June 5, 2025 • 34 mins
What really helps prevent injuries—and what should you do when one inevitably strikes? In this episode, I use my friend Tim’s pickleball injury as a jumping-off point to explore what the evidence actually says about ice, rest, NSAIDs, stretching, and more.
When Tim skipped his warm-up and pulled a calf muscle, it raised a question many of us face: was it avoidable? While ancient wisdom and modern influencers often shout conflicting advice, this episode sorts through the noise to uncover what’s evidence-backed, what’s outdated, and what might actually delay healing. For pain, yes, ice works—cooling slows nerve conduction and can help with comfort, as seen in this study of ankle injuries. But does it reduce inflammation in a helpful way? Possibly not. Some research suggests that vasoconstriction may hinder the delivery of reparative cells and removal of waste, as noted in this trial.
The evolution from RICE to PEACE to MEAT and even PEACE & LOVE reflects our shifting understanding. A meta-analysis of 22 randomized trials found no conclusive benefit of ice when added to compression or elevation. As for NSAIDs like ibuprofen, the Cochrane Review revealed no significant advantage over acetaminophen in pain relief or swelling reduction—and no clear evidence they speed up recovery.
What about rest? Surprisingly, prolonged rest may do more harm than good. The Deyo study and later NEJM data show that continued normal activity (within pain tolerance) results in faster recovery than either bed rest or structured exercises, at least for acute low back pain—offering insights that might extend to other strains or sprains.
Can you prevent injuries altogether? Static stretching (think toe touches) doesn’t show strong support in RCT reviews, and while a recent meta-analysis found a small reduction in muscle injuries, the impact was modest. Dynamic stretching remains inconclusive according to current evidence.
The takeaway? When treatments or prevention strategies are studied over and over yet results remain ambiguous, it likely means any real benefit is small—a principle I call “Dr. Bobby’s Law of Many Studies.” Compare that with fall prevention in older adults: 66 RCTs involving 47,000 people showed strength and balance training significantly reduces falls by 20–30%. When something works, it tends to show up clearly and consistently.
Takeaways:
If you’re injured, ice and NSAIDs can ease discomfort—but don’t count on them to speed up healing. Resting too much may slow recovery; try gentle movement instead. Stretching might help a bit with prevention, but don’t expect miracles. Evidence
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
My buddy Tim drives 30 minutes to play pickleball.
He arrives and someone saysHurry, tim, hurry, we need one
more for a fourth.
Tim skips his usual warm-up,starts a game and then quickly
sprains a calf muscle.
Was this avoidable?
What does the evidence tell usand what is the best treatment
(00:25):
for his injury?
Should he ice it, rest orcontinue moving?
Take ibuprofen, what actuallyworks?
Let's see where the evidencetakes us.
(00:53):
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well, a
podcast where we will talkabout what you can do to live as
long as possible and with asmuch energy and figure that you
wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(01:14):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome, my dear listeners, tonow episode 40, how to avoid
(01:35):
injuries and what to do whenthey occur.
Well, an injury is typicallysomething sudden, accidental,
and commonly is a sprain or astrain or a bruise.
Well, what should we do when aninjury occurs?
Well, should you ice it or not?
(01:58):
Is ibuprofen or naproxen a goodidea or not?
Should you rest or remainactive?
And how might we preventinjuries from occurring?
Will stretching help?
Is it better to do dynamicstretches versus static
(02:19):
stretches?
And we hear so many people tellus what we should do.
Is that based upon credibleevidence?
Social media and health expertsare each proposing their own
special approach, which mightinclude ice.
It might include this.
(02:39):
It might include that theymight be suggesting oh, you need
to do cryotherapy or red lighttherapy, or you must do
acupuncture or massage, or asupplement or a topical
treatment or an ointment.
Too often, what's recommended isnot evidence-based medicine,
(03:02):
but what some calleminence-based medicine, meaning
a supposedly knowledgeableperson says this is what you
need to do, whether it's aboutinjuries or injury prevention or
almost any other aspect ofhealthcare and longevity.
Often it's reallyloudness-based medicine or
(03:27):
confidence-based medicine, theperson who says, oh, this is the
way it's done.
I've done this with all of mypatients and they all do great,
you need to do this.
Or it's frequency-basedmedicine, meaning I've read
about icing forever.
It must be correct, because youjust run across it all the time
(03:47):
.
Well, what really works?
And is there any rigorousevidence to support one
particular way to treat aninjury versus another, and it's
perhaps remarkable that weactually don't fully know.
Now.
There are a lot of studies.
(04:07):
Most of them are small, mostare not very rigorous and most
don't apply to you, my listeners.
There might have been a studyin high school athletes.
I doubt I have too many of youlistening.
Some of these studies are donein military recruits, young
people with a particular type ofexercise they're doing.
(04:28):
Also may or may not apply tomost of us.
Let me just point out that todayI'm not talking about an injury
that involves a broken bone andI'm not talking about chronic
injuries.
I'm really focusing on whathappens so often to us.
We pull a muscle in our calf orour hamstring or our back goes
(04:52):
out.
These are strains, sprains andbruises, and that's what I want
to focus on.
Well, as always, why now?
Well, I had coffee about a weekor so ago with Tim and I began
at the beginning sharing hispickleball story.
He skips his warmup, he injuresa calf muscle and was it
(05:15):
avoidable?
And now that he's got theinjury, what should he do?
I'm an Ironman triathlete andI've had my share of minor
injuries.
I sprain my ankle all the time.
Sometimes I pull a muscle in mykind of hip back area and I've
(05:36):
obviously had to try all sortsof approaches both to treat them
and to avoid them impossible.
So yesterday I had a triathlonand fortunately I felt good.
This morning I'm not feelinginjured.
Was I just lucky?
Did I do something that causedit to happen?
(05:57):
Is it based upon evidence?
Well, let's see.
Well, when I was in my earlymedical training, there was a
formative study that waspublished on back pain.
Now, at the time therecommendation was you should go
(06:17):
to bed for about a week andduring that time inflammation
will go away and you'll feelmuch better.
