You Are Going To Get Hurt

Until recently, RICE was the standard protocol for treating acute soft tissue injuries after physician Gabe Mirkin recommended it in 1978 in The Sportsmedicine Book. Like many colorful mnemonics, RICE is sticky. Although Mirkin himself renounced the protocol a decade ago, the concept persists in popular culture, among coaches and trainers, and in some medical practices. But you shouldn’t use it because it doesn’t work.

There are lots of ways to get hurt in life, but in the realm of physical movement, there are only two kinds of injury: the kind that builds slowly from overuse or poor mechanics and the kind that arrives out of nowhere like a thunderclap, pure bad luck. I’ve had plenty of both over the years, and I expect more. But the older I get, it seems, the higher the stakes. The penalty for tripping on a broken sidewalk could be months or years of rehab or worse.

Some people choose to play it safe. I respect that strategy—it’s why I don’t skateboard downhill or ride a bike in Philadelphia traffic. But as an animal species, we are designed to move. We must move. Whenever you hold yourself back out of fear, your life shrinks a little, and the world becomes sharper and more perilous. Think of it as “withdraw-creep.” The smaller your movements, the smaller your life. And, the smaller your life becomes, the smaller you’ll move until you are boxed in, tiny, unstable, and stiff.

For a long time, I wanted to try box-jumping, but I was afraid. Because what happens if you miss the box?

And then I found out.

But first, you may be wondering, what is box-jumping? Exactly what it sounds like: jumping onto a box. I learned about it on Instagram, which is where I get most of my bad ideas. It’s a CrossFit thing. I don’t do CrossFit (for the same reason I don’t skateboard downhill), but I do love hopping. It fills me with joy. So, after weeks of hesitation, I ordered myself a nylon-covered plywood box.

When The Box arrived (inside a larger box), I carried it upstairs to my yoga room and stared at it for a very long time. Nope. I used it as a laptop desk and water bottle stand for a couple of weeks. Every now and then, I’d clear the stuff off and consider leaping onto The Box, but I could not work up the courage to try. It wasn’t even that tall, only a foot high on its lowest side. How ridiculous, a full-grown human, intimidated by such a little box.

I found an old-fashioned aerobics step like the one we all used for Kathy Smith workouts in the 90s. It was eight inches high and as squat as a curb. Jumping onto it felt exhilarating and easy—too easy. Buoyed with confidence, I returned to The Box.

You can probably guess where this is going. But not right away. I cleared twelve inches on the first try. Then I moved up to the scarier medium height, fourteen inches. Aced it. Look at me, an Elderly Box Prodigy! After that, I couldn’t stop jumping. “Study break” from work? Jump on The Box. Folding some laundry? Jump on The Box. Late for a meeting? Okay, but first, jump on The Box.

The next week, my youngest daughter, Calla, and her fiancé took the train down from New York to stay in our guest room, which is behind the yoga room. As soon as their suitcases were in place, I dragged them into the yoga room to show off my box jumps.

Have I mentioned I am distractible? It turns out that explaining about The Box while simultaneously jumping on The Box is an unwise beginner move. My very first demo was a dollar short and a split second late. The Box toppled forward, and I crunched my right ankle.

“Are you okay?” they exclaimed as I hopped around the room on my left foot.

I was fine, totally fine.

So we went for a walk. (I told you I was fine.) It was a luminous spring morning, daffodils everywhere, bright green pollen coating the sidewalks, cherry trees in bloom. We strolled to a local Mexican restaurant, where we met up with more family and talked about the upcoming wedding. I forgot all about my injured ankle (have I mentioned I’m distractible?) It was not until hours later, when I was standing quietly in the register line at my local food co-op that I realized something was wrong, very wrong in my body. Ah yes, the dread bone-deep ache in my suppressed-from-consciousness ankle. I paid for the groceries, packed them in one of the cardboard boxes by the checkout, and hobbled home, teeth clenched, a grim smile on my face as I nodded to passing neighbors who kept wanting to flag me down and talk about the splendid weather.

