Live Long and Well with Dr. Bobby
Let's explore how you can Live Long and Well with six evidence based pillars: exercise, good sleep, proper nutrition, mind-body activities, exposure to heat/cold, and social relationships. I am a physician scientist, Ironman Triathlete, and have a passion for helping others achieve their best self.
Live Long and Well with Dr. Bobby
#40: Can you avoid injury and what to do when it occurs?
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often shout conflicting advice, this episode sorts through the noise to uncover what’s evidence-backed, what’s outdated, and what might actually delay healing.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
My buddy Tim drives 30 minutes to play pickleball. He arrives and someone says Hurry, 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 us and what is the best treatment for his injury? Should he ice it, rest or continue moving? Take ibuprofen, what actually works? Let's see where the evidence takes us.
Speaker 1:Hi, I'm Dr Bobby DuBois and welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and figure that you wish. Together, we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey and I hope that you feel empowered along the way. I'm a physician, ironman, triathlete and have published several hundred scientific studies. I'm honored to be your guide. Welcome, my dear listeners, to now episode 40, how to avoid injuries and what to do when they occur.
Speaker 1:Well, an injury is typically something sudden, accidental, and commonly is a sprain or a strain or a bruise. Well, what should we do when an injury occurs? Well, should you ice it or not? Is ibuprofen or naproxen a good idea or not? Should you rest or remain active? And how might we prevent injuries from occurring? Will stretching help? Is it better to do dynamic stretches versus static stretches? And we hear so many people tell us what we should do. Is that based upon credible evidence? Social media and health experts are each proposing their own special approach, which might include ice. It might include this. It might include that they might be suggesting oh, you need to do cryotherapy or red light therapy, or you must do acupuncture or massage, or a supplement or a topical treatment or an ointment.
Speaker 1:Too often, what's recommended is not evidence-based medicine, but what some call eminence-based medicine, meaning a supposedly knowledgeable person says this is what you need to do, whether it's about injuries or injury prevention or almost any other aspect of healthcare and longevity. Often it's really loudness-based medicine or confidence-based medicine, the person who says, oh, this is the way it's done. I've done this with all of my patients and they all do great, you need to do this. Or it's frequency-based medicine, meaning I've read about icing forever. It must be correct, because you just run across it all the time. Well, what really works? And is there any rigorous evidence to support one particular way to treat an injury versus another, and it's perhaps remarkable that we actually don't fully know. Now. There are a lot of studies. Most of them are small, most are not very rigorous and most don't apply to you, my listeners. There might have been a study in high school athletes. I doubt I have too many of you listening. Some of these studies are done in military recruits, young people with a particular type of exercise they're doing. Also may or may not apply to most of us.
Speaker 1:Let me just point out that today I'm not talking about an injury that involves a broken bone and I'm not talking about chronic injuries. I'm really focusing on what happens so often to us. We pull a muscle in our calf or our hamstring or our back goes out. These are strains, sprains and bruises, and that's what I want to focus on. Well, as always, why now? Well, I had coffee about a week or so ago with Tim and I began at the beginning sharing his pickleball story. He skips his warmup, he injures a calf muscle and was it avoidable? And now that he's got the injury, what should he do?
Speaker 1:I'm an Ironman triathlete and I've had my share of minor injuries. I sprain my ankle all the time. Sometimes I pull a muscle in my kind of hip back area and I've obviously had to try all sorts of approaches both to treat them and to avoid them impossible. So yesterday I had a triathlon and fortunately I felt good. This morning I'm not feeling injured. Was I just lucky? Did I do something that caused it to happen? Is it based upon evidence? Well, let's see.
Speaker 1:Well, when I was in my early medical training, there was a formative study that was published on back pain. Now, at the time the recommendation was you should go to bed for about a week and during that time inflammation will go away and you'll feel much better. And Richard Dale, the investigator, said I don't know if that's a good idea or not being in bed for a week. So he did a study, a randomized control trial, where he compared a very brief period of rest with the full week in bed, and what he found was the prolonged rest actually made things worse. And this was very formative to me during my training that what we hear isn't necessarily always true and that we need good studies to help us sort that out.
Speaker 1:I'm also reminded of the French philosopher Voltaire, and I love this quote and I've used it in prior episodes the art of medicine consists of amusing the patient while nature cures the disease. What this means is so many things are going to get better on their own, no matter what we do or what we don't do. Own no matter what we do or what we don't do. So if we have to be cautious when people say, oh, I did this, I got better, well, it may or may not have had anything to do with what they are proposing.
Speaker 1:Well, before we dive into the full episode, I want to thank you for those that referred me to other people on my podcast, for my podcast to be a little more known. Many people have joined since my last podcast and thank you. Thank you so much for referring people and telling them about it. If you have done so, please continue. It worked. I'll keep posted on what happens in the future. If you have done so, please continue. It worked. I'll keep posted on what happens in the future. If you haven't had a chance yet, please. If you enjoy my podcast, I suspect others might enjoy it too, and I will be very happy when I see more people that might be benefited from it. So thanks.