And Richard Dale, theinvestigator, said I don't know
if that's a good idea or notbeing in bed for a week.
So he did a study, a randomizedcontrol trial, where he
compared a very brief period ofrest with the full week in bed,
(06:41):
and what he found was theprolonged rest actually made
things worse.
And this was very formative tome during my training that what
we hear isn't necessarily alwaystrue and that we need good
studies to help us sort that out.
I'm also reminded of the Frenchphilosopher Voltaire, and I love
(07:04):
this quote and I've used it inprior episodes the art of
medicine consists of amusing thepatient while nature cures the
disease.
What this means is so manythings are going to get better
on their own, no matter what wedo or what we don't do.
Own no matter what we do orwhat we don't do.
(07:28):
So if we have to be cautiouswhen people say, oh, I did this,
I got better, well, it may ormay not have had anything to do
with what they are proposing.
Well, before we dive into thefull episode, I want to thank
you for those that referred meto other people on my podcast,
(07:48):
for my podcast to be a littlemore known.
Many people have joined sincemy last podcast and thank you.
Thank you so much for referringpeople and telling them about
it.
If you have done so, pleasecontinue.
It worked.
I'll keep posted on whathappens in the future.
If you have done so, pleasecontinue.
It worked.
I'll keep posted on whathappens in the future.
If you haven't had a chance yet, please.
(08:08):
If you enjoy my podcast, Isuspect others might enjoy it
too, and I will be very happywhen I see more people that
might be benefited from it.
So thanks.
Okay, let's dive in.
You've been injured Again.
You haven't broken a bone.
This isn't a chronic injury.
This is something acute like,happens to almost all of us very
(08:33):
regularly.
So you're injured, now what Ice?
So let's talk about ice Now.
Ice and cooling the area that'sinjured goes back thousands of
years.
2500 BC, the ancient Egyptiansused cold compresses to treat
(08:55):
injuries and the famousHippocrates, the sort of father
of of medicine, in the 4thcentury BC, they used to use
snow and ice to reduce pain andbleeding in wounded soldiers.
And then in the 60s and 70s weheard about rice Rest for the R.
(09:19):
I was ice, c is compression andE is elevation.
No matter what the injury was,rice was what you should do Rest
, ice, compression and elevationof that limb.
Well, the ice belief and therice belief has changed over the
(09:42):
years.
So ice became rice.
But then people said wait, asecond rice approach isn't right
.
We now need peace, and peace isprotect E, elevate A, avoid
ibuprofen, c compression and Eelevation.
(10:03):
So PEACE approach removes iceand says don't do non-steroidal
anti -inflammatories likeibuprofen.
But not to stop there, there'salso the MEAT approach movement,
you should continue to move andexercise, analics and various
(10:24):
types of other treatments.
Well, the peace approach becamethe peace and love approach,
where love means load, optimism,vascular and exercise.
Now, how can all the rightthing keep changing from ice to
(10:44):
rice, to peace, to peace andlove to meat?
It's mind-boggling, and whenyou think you know what you're
supposed to do to treat aninjury, we still don't know.
How is that possible?
Well, for those of you who'velistened to my podcast for a
while, this is a common theme ofnot knowing and thinking we
(11:07):
know and then being told lateroops, we had it wrong.
Eggs used to be bad.
Now eggs are good Peanuts.
Oh, avoid those in the veryyoung kiddos.
Well, that turned out not to bea good idea.
In this area of treating aninjury and avoiding injuries,
(11:28):
there's a lot of studies, butthey're not very convincing, and
in a few minutes I'm going totell you Dr Bobby's law of many
studies.
So this is a teaser.
I'll answer this in a fewminutes.
You've probably heard the lawof large numbers, where if you
study a large enough group ofpeople, you kind of get the
(11:51):
right answer.
Well, you're going to get avariation called Dr Bobby's Law
of Many Studies.
So we're now injured.
What do we want to accomplish?
We would like to relieve pain.
Of course, nobody wants to bein pain.
We think we want to reduceswelling and inflammation.
(12:11):
Well, as we'll see in a fewminutes, maybe that's a good
idea, Maybe it's not such a goodidea, and of course, we want to
return to function.
Definitely we want to do thatand obviously as quickly as
possible.
Well, from my beginningdiscussion, you can see that
(12:33):
three elements seem to bediametrically opposed about
whether it's a good idea or abad idea Ice, yes or no,
ibuprofen yes or no, rest ormovement which is best?
So let's walk through each ofthese and I'll share the
(12:54):
evidence that I found or didn'tfind.
So let's begin with ice Now.
Ice really does work for paincontrol.
So when you put ice on an areathat hurts, it works.
There was a randomized controltrial of 105 folks with ankle
(13:18):
injuries.
As you're going to see, a lotof the studies in this area are
done with ankle injuries.
Well, what did they find?
They found that, in terms ofpain control, ice worked, and
the feeling is that the iceslows down the nerve conduction
(13:40):
in that part of your body, thatit numbs things.
So it appears and this has beenfor thousands of years that ice
helps pain.
Okay, but what aboutinflammation and returning to
full use?
Where does ice fit in here?
Well, the theory is, if we putice on a limb or anywhere else,
(14:05):
it will cause the blood vesselsto constrict, reducing blood
flow into that area.
And the theory is that by sodoing, you'll get less swelling,
and swelling can't be good.
Swelling hurts, swelling looksbad.
Swelling definitely issomething let's avoid.
(14:25):
So ice seems like a good idea.
But if you're reducing theblood flow into that area, maybe
there's cells or reparativeparts of our body that are
trying to get there to solve theproblem, and now we've reduced
the ability to get there.
(14:46):
Also, there may be bad thingsthat are formed in the injured
areas.
You'd like to get them out ofthere, and when you constrict
the blood vessels, that can'thappen.
So what seems like a good idealet's get rid of the swelling
may or may not be Okay.
Well, that's theory.
(15:06):
What about evidence?
There was a study that looked atcompressing the area with ice,
or just compressing it and noice, and this was ankle sprains.
It was a randomized, controlledtrial and there was no
difference.
