Approximately 30% of all visits to a primary care physician are for musculoskeletal issues, yet the amount of time, and education during medical school and residency, dedicated to musculoskeletal conditions is abysmally low. I had 2 weeks in my entire 4 years of medical school dedicated to musculoskeletal medicine. And yet, an exceptionally esoteric condition like pheochromocytoma is etched into all our memories during medical training.
Why is this? Why are we trained and tested in a way that does not set us up to truly care for the patients and the conditions that many of us will see every day in clinical practice?
That discrepancy aside, I would like to discuss a common misconception among many physicians regarding musculoskeletal care. Many of us were taught “RICE” (rest, ice/ibuprophen, compression, and elevation). I hope you’re sitting down, because it is not evidence-based, and furthermore, there is a growing body of evidence that RICE may hamper the healing and recovery process for many soft tissue injuries after the first 48-72 hours.
In 1978, sports medicine specialist Dr. Gabe Mirkin coined the term RICE;1 however, in 2015, he reversed this thinking, writing that ice “may delay healing, instead of helping.” Although there is limited high-quality evidence to recommend RICE, it’s what we have recommended for so long, and like many things in medicine, it will take time and high-quality evidence to really make that change.
Some researchers, including Dr. Gary Reinl, have written extensively that ice is “wrong and delays healing.”2 Several have also proposed that after an injury, an acute inflammatory process begins, with increased blood flow and recruitment of immune cells, neutrophils, and then macrophages to clean up secret cytokines and other pro-inflammatory factors. Ice results in vasoconstriction, which may inhibit this response. Many have proposed that diminishing the vascular influx also reduces the subsequent process of laying down fibrinogen and platelets for hemostatic and subsequent leukocyte and monocyte recruitment to include phagocytose debris and ultimately impair fibroblast activity for collagen, protein synthesis, and ability to rebuild damaged tissue.3,4 It should be noted that much of this is theoretical and difficult to demonstrate in real life, and the vascular influx may also be too robust at times, resulting in more swelling and pain than is required and resulting in greater pain. So, there is likely a balance between vascular influx for healing and excessive swelling pain and limited range of motion of a joint, tendon, or muscle.
The “I” for ibuprophen—which is often used for musculoskeletal injuries—has also come under fire recently. A Cochrane review concluded that topical NSAIDS may be beneficial for acute pain after a soft tissue injury; however, they note a large amount of unpublished data regarding NSAIDS and acute musculosketal injuries that may change future recommendations.5 Medicine by the Numbers gave NSAIDS for musculoskeletal injuries a “green” rating, as its benefits outweigh its harms, after reviewing 61 studies. This review did note significant heterogeneity to those studies, and there is no evidence showing benefit of oral versus topical NSAIDS, resulting in a possible preference of topical NSAIDS with potentially few systemic side effects.6 However, another Cochrane review also concluded that oral NSAIDS did not make much difference in pain levels at 1, 3, and 7 days after acute low back soft tissue injury.7 Others argue that anti-inflammatories inhibit the above healing response and inhibit collagen and granulation tissue breakdown.8
Part of the issue with all the fancy and flashy recovery devices on the market—be it simple compression, sequential compression, elevation, or cryotherapy—is that there is a huge placebo effect. A study on the effect of compression socks on recovery from a 5 km sprint confirmed that those who believed the socks would help did do better than those who were skeptical of their benefit.9 My preference is to utilize gentle muscle contraction to reduce swelling and edema, calf pumps, range of motion, walking, or manual upper body muscle contraction, which has been shown to be beneficial as well.10
The first 48 hours after an injury, ice, relative rest, and nonsteroidal anti-inflammatories can help with acute symptoms, swelling, and pain; however, if utilized for more time, they may actually delay the healing process. I have seen this anecdotally countless time in our sports medicine clinc. Some have replaced “Rest” for “Movement,” changing the acronym from RICE to MICE. Without acute trauma (broken bones, completely ruptured tendons, etc), early range of motion, mobilization, and perhaps heat are likely better to mobilize tissues, promote blood flow, and stimulate the healing response.
Some have taken it a step farther, such as Dr. Jennifer Robinson at The University of British Columbia, who proposes the acronym MOVE, which stands for Movement, Options (cross training, active recovery), Vary rehabilitation with light strength activation, eccentric exercises, drills, and Ease back into activity.
The bottom line is that although evidence is lacking for any one-size-fits-all recommendations for minor musculoskeletal soft tissue injuries—and while we don’t need to throw the baby out with the bathwater—we likely need to incorporate more early mobilization, stretching, muscle activation, topical NSAIDS, and heat the first few days after a musculoskeletal injury and re-educate physicians, as well as patients, to utilize less RICE and more MOVEment.