints. Alternate four-minute warm baths (100 to 110 degrees F) with one-minute cold baths (55 to 60 degrees F) and do stretching and range of motion exercises during the warm phase.

Moist heat is generally preferable to dry heat. Damp towels heated in hot water or in a microwave oven can be used, although these will need to be reheated every 5 minutes to maintain a useful temperature. If a heating pad is well insulated, place a moist towel between the skin and the pad, using a low or medium setting only.

A very good way to apply heat is with a silica-gel hydrocollator, a heat pack that keeps the water inside above 160 degrees F. Hydrocollator packs, sold in drug stores, should be wrapped in towels before applying them to the skin. Whirlpool baths at 100 to105 degrees F are also helpful but limit immersion to a maximum of 30 minutes.

Sports medicine specialists caution against using heat on injured areas that are inflamed or infected or that have lost sensation. Also, stop using heat and return to cold therapy if heat causes inflammation or makes the pain worse.

Rehabilitation and Massage

“How poor are they that have not patience. What wound did ever heal but by degrees?”
Shakespeare

When in doubt as to the severity of an injury or if you are unclear what your rehabilitation plan should be, consult with other health care professionals. Massage therapists often work in conjunction with others in health care to ensure your progress through the various stages of soft tissue healing. Whatever therapies you use, as you recover, beware of returning prematurely to your previous activity level. “No pain, no gain” is not valid in your injury recovery program! Weight bearing, stretching, and other forms of exercise should be done below your pain threshold, lest you re-injure yourself and start the inflammatory process over again.

But neither should you rest for too long. Once the initial pain and swelling subside,
begin light stretching and strengthening exercises. It’s remarkable how fast muscles atrophy and excess scar tissue binds structures. But be aware that engaging in vigorous exercise with chronically tight or bound-up musculature is asking for trouble by re-tearing the fibers. Strengthen, yes…but lengthen first!

This would be an ideal time to schedule an appointment with your massage therapist. Therapy is applied to tight or spasming muscles to decompress joints and relieve constrictions of normal circulation and painful movement. Massage is particularly helpful right after swelling subsides because this is a critical stage in the prevention of re-injury or the development of a chronic condition. We’ll work together to ensure your speedy and complete recovery, and to reduce your risk of “a bum knee” or “a bad back.”

Neuromuscular and Deep Tissue massage techniques enhance the healing process by promoting circulation, preventing adhesions, and influencing the efficient remodeling of scar tissue. Massage strokes that drain and return excess fluid to the circulatory system would be used after the acute inflammatory response. Circulatory strokes that enhance deep circulation provide oxygen and nutrients, remove wastes and aid in the processes of the regenerative phase. Cross-fiber Frictioning prevents the “gumming-up” of independent structures. Strokes that move in line with the muscle fibers, along with cross-fiber strokes, will help form a strong weave to the scar tissue necessary for maximum durability. Passive and active stretches are added to ensure that normal healing occurs and mobility is restored.

“There is no point conceivable in the human experience at which the upward climb cannot begin.”
Stanwood Cobb

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