So adding the ice to theregimen didn't make a difference
(15:29):
.
Well, what about more broadly,not just ankle injuries?
So they had a publication of asummary, a meta-analysis of 22
randomized control trials, whereagain, they tried ice in
addition to compression of thearea.
Again, it didn't make adifference.
(15:51):
The ice didn't seem to solvethe problem.
Didn't seem to solve theproblem.
Well, what about RICE, which,as we've said, is not just ice,
it also includes R, which isrest, c compression and E
elevation.
There were 11 randomizedcontrol trials, almost 900
people, and what did they find?
(16:13):
Well, it wasn't clear whetherrice, this approach that
included the ice, helped or not.
Now, the studies that were inthis were not all that well
designed and we really couldn'tfully answer the question.
So, all of these studies,what's going on?
Why isn't it clear?
(16:34):
Well, I have three theories,and again we're talking about
ice right now.
Ice may reduce pain.
Clearly, that seems to work,and it may reduce inflammation.
But that may or may not be agood idea.
Maybe the inflammation, theswelling, is our body's way of
helping you, and by stopping ityou're not helping yourself.
(16:57):
So that's one theory that theice actually doesn't work.
In fact, it might make thingsworse.
The second theory as to what'sgoing on Well, maybe we just
don't know.
Because the studies are poorand you do a bunch of poor
studies, you're really notnecessarily going to know and
you do a bunch of poor studies,you're really not necessarily
going to know.
Third theory is when peopletout that ice is the way to go,
(17:22):
it could be our famous placeboeffect.
If you want to learn more aboutthat, listen to episode 28.
(17:43):
And now, as I alluded to earlier, I want to bring you to Dr
Bobby's law of large number ofstudies.
Okay, so this is what the lawis, or the theory is, or the
hypothesis.
If there are a large number ofstudies examining a treatment or
an approach to taking care ofsomething, and at the end of all
these studies, if we look atthem and we scratch our head and
say I still don't know whetherit works or not, my law, my
(18:06):
hypothesis, is that it likelydoesn't work.
And, yes, the studies were poor.
But because there are a lot ofstudies and they never show a
clear, clear benefit, I'mguessing it doesn't work.
Or if it does work, the actualbenefit is probably really small
(18:27):
.
So that's my law.
When you see lots of studiesand you don't know, at the end
of it all, I'm guessing ifthere's any benefit, it's not
huge.
So what do I take from theliterature and evidence on ice.
There's no need to rush to getice.
It might help the discomfort,but we don't know in the long
(18:49):
run whether that reduction ofinflammation is a good idea or
not.
And let me also re-point outthat all of these studies not
all, but most all of thesestudies on ice were done with
people who either had an ankleinjury or just had surgical
repair.
So again, we don't really knowabout routine muscle injuries
(19:13):
like a calf strain or pulling ahamstring, but nothing that's
clearly saying ice works Allright.
The second area that we thinkmight help how about ibuprofen
or naproxen or a non-steroidalanti-inflammatory Very commonly
(19:33):
recommended?
Well, there was an importantreview of the evidence, the
Cochrane Collaboration, whichare groups around the world that
summarize evidence in veryrigorous ways.
They found 20 studies lookingat this topic in over 3,300
people.
And what do they find?
(19:54):
That there was no differencebetween the patients who took
ibuprofen or a non-steroidal andthose that took an alternative
drug called paracetamol, whichis like Tylenol.
It's like an acetaminophen, andthey looked at whether pain was
better at one to two hours, twoto three days, changes in
(20:16):
swelling and basically theyfound no difference.
So if you are in pain, by allmeans do something.
But Tylenol is probably just asgood.
Why not take the ibuprofen?
Well, ibuprofen reducesinflammation, and just like ice.
Well, ibuprofen reducesinflammation, and just like ice,
reducing the inflammation mayor may not be a good idea.
(20:40):
Unfortunately, the studieshaven't really been done well
enough to say whether ibuprofenwill help you return to exercise
and function.
It just didn't fully answerthat, so we don't know.
Okay, so ice doesn't seem to bea great idea.
Ibuprofen doesn't seem to be agreat idea.
(21:03):
Now, should you rest?
You've injured that muscle.
You've injured your ankle.
Should you rest or not?
Now, before we get too far inthis, I did not find any studies
that compared rest versusgentle exercise for the typical
(21:23):
leg muscle strain.
So what am I going to do?
I'm going to now tell you moreabout that low back pain set of
studies, because a low back painepisode is kind of like pulling
a muscle.
You are feeling good, you movesome furniture, you pull a
(21:44):
muscle in your back and you arein pain.
So I don't have an example onrest or not for some of these
other parts of our body, but Ido have some data on low back,
and I did mention that studythat looked at two days of rest
versus seven days of bed rest.
(22:04):
And again there were nodifferences.
And there were no differencesin getting back to work sooner,
except that the people who werein bed longer, of course, didn't
get back to work very soon atall, that the people who were in
bed longer, of course, didn'tget back to work very soon at
all.
(22:26):
Then in 1995, there was arandomized trial that compared
two days of bed rest, backexercises or just continue your
normal activities.
And then they looked at peoplewho had hurt their back Again an
acute injury, not a chronicproblem.
They looked to see at threeweeks and 12 weeks who did best.
Well, it turns out it wasn'tthe people who had two days of
(22:47):
bed rest, it wasn't the peoplewho did the back exercises.
The people who did best werethe ones that continued their
normal activity.
The duration of pain was less,the intensity of the pain was
less and their ability to workwas better.
And in fact the people who wentto bed for a couple of days
(23:07):
actually had the slowest injuryresolution.
So this was fascinating.
Again, it's not in some of theother areas of your body it
doesn't tell us necessarily formy buddy tim with his calf
muscle.
But in the area of back pain itlooks like if you have an acute
injury you really just want tocontinue normal activities.
(23:30):
Obviously you don't want to doanything that's making it cause
severe pain.
But resting the other thingsdidn't do better than just
continuing normal activity, andin fact normal activity did even
better.
So well, what about otherthings you might do?
(23:50):
Acupuncture or massage.