My intention was to ice the ankle right away, but first, I had to put the ice cream away, and wouldn’t you know, it was almost time for a Zoom meeting with my thesis student. Elise’s final project, a short story collection, was due in three days, and we’d blocked out several hours for a last-minute line editing session. The longer we worked, the more my right ankle screamed for attention. Shut up, right ankle. It was hard to focus. I tried propping the foot on the desk, but that didn’t help. After an hour, I blurted, “I’m in terrible pain. I need to run upstairs and get some ice for my ankle.” Elise looked startled and asked if we should end the meeting. I assured her I was fine, then lurched out of the camera frame. Upstairs, I found some Naproxen—but no cold packs. I had given them all away in a fit of optimism after my last injury. So I grabbed a frozen Sockeye salmon filet from the freezer and hobbled back down to my office.

In case you are wondering, frozen salmon makes a lousy ankle wrap; I don’t recommend it. By the time the meeting was over, I was inarticulate from pain. The ankle was now eleven, no fifteen, on a pain scale of one to ten. I staggered across the room to my office couch with the useless thawing piece of salmon and called Calla at the other end of the house, waking her from a migraine nap. I begged her to bring me some ice in a bag and to find the walking boot I’d stashed away in the attic after my last ankle sprain in 2019. That sprain had taken six weeks to heal. Six weeks! Feeling a little hysterical, I called my daughter Lauren across town and asked her to bring back the crutches I’d lent her for her recent sprained ankle. Then I called my daughter Madeline, who lives across the street from me, and told her I needed all my cold packs back.

Draped across my fainting couch with a bag of ice cubes dripping across my now-elevated ankle, I posted a photo to Facebook for sympathy. Sixty-four of my closest friends instantly rushed to my succor with care emojis, tales of their own sprained and broken ankles, and recommendations for what to do. Their advice was unanimous: rest, take it easy, get it x-rayed, and do RICE. I thanked them.

But I wouldn’t.

Reverse-engineering a protocol to create a catchy acronym is a bad idea. A few bizarrely clumsy acronyms are floating around the physical therapy lexicon in an attempt to represent the current thinking about healing protocols.

Until recently, RICE was the standard protocol for treating acute soft tissue injuries after physician Gabe Mirkin recommended it in 1978 in The Sportsmedicine Book. Like many colorful mnemonics, RICE is sticky. Although Mirkin himself renounced the protocol a decade ago, the concept persists in popular culture, among coaches and trainers, and in some medical practices. But you shouldn’t use it because it doesn’t work. Here’s the breakdown:

• REST. When you’re hurt, your first impulse might be to keep the injured area as still as possible. However, immobilized muscles and tendons grow quickly stiff and weak, and your fascia loses its elasticity. Inactivity decreases circulation and lymphatic drainage, leaving your tissues stagnant. Think of how your legs and low back feel after sitting in coach for six hours on a cross-country flight. Now imagine doing that all day for weeks to your sprained ankle.

• ICE. Use cold packs for analgesic purposes and to reduce excessive swelling for brief (ten to fifteen-minute) sessions during the first few hours. After that, icing slows down collagen formation and tissue repair by delaying the inflammation you need to heal. (Acute inflammation is a completely different physiological process from chronic inflammation. Stay tuned for my upcoming essay, “Wellness Has a Vocabulary Problem.”)

• COMPRESSION. Like ice and rest, compression inhibits healing by blocking lymph flow and slowing circulation. Compressive sleeves and Ace bandages may feel supportive, but they bring a false sense of confidence, encouraging you to overstress injured tissue before it’s ready to take on a full load.

• ELEVATION. If you practice inversions in yoga or other sports, you know that gravity helps fluid drain from elevated limbs toward the heart. Elevating your injury will appear to reduce swelling, but this passive drainage is temporary; fluid (and the “good” inflammation) will return when you lower the limb. Elevating immediately after the injury can help reduce excess tissue swelling, but after that, it’s useless at best and may undermine your progress.

Reverse-engineering a protocol to create a catchy acronym is a bad idea. A few bizarrely clumsy acronyms are floating around the physical therapy lexicon in an attempt to represent the current thinking about healing protocols. Which do you think is the worst?

METH: Movement, Elevation, Tension/Traction, Heat

MEAT, Exercise, Analgesics, Treatment

PEACE & LOVE: (Acute phase): Protect, Elevate, Avoid Anti-inflammatories, Compress, Educate. (Aubacute phase): Load, Optimism, Vascularization, Exercise

Sometimes, you just have to define a thing by what it’s not. Each of these four acronyms makes sense only in the context of being not-RICE, which goes to show how hard it is to get unstuck from RICE.

