I love a good acronym. Medicine is full of them, and when talking about acute musculoskeletal injuries we've all heard of the RICE principle. Ask any high school runner or football player what they should do after rolling their ankle, and you’ll no doubt be told that rest, icing, compression and elevation of the injured limb is key to a prompt and complete recovery. Resting the injured limb seems to make sense, as does icing to keep the swelling down. Wrapping and elevating the ankle will also minimise swelling and all of this gets you back on the field in no time. Or does it?
It never ceases to amaze me how much of modern medical practice is dogma. Interventions that have been widely held to be true, often have precious little evidence to back them up; as time passes, the principles are repeated over and over again to cohorts of medical students, and ultimately become “truths”. Eventually someone rises to challenge a widely held belief, and lo and behold, it turns out we’ve been doing it wrong all along! I think that this is partly the case with RICE.
The underlying theme of RICE is to decrease inflammation. Complete rest limits the risk of further injury and should speed recovery, right? Icing and compression limit tissue damage, right? Well maybe not, and maybe we are just hampering our recovery.
Aggressive icing and compressive bandages cause constriction of blood vessels in our injured tissue. Less blood flow equals less inflammation and less swelling. We usually throw a few anti-inflammatories into the mix as well. This all sounds reasonable but in fact tendons and ligaments have very little blood flow in the first place and reducing their limited blood supply still further may not be a good idea. Following an injury, the increase in blood flow that occurs is a beneficial mechanism to bring additional nutrients into the tissues. This inflammation promotes healing! Why try to stop all that? Complete rest results in stiffness, and a stiff joint is a painful joint. More pain means less movement, more fear of re injury and a slower return to activity. Elevation seems reasonable as we want to promote flow of stagnant blood away from the injury, but there really is clear evidence now that overly aggressive icing of injuries and tight compressive bandage delay healing! Anti-inflammatories may do the same. We want to promote the influx of fresh blood, promote the removal of stagnant blood, and allow some inflammation, promoting healing.
Enter the MEAT acronym. Movement, Exercise, Analgesia and Treatments. RICE, in my opinion, should be replaced by MEAT!
The primary principle here is the promotion of early movement and exercise. Movement and exercise promote blood flow, bringing nutrients to our injured tissues, and helps to restore full, active, range of motion more rapidly. Studies on injured athletes show that, in general, early mobilisation results in less stiffness and less scar tissue formation. Exercise promotes more rapid restoration of strength and stability in a joint. Complete rest may be valuable for only a very short period after an acute injury, but we should be moving our injured joints as soon as our symptoms allow. Analgesia refers to painkillers other than anti-inflammatories. Acetaminophen is generally the most appropriate option. Patients often worry that analgesics just ‘mask’ the pain, but if less pain promotes more movement and exercise, then any potential downside is usually outweighed by a significant benefit. Treatment refers to the full gamut of physiotherapy interventions, including mobilisations and exercises to restore full range of motion, strength and balance.
So the next time you roll your ankle, forget the days of aggressive icing and tight tensor bandages. If you wish to apply some ice, do so for no more than a day, and get that ankle moving in circles as soon as you can. Take some acetaminophen if need be and get in the pool or on your bike as soon as possible to get the blood flowing; take some advice from a physiotherapist on the best exercises for your injury.