Well, another day I may drillinto those.
I don't think there's greatdata for an acute injury to your
hamstring for that, but we'lldive into it.
And if any of you out there inlistener land have some good
studies, by all means send themmy way.
And if you're interested inwhere does red light therapy fit
(24:14):
into all this, you can listenagain to episode 31 of my
podcast.
Okay, so the obvious thingspeople tell you to do don't seem
to make a difference to get theinjury to go away.
But how about preventing aninjury?
That seems really important.
How about stretching?
(24:35):
Does it work?
And what type of stretching?
You might have heard of staticstretching or dynamic stretching
.
When should you do thestretching?
Before exercise, in the middleof exercise or after?
Well, I went to a set ofguidelines by the American
Academy of Orthopedic Surgeons.
(24:57):
This is a very well-recognizedgroup of physicians and surgeons
and I asked the question intheir guidelines, do they say
anything about ways to preventsports injuries?
And they basically say, well,stretching is the way to go to
help reduce injury.
(25:17):
Well, I looked at the evidenceand I wanted to figure out is
that true?
Well, there was an article thatreviewed four randomized
control trials and they lookedat static stretching.
Now, what is static stretching?
That's the kind of typicalstretching you usually think
(25:38):
about.
You know touching your toes,you know twisting your back a
little bit to make it, you know,stretch certain muscles.
So these are the types ofstretching that's called static.
And what these four studiesfound was there was really no
(26:02):
significant difference betweenthe people who did the static
stretching or didn't to preventinjury.
And if there is some suggestionthat maybe there's a tiny bit
of benefit and we're going tocome back to what a tiny bit of
benefit means in just a littlebit Well, there was another
(26:24):
study.
They looked at 5,000 papers,5,000 published articles, and it
turns out of the 5,000 articles, only four of those articles
qualified for review.
Meaning all of these studieswere really poorly done, except
for the four, and those fourwere kind of atypical, meaning
(26:49):
three of them were in militaryrecruits, who do get injured
regularly, and one was in soccerplayers.
Now, what they tested was apretty significant regimen of
stretching, so 20 seconds at atime, one to two sets for each
of the key muscle areas, andthey followed up at 12 weeks to
(27:11):
see whether stretching beforevigorous activity and obviously
military recruits are doingvigorous activity and also the
soccer players.
What did they find?
The stretching did not preventtendon injuries.
Now, it did seem to reducemuscle injuries and in fact they
(27:33):
had what's called an odds ratioof 0.37, meaning that it
reduced the rate of muscleinjuries by two-thirds.
That sounds fantastic, but, asMark Twain said well over a
century ago, there are lies,damn lies and statistics.
(27:54):
So in these studies of 1,300people the people who did
nothing, no stretching only 65muscle injuries.
In the people who did thestatic stretching, there were
fewer muscle injuries.
There were about 33.
(28:15):
So the rate of injury went fromabout 5% to 2.6 or 7%.
Now, what does this mean?
It seems like it made adifference, but 95% of the
people had no injurieswhatsoever.
So a whole lot of people werestretching to reduce the number
(28:37):
of injuries by a very smallnumber, and there's something
called the number needed totreat and basically it would
take 33 people stretching for 12weeks to prevent one injury.
Now, this isn't one person dyingor having a heart attack you're
(28:58):
trying to avoid.
It's just a muscle sprain orstrain.
So even if you think the dataare compelling, the impact isn't
huge at all.
And these studies were in youngpeople, you know, military
recruits and such.
What does it tell us aboutstretching for people who are 40
(29:19):
or 50 year olds more like mylisteners?
We just don't know.
Okay, what about dynamicstretching?
Dynamic stretching has beensomething that's gotten a lot of
attention.
Now, what is dynamic stretching?
Dynamic stretching is thingslike, you know, shoulder
rotation or trunk rotation orhip flexion or lifting your
(29:43):
knees up high, so it's basicallystretching while you're moving
the joint, as opposed to justholding a stretch for a
significant period of time.
Now, there weren't many studies.
They were small, they weren'twell done.
But what about dynamicstretching?
There's conflicting evidenceNow.
(30:04):
Stretching may increase yourrange of motion, it might make
you feel better, it might evenimprove performance.
So if you can move your musclesin your leg better, maybe
you'll run faster.
But that isn't the question onthe table.
The question on the table isnot whether it feels better, not
whether you'll run a little bitfaster, but does it prevent
(30:28):
injury?
Turns out, not much evidence tosupport it.
Okay, I talked with you earlierabout the law Dr Bobby's law of
the large number of studies.
You know, when something works,it's often quite clear and not
all prevention efforts fail.
(30:49):
Now this is a less sexy areaand might not apply to you, but
the reason I want to explainthis to you is that when
something works, it can bepretty clear and pretty obvious.
So old people fall.
About a third of people willfall each year who are older
than 65.
And people who fall leads todisability and death.
(31:12):
So we want to help our elderlyfolks avoid falls.
Less sexy area.
If you're in your 30s and 40s,you want to know what helps for
you.
The reason I'm sharing this wasthere was a meta-analysis of 66
clinical trials, 47,000 peoplewho are about 77 years old.
(31:34):
So they did strength training.
Would strength training andbalance-oriented core muscles
would that reduce falls?
Well, it turned out.
It was pretty obvious 20 to 30%reduction in falls in thousands
of people observed.
When something works, it'spretty clear and it's
(31:57):
reproducible.
So again, dr Bobby's law of alarge number of studies.
When it works, it's usually notthat hard to show, and if you
can't find evidence, probably ifthere's any benefit, it's
pretty small.
All right, let's wrap things up.
Injuries are common.
We're all going to get them.
Too many experts, even realexperts, tell you you need to do
(32:22):
this approach, or that it'swhat I call eminence-based
medicine.
They're promoting theirapproaches and usually there's
not evidence to support it, notjust in the injury space but
more generally.
Ice ibuprofen definitely canhelp your pain, but there's no
real evidence it will get youback to your activities any
(32:44):
sooner.
Rest Well, strict rest of thatarea of your body probably isn't
a good idea.