For the purposes of this essay, I picked METH because it’s the easiest to remember and has the advantage of shock value. (“I used METH to cure my ankle.”)

You are going to get hurt. That much is certain. The question is, when will it happen (never at a convenient time!), and how will you recover?

After my bout of icing and self-pity, I wore the ankle boot for the rest of the evening. I found I could hobble around the house with minimal pain, much less pain than with my bare ankle. (“Protect” from the PEACE & LOVE protocol.) It’s convenient to have one of these boots on hand for the first hours after an injury. But if you don’t happen to have one kicking around from a previous injury, don’t bother. One of the reasons it took me six long weeks to recover from my last sprained ankle is that this very boot, which was prescribed by an orthopedic surgeon and paid for by my insurance company, immobilized the joint, thus weakening my muscles and tendons.

• Mobilization At the end of the night, I removed the ankle boot, tossed it aside for good, and began to move the ankle slowly, exploring and gently massaging the tissue, backing away from pain.

• Exercise. The next morning, first thing, I worked on mobilizing the ankle and carefully testing its weight-bearing (ouch!) Then, I took a Zoom yoga class. (Yes, I even surprised myself, but it felt like the right thing to do.) I told the teacher in advance that I wouldn’t be following all her cues. I practiced with heightened awareness and some apprehension, but it was fine. Obviously, I avoided jumping and single-leg balance work. After the class, I was glad I’d done it. I continued practicing yoga every day for the rest of the week. Note: I had been planning to attend a protest march downtown that afternoon, but I stayed home. I was fine to walk inside the house that first day, but even a stroll to the end of my driveway felt like too much too soon.

• Tension/Traction. By day four, I was able to cautiously resume my regular ankle exercises, which involve a circuit of dorsiflexion, plantar flexion, inversion, eversion, and toe flexing/pointing. I reintroduced some careful one-leg balance work on the recovering ankle.

• Heat. (For the purposes of the acronym, I’ll list this one out of chronological order—but remember, you need heat from the start.) I found my Incrediwear ankle sleeve, which, I realize, writing this, sounds like something from a Superman movie. It’s a therapeutic sleeve made from a non-constricting fabric that increases blood flow, activated by body heat. (There may be other brands, but I haven’t found them.) The sleeve creates a sensation of warmth without problematic “support” or compression, giving you enhanced proprioceptive awareness. I have a set for knees, ankles, and elbows that I wear to accelerate healing when I need them. For this ankle sprain, I wore the sleeve continually for eight days. However, you don’t need a fancy high-tech sleeve to keep your injury warm. An extra sock with the foot cut out will do the trick.

Here’s what else I did that doesn’t fit in the acronym:

• After those first moments on the fainting couch, I did not use ice or analgesics. I canceled the request for my crutches and returned all the cold packs except for one, which I am keeping in the freezer for my next accident.

• To help remodel the injury tissue and avoid reinjury, I focused on interoception and proprioception to heighten my awareness of the recovery process. Interoception is your awareness of your body’s internal state. Lack of interoception got me in trouble in the first place when I ignored my body’s signals for most of the day after the miscalculated box jump. Proprioception is your brain’s ability to know where your body is in space. (That would have helped me nail the box jump!)

• I returned gradually to full activity, taking care to stop and mobilize the ankle frequently and to practice progressive loading on the joint: at first, just a few seconds, gradually adding more time, weight, movement, and mechanical stress, allowing pain to be my guide. Did the ankle still hurt? At first, yes. But less each day. By day eight, I was doing single-leg balances, plyometrics, and pogo jumps. I’m even back to box jumping—with less wild enthusiasm and better focus.

You are going to get hurt. That much is certain. The question is, when will it happen (never at a convenient time!), and how will you recover? Injuries are coming for you, no matter how cautious you are and whether or not you exercise or play sports. You can wrap yourself in cotton batting and wear a hard hat to dinner parties. You will still get injured.

It is how you recover that matters. Your life is a series of recoveries. Have a strategy in place for when the inevitable happens, and open your mind to what you will learn about yourself as you heal.

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