Gentle return to activitiesseems like a good idea.
But again, the only real datais on low back pain.
Well, dr Bobby, shouldn't Ijust do one of the famous N of 1
(33:05):
studies and see what works forme?
Maybe by stretching I can avoidproblems?
Here's the difficulty.
You don't have an injury thatoften, so it might be once a
year and you might do yourstretching.
And to be statisticallysignificant, you know, you might
(33:28):
have to try stretching foryears and years to see whether
it works and then if you stopstretching, you might have to
wait years and years to see ifthe problems come back.
So a little hard to do the N ofone here come back.
So a little hard to do the N of1 here.
I wish there were a magicalapproach, but sadly there is no
(33:53):
magical approach to avoidinjuries.
There are some approaches thatseem to work or don't, when you
have some discomfort from aninjury, but again, no magic
approach.
I hope you all can live long andwell and be as active as much
of the time as possible.
Take care Until next time.
Thanks so much for listening toLive Long and Well with Dr
(34:17):
Bobby.
If you like this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at that's
(34:38):
drbobblivelongandwellcom.
That's doctor, as in D-R Bobbylivelongandwellcom.
My buddy Tim drives 30 minutes to play pickleball.
He arrives and someone saysHurry, tim, hurry, we need one
more for a fourth.
Tim skips his usual warm-up,starts a game and then quickly
sprains a calf muscle.
Was this avoidable?
What does the evidence tell usand what is the best treatment
(00:25):
for his injury?
Should he ice it, rest orcontinue moving?
Take ibuprofen, what actuallyworks?
Let's see where the evidencetakes us.
(00:53):
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well, a
podcast where we will talkabout what you can do to live as
long as possible and with asmuch energy and figure that you
wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(01:14):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome, my dear listeners, tonow episode 40, how to avoid
(01:35):
injuries and what to do whenthey occur.
Well, an injury is typicallysomething sudden, accidental,
and commonly is a sprain or astrain or a bruise.
Well, what should we do when aninjury occurs?
Well, should you ice it or not?
(01:58):
Is ibuprofen or naproxen a goodidea or not?
Should you rest or remainactive?
And how might we preventinjuries from occurring?
Will stretching help?
Is it better to do dynamicstretches versus static
(02:19):
stretches?
And we hear so many people tellus what we should do.
Is that based upon credibleevidence?
Social media and health expertsare each proposing their own
special approach, which mightinclude ice.
It might include this.
(02:39):
It might include that theymight be suggesting oh, you need
to do cryotherapy or red lighttherapy, or you must do
acupuncture or massage, or asupplement or a topical
treatment or an ointment.
Too often, what's recommended isnot evidence-based medicine,
(03:02):
but what some calleminence-based medicine, meaning
a supposedly knowledgeableperson says this is what you
need to do, whether it's aboutinjuries or injury prevention or
almost any other aspect ofhealthcare and longevity.
Often it's reallyloudness-based medicine or
(03:27):
confidence-based medicine, theperson who says, oh, this is the
way it's done.
I've done this with all of mypatients and they all do great,
you need to do this.
Or it's frequency-basedmedicine, meaning I've read
about icing forever.
It must be correct, because youjust run across it all the time
(03:47):
.
Well, what really works?
And is there any rigorousevidence to support one
particular way to treat aninjury versus another, and it's
perhaps remarkable that weactually don't fully know.
Now.
There are a lot of studies.
(04:07):
Most of them are small, mostare not very rigorous and most
don't apply to you, my listeners.
There might have been a studyin high school athletes.
I doubt I have too many of youlistening.
Some of these studies are donein military recruits, young
people with a particular type ofexercise they're doing.
(04:28):
Also may or may not apply tomost of us.
Let me just point out that todayI'm not talking about an injury
that involves a broken bone andI'm not talking about chronic
injuries.
I'm really focusing on whathappens so often to us.
We pull a muscle in our calf orour hamstring or our back goes
(04:52):
out.
These are strains, sprains andbruises, and that's what I want
to focus on.
Well, as always, why now?
Well, I had coffee about a weekor so ago with Tim and I began
at the beginning sharing hispickleball story.
He skips his warmup, he injuresa calf muscle and was it
(05:15):
avoidable?
And now that he's got theinjury, what should he do?
I'm an Ironman triathlete andI've had my share of minor
injuries.
I sprain my ankle all the time.
Sometimes I pull a muscle in mykind of hip back area and I've
(05:36):
obviously had to try all sortsof approaches both to treat them
and to avoid them impossible.
So yesterday I had a triathlonand fortunately I felt good.
This morning I'm not feelinginjured.
Was I just lucky?
Did I do something that causedit to happen?
(05:57):
Is it based upon evidence?
Well, let's see.
Well, when I was in my earlymedical training, there was a
formative study that waspublished on back pain.
Now, at the time therecommendation was you should go
(06:17):
to bed for about a week andduring that time inflammation
will go away and you'll feelmuch better.
And Richard Dale, theinvestigator, said I don't know
if that's a good idea or notbeing in bed for a week.
So he did a study, a randomizedcontrol trial, where he
compared a very brief period ofrest with the full week in bed,
(06:41):
and what he found was theprolonged rest actually made
things worse.
And this was very formative tome during my training that what
we hear isn't necessarily alwaystrue and that we need good
studies to help us sort that out.
I'm also reminded of the Frenchphilosopher Voltaire, and I love
(07:04):
this quote and I've used it inprior episodes the art of
medicine consists of amusing thepatient while nature cures the
disease.
What this means is so manythings are going to get better
on their own, no matter what wedo or what we don't do.
Own no matter what we do orwhat we don't do.
(07:28):
So if we have to be cautiouswhen people say, oh, I did this,
I got better, well, it may ormay not have had anything to do
with what they are proposing.
Well, before we dive into thefull episode, I want to thank
you for those that referred meto other people on my podcast,
(07:48):
for my podcast to be a littlemore known.
Many people have joined sincemy last podcast and thank you.
Thank you so much for referringpeople and telling them about
it.
If you have done so, pleasecontinue.
It worked.
I'll keep posted on whathappens in the future.
If you have done so, pleasecontinue.
It worked.
I'll keep posted on whathappens in the future.
If you haven't had a chance yet, please.
(08:08):
If you enjoy my podcast, Isuspect others might enjoy it
too, and I will be very happywhen I see more people that
might be benefited from it.
So thanks.
Okay, let's dive in.
You've been injured Again.
You haven't broken a bone.
This isn't a chronic injury.
This is something acute like,happens to almost all of us very
(08:33):
regularly.
So you're injured, now what Ice?
So let's talk about ice Now.
Ice and cooling the area that'sinjured goes back thousands of
years.
2500 BC, the ancient Egyptiansused cold compresses to treat
(08:55):
injuries and the famousHippocrates, the sort of father
of of medicine, in the 4thcentury BC, they used to use
snow and ice to reduce pain andbleeding in wounded soldiers.
And then in the 60s and 70s weheard about rice Rest for the R.
(09:19):
I was ice, c is compression andE is elevation.
No matter what the injury was,rice was what you should do Rest
, ice, compression and elevationof that limb.
Well, the ice belief and therice belief has changed over the
(09:42):
years.
So ice became rice.
But then people said wait, asecond rice approach isn't right
.
We now need peace, and peace isprotect E, elevate A, avoid
ibuprofen, c compression and Eelevation.
(10:03):
So PEACE approach removes iceand says don't do non-steroidal
anti -inflammatories likeibuprofen.
But not to stop there, there'salso the MEAT approach movement,
you should continue to move andexercise, analics and various
(10:24):
types of other treatments.
Well, the peace approach becamethe peace and love approach,
where love means load, optimism,vascular and exercise.
Now, how can all the rightthing keep changing from ice to
(10:44):
rice, to peace, to peace andlove to meat?
It's mind-boggling, and whenyou think you know what you're
supposed to do to treat aninjury, we still don't know.
How is that possible?
Well, for those of you who'velistened to my podcast for a
while, this is a common theme ofnot knowing and thinking we
(11:07):
know and then being told lateroops, we had it wrong.
Eggs used to be bad.
Now eggs are good Peanuts.
Oh, avoid those in the veryyoung kiddos.
Well, that turned out not to bea good idea.
In this area of treating aninjury and avoiding injuries,
(11:28):
there's a lot of studies, butthey're not very convincing, and
in a few minutes I'm going totell you Dr Bobby's law of many
studies.
So this is a teaser.
I'll answer this in a fewminutes.
You've probably heard the lawof large numbers, where if you
study a large enough group ofpeople, you kind of get the
(11:51):
right answer.
Well, you're going to get avariation called Dr Bobby's Law
of Many Studies.
So we're now injured.
What do we want to accomplish?
We would like to relieve pain.
Of course, nobody wants to bein pain.
We think we want to reduceswelling and inflammation.
(12:11):
Well, as we'll see in a fewminutes, maybe that's a good
idea, Maybe it's not such a goodidea, and of course, we want to
return to function.
Definitely we want to do thatand obviously as quickly as
possible.
Well, from my beginningdiscussion, you can see that
(12:33):
three elements seem to bediametrically opposed about
whether it's a good idea or abad idea Ice, yes or no,
ibuprofen yes or no, rest ormovement which is best?
So let's walk through each ofthese and I'll share the
(12:54):
evidence that I found or didn'tfind.
So let's begin with ice Now.
Ice really does work for paincontrol.
So when you put ice on an areathat hurts, it works.
There was a randomized controltrial of 105 folks with ankle
(13:18):
injuries.
As you're going to see, a lotof the studies in this area are
done with ankle injuries.
Well, what did they find?
They found that, in terms ofpain control, ice worked, and
the feeling is that the iceslows down the nerve conduction
(13:40):
in that part of your body, thatit numbs things.
So it appears and this has beenfor thousands of years that ice
helps pain.
Okay, but what aboutinflammation and returning to
full use?
Where does ice fit in here?
Well, the theory is, if we putice on a limb or anywhere else,
(14:05):
it will cause the blood vesselsto constrict, reducing blood
flow into that area.
And the theory is that by sodoing, you'll get less swelling,
and swelling can't be good.
Swelling hurts, swelling looksbad.
Swelling definitely issomething let's avoid.
(14:25):
So ice seems like a good idea.
But if you're reducing theblood flow into that area, maybe
there's cells or reparativeparts of our body that are
trying to get there to solve theproblem, and now we've reduced
the ability to get there.
(14:46):
Also, there may be bad thingsthat are formed in the injured
areas.
You'd like to get them out ofthere, and when you constrict
the blood vessels, that can'thappen.
So what seems like a good idealet's get rid of the swelling
may or may not be Okay.
Well, that's theory.
(15:06):
What about evidence?
There was a study that looked atcompressing the area with ice,
or just compressing it and noice, and this was ankle sprains.
It was a randomized, controlledtrial and there was no
difference.
So adding the ice to theregimen didn't make a difference
(15:29):
.
Well, what about more broadly,not just ankle injuries?
So they had a publication of asummary, a meta-analysis of 22
randomized control trials, whereagain, they tried ice in
addition to compression of thearea.
Again, it didn't make adifference.
(15:51):
The ice didn't seem to solvethe problem.
Didn't seem to solve theproblem.
Well, what about RICE, which,as we've said, is not just ice,
it also includes R, which isrest, c compression and E
elevation.
There were 11 randomizedcontrol trials, almost 900
people, and what did they find?
(16:13):
Well, it wasn't clear whetherrice, this approach that
included the ice, helped or not.
Now, the studies that were inthis were not all that well
designed and we really couldn'tfully answer the question.
So, all of these studies,what's going on?
Why isn't it clear?
(16:34):
Well, I have three theories,and again we're talking about
ice right now.
Ice may reduce pain.
Clearly, that seems to work,and it may reduce inflammation.
But that may or may not be agood idea.
Maybe the inflammation, theswelling, is our body's way of
helping you, and by stopping ityou're not helping yourself.
(16:57):
So that's one theory that theice actually doesn't work.
In fact, it might make thingsworse.
The second theory as to what'sgoing on Well, maybe we just
don't know.
Because the studies are poorand you do a bunch of poor
studies, you're really notnecessarily going to know and
you do a bunch of poor studies,you're really not necessarily
going to know.
Third theory is when peopletout that ice is the way to go,
(17:22):
it could be our famous placeboeffect.
If you want to learn more aboutthat, listen to episode 28.
(17:43):
And now, as I alluded to earlier, I want to bring you to Dr
Bobby's law of large number ofstudies.
Okay, so this is what the lawis, or the theory is, or the
hypothesis.
If there are a large number ofstudies examining a treatment or
an approach to taking care ofsomething, and at the end of all
these studies, if we look atthem and we scratch our head and
say I still don't know whetherit works or not, my law, my
(18:06):
hypothesis, is that it likelydoesn't work.
And, yes, the studies were poor.
But because there are a lot ofstudies and they never show a
clear, clear benefit, I'mguessing it doesn't work.
Or if it does work, the actualbenefit is probably really small
(18:27):
.
So that's my law.
When you see lots of studiesand you don't know, at the end
of it all, I'm guessing ifthere's any benefit, it's not
huge.
So what do I take from theliterature and evidence on ice.
There's no need to rush to getice.
It might help the discomfort,but we don't know in the long
(18:49):
run whether that reduction ofinflammation is a good idea or
not.
And let me also re-point outthat all of these studies not
all, but most all of thesestudies on ice were done with
people who either had an ankleinjury or just had surgical
repair.
So again, we don't really knowabout routine muscle injuries
(19:13):
like a calf strain or pulling ahamstring, but nothing that's
clearly saying ice works Allright.
The second area that we thinkmight help how about ibuprofen
or naproxen or a non-steroidalanti-inflammatory Very commonly
(19:33):
recommended?
Well, there was an importantreview of the evidence, the
Cochrane Collaboration, whichare groups around the world that
summarize evidence in veryrigorous ways.
They found 20 studies lookingat this topic in over 3,300
people.
And what do they find?
(19:54):
That there was no differencebetween the patients who took
ibuprofen or a non-steroidal andthose that took an alternative
drug called paracetamol, whichis like Tylenol.
It's like an acetaminophen, andthey looked at whether pain was
better at one to two hours, twoto three days, changes in
(20:16):
swelling and basically theyfound no difference.
So if you are in pain, by allmeans do something.
But Tylenol is probably just asgood.
Why not take the ibuprofen?
Well, ibuprofen reducesinflammation, and just like ice.
Well, ibuprofen reducesinflammation, and just like ice,
reducing the inflammation mayor may not be a good idea.
(20:40):
Unfortunately, the studieshaven't really been done well
enough to say whether ibuprofenwill help you return to exercise
and function.
It just didn't fully answerthat, so we don't know.
Okay, so ice doesn't seem to bea great idea.
Ibuprofen doesn't seem to be agreat idea.
(21:03):
Now, should you rest?
You've injured that muscle.
You've injured your ankle.
Should you rest or not?
Now, before we get too far inthis, I did not find any studies
that compared rest versusgentle exercise for the typical
(21:23):
leg muscle strain.
So what am I going to do?
I'm going to now tell you moreabout that low back pain set of
studies, because a low back painepisode is kind of like pulling
a muscle.
You are feeling good, you movesome furniture, you pull a
(21:44):
muscle in your back and you arein pain.
So I don't have an example onrest or not for some of these
other parts of our body, but Ido have some data on low back,
and I did mention that studythat looked at two days of rest
versus seven days of bed rest.
(22:04):
And again there were nodifferences.
And there were no differencesin getting back to work sooner,
except that the people who werein bed longer, of course, didn't
get back to work very soon atall, that the people who were in
bed longer, of course, didn'tget back to work very soon at
all.
(22:26):
Then in 1995, there was arandomized trial that compared
two days of bed rest, backexercises or just continue your
normal activities.
And then they looked at peoplewho had hurt their back Again an
acute injury, not a chronicproblem.
They looked to see at threeweeks and 12 weeks who did best.
Well, it turns out it wasn'tthe people who had two days of
(22:47):
bed rest, it wasn't the peoplewho did the back exercises.
The people who did best werethe ones that continued their
normal activity.
The duration of pain was less,the intensity of the pain was
less and their ability to workwas better.
And in fact the people who wentto bed for a couple of days
(23:07):
actually had the slowest injuryresolution.
So this was fascinating.
Again, it's not in some of theother areas of your body it
doesn't tell us necessarily formy buddy tim with his calf
muscle.
But in the area of back pain itlooks like if you have an acute
injury you really just want tocontinue normal activities.
(23:30):
Obviously you don't want to doanything that's making it cause
severe pain.
But resting the other thingsdidn't do better than just
continuing normal activity, andin fact normal activity did even
better.
So well, what about otherthings you might do?
(23:50):
Acupuncture or massage.
Well, another day I may drillinto those.
I don't think there's greatdata for an acute injury to your
hamstring for that, but we'lldive into it.
And if any of you out there inlistener land have some good
studies, by all means send themmy way.
And if you're interested inwhere does red light therapy fit
(24:14):
into all this, you can listenagain to episode 31 of my
podcast.
Okay, so the obvious thingspeople tell you to do don't seem
to make a difference to get theinjury to go away.
But how about preventing aninjury?
That seems really important.
How about stretching?
(24:35):
Does it work?
And what type of stretching?
You might have heard of staticstretching or dynamic stretching
.
When should you do thestretching?
Before exercise, in the middleof exercise or after?
Well, I went to a set ofguidelines by the American
Academy of Orthopedic Surgeons.
(24:57):
This is a very well-recognizedgroup of physicians and surgeons
and I asked the question intheir guidelines, do they say
anything about ways to preventsports injuries?
And they basically say, well,stretching is the way to go to
help reduce injury.
(25:17):
Well, I looked at the evidenceand I wanted to figure out is
that true?
Well, there was an article thatreviewed four randomized
control trials and they lookedat static stretching.
Now, what is static stretching?
That's the kind of typicalstretching you usually think
(25:38):
about.
You know touching your toes,you know twisting your back a
little bit to make it, you know,stretch certain muscles.
So these are the types ofstretching that's called static.
And what these four studiesfound was there was really no
(26:02):
significant difference betweenthe people who did the static
stretching or didn't to preventinjury.
And if there is some suggestionthat maybe there's a tiny bit
of benefit and we're going tocome back to what a tiny bit of
benefit means in just a littlebit Well, there was another
(26:24):
study.
They looked at 5,000 papers,5,000 published articles, and it
turns out of the 5,000 articles, only four of those articles
qualified for review.
Meaning all of these studieswere really poorly done, except
for the four, and those fourwere kind of atypical, meaning
(26:49):
three of them were in militaryrecruits, who do get injured
regularly, and one was in soccerplayers.
Now, what they tested was apretty significant regimen of
stretching, so 20 seconds at atime, one to two sets for each
of the key muscle areas, andthey followed up at 12 weeks to
(27:11):
see whether stretching beforevigorous activity and obviously
military recruits are doingvigorous activity and also the
soccer players.
What did they find?
The stretching did not preventtendon injuries.
Now, it did seem to reducemuscle injuries and in fact they
(27:33):
had what's called an odds ratioof 0.37, meaning that it
reduced the rate of muscleinjuries by two-thirds.
That sounds fantastic, but, asMark Twain said well over a
century ago, there are lies,damn lies and statistics.
(27:54):
So in these studies of 1,300people the people who did
nothing, no stretching only 65muscle injuries.
In the people who did thestatic stretching, there were
fewer muscle injuries.
There were about 33.
(28:15):
So the rate of injury went fromabout 5% to 2.6 or 7%.
Now, what does this mean?
It seems like it made adifference, but 95% of the
people had no injurieswhatsoever.
So a whole lot of people werestretching to reduce the number
(28:37):
of injuries by a very smallnumber, and there's something
called the number needed totreat and basically it would
take 33 people stretching for 12weeks to prevent one injury.
Now, this isn't one person dyingor having a heart attack you're
(28:58):
trying to avoid.
It's just a muscle sprain orstrain.
So even if you think the dataare compelling, the impact isn't
huge at all.
And these studies were in youngpeople, you know, military
recruits and such.
What does it tell us aboutstretching for people who are 40
(29:19):
or 50 year olds more like mylisteners?
We just don't know.
Okay, what about dynamicstretching?
Dynamic stretching has beensomething that's gotten a lot of
attention.
Now, what is dynamic stretching?
Dynamic stretching is thingslike, you know, shoulder
rotation or trunk rotation orhip flexion or lifting your
(29:43):
knees up high, so it's basicallystretching while you're moving
the joint, as opposed to justholding a stretch for a
significant period of time.
Now, there weren't many studies.
They were small, they weren'twell done.
But what about dynamicstretching?
There's conflicting evidenceNow.
(30:04):
Stretching may increase yourrange of motion, it might make
you feel better, it might evenimprove performance.
So if you can move your musclesin your leg better, maybe
you'll run faster.
But that isn't the question onthe table.
The question on the table isnot whether it feels better, not
whether you'll run a little bitfaster, but does it prevent
(30:28):
injury?
Turns out, not much evidence tosupport it.
Okay, I talked with you earlierabout the law Dr Bobby's law of
the large number of studies.
You know, when something works,it's often quite clear and not
all prevention efforts fail.
(30:49):
Now this is a less sexy areaand might not apply to you, but
the reason I want to explainthis to you is that when
something works, it can bepretty clear and pretty obvious.
So old people fall.
About a third of people willfall each year who are older
than 65.
And people who fall leads todisability and death.
(31:12):
So we want to help our elderlyfolks avoid falls.
Less sexy area.
If you're in your 30s and 40s,you want to know what helps for
you.
The reason I'm sharing this wasthere was a meta-analysis of 66
clinical trials, 47,000 peoplewho are about 77 years old.
(31:34):
So they did strength training.
Would strength training andbalance-oriented core muscles
would that reduce falls?
Well, it turned out.
It was pretty obvious 20 to 30%reduction in falls in thousands
of people observed.
When something works, it'spretty clear and it's
(31:57):
reproducible.
So again, dr Bobby's law of alarge number of studies.
When it works, it's usually notthat hard to show, and if you
can't find evidence, probably ifthere's any benefit, it's
pretty small.
All right, let's wrap things up.
Injuries are common.
We're all going to get them.
Too many experts, even realexperts, tell you you need to do
(32:22):
this approach, or that it'swhat I call eminence-based
medicine.
They're promoting theirapproaches and usually there's
not evidence to support it, notjust in the injury space but
more generally.
Ice ibuprofen definitely canhelp your pain, but there's no
real evidence it will get youback to your activities any
(32:44):
sooner.
Rest Well, strict rest of thatarea of your body probably isn't
a good idea.
Gentle return to activitiesseems like a good idea.
But again, the only real datais on low back pain.
Well, dr Bobby, shouldn't Ijust do one of the famous N of 1
(33:05):
studies and see what works forme?
Maybe by stretching I can avoidproblems?
Here's the difficulty.
You don't have an injury thatoften, so it might be once a
year and you might do yourstretching.
And to be statisticallysignificant, you know, you might
(33:28):
have to try stretching foryears and years to see whether
it works and then if you stopstretching, you might have to
wait years and years to see ifthe problems come back.
So a little hard to do the N ofone here come back.
So a little hard to do the N of1 here.
I wish there were a magicalapproach, but sadly there is no
(33:53):
magical approach to avoidinjuries.
There are some approaches thatseem to work or don't, when you
have some discomfort from aninjury, but again, no magic
approach.
I hope you all can live long andwell and be as active as much
of the time as possible.
Take care Until next time.
Thanks so much for listening toLive Long and Well with Dr
(34:17):
Bobby.
If you like this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at that's
(34:38):
drbobblivelongandwellcom.
That's doctor, as in D-R Bobbylivelongandwellcom.
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I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com