Speaker 1: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 regularly. So you're injured, now what Ice? So let's talk about ice Now.
Speaker 1:Ice and cooling the area that's injured goes back thousands of years. 2500 BC, the ancient Egyptians used cold compresses to treat injuries and the famous Hippocrates, the sort of father of of medicine, in the 4th century BC, they used to use snow and ice to reduce pain and bleeding in wounded soldiers. And then in the 60s and 70s we heard about rice Rest for the R. I was ice, c is compression and E is elevation. No matter what the injury was, rice was what you should do Rest, ice, compression and elevation of that limb. Well, the ice belief and the rice belief has changed over the years. So ice became rice. But then people said wait, a second rice approach isn't right. We now need peace, and peace is protect E, elevate A, avoid ibuprofen, c compression and E elevation.
Speaker 1:So PEACE approach removes ice and says don't do non-steroidal anti -inflammatories like ibuprofen. But not to stop there, there's also the MEAT approach movement, you should continue to move and exercise, analics and various types of other treatments. Well, the peace approach became the peace and love approach, where love means load, optimism, vascular and exercise. Now, how can all the right thing keep changing from ice to rice, to peace, to peace and love to meat? It's mind-boggling, and when you think you know what you're supposed to do to treat an injury, we still don't know. How is that possible? Well, for those of you who've listened to my podcast for a while, this is a common theme of not knowing and thinking we know and then being told later oops, we had it wrong. Eggs used to be bad. Now eggs are good Peanuts. Oh, avoid those in the very young kiddos. Well, that turned out not to be a good idea.
Speaker 1:In this area of treating an injury and avoiding injuries, there's a lot of studies, but they're not very convincing, and in a few minutes I'm going to tell you Dr Bobby's law of many studies. So this is a teaser. I'll answer this in a few minutes. You've probably heard the law of large numbers, where if you study a large enough group of people, you kind of get the right answer. Well, you're going to get a variation called Dr Bobby's Law of Many Studies. So we're now injured.
Speaker 1:What do we want to accomplish? We would like to relieve pain. Of course, nobody wants to be in pain. We think we want to reduce swelling and inflammation. Well, as we'll see in a few minutes, maybe that's a good idea, Maybe it's not such a good idea, and of course, we want to return to function. Definitely we want to do that and obviously as quickly as possible.
Speaker 1:Well, from my beginning discussion, you can see that three elements seem to be diametrically opposed about whether it's a good idea or a bad idea Ice, yes or no, ibuprofen yes or no, rest or movement which is best? So let's walk through each of these and I'll share the evidence that I found or didn't find. So let's begin with ice Now. Ice really does work for pain control. So when you put ice on an area that hurts, it works. There was a randomized control trial of 105 folks with ankle injuries. As you're going to see, a lot of the studies in this area are done with ankle injuries. Well, what did they find? They found that, in terms of pain control, ice worked, and the feeling is that the ice slows down the nerve conduction in that part of your body, that it numbs things. So it appears and this has been for thousands of years that ice helps pain.
Speaker 1:Okay, but what about inflammation and returning to full use? Where does ice fit in here? Well, the theory is, if we put ice on a limb or anywhere else, it will cause the blood vessels to constrict, reducing blood flow into that area. And the theory is that by so doing, you'll get less swelling, and swelling can't be good. Swelling hurts, swelling looks bad. Swelling definitely is something let's avoid. So ice seems like a good idea. But if you're reducing the blood flow into that area, maybe there's cells or reparative parts of our body that are trying to get there to solve the problem, and now we've reduced the ability to get there. Also, there may be bad things that are formed in the injured areas. You'd like to get them out of there, and when you constrict the blood vessels, that can't happen. So what seems like a good idea let's get rid of the swelling may or may not be Okay. Well, that's theory. What about evidence?
Speaker 1:There was a study that looked at compressing the area with ice, or just compressing it and no ice, and this was ankle sprains. It was a randomized, controlled trial and there was no difference. So adding the ice to the regimen didn't make a difference. Well, what about more broadly, not just ankle injuries? So they had a publication of a summary, a meta-analysis of 22 randomized control trials, where again, they tried ice in addition to compression of the area. Again, it didn't make a difference. The ice didn't seem to solve the problem. Didn't seem to solve the problem. Well, what about RICE, which, as we've said, is not just ice, it also includes R, which is rest, c compression and E elevation. There were 11 randomized control trials, almost 900 people, and what did they find? Well, it wasn't clear whether rice, this approach that included the ice, helped or not.
Speaker 1:Now, the studies that were in this were not all that well designed and we really couldn't fully answer the question. So, all of these studies, what's going on? Why isn't it clear? Well, I have three theories, and again we're talking about ice right now.
Speaker 1:Ice may reduce pain. Clearly, that seems to work, and it may reduce inflammation. But that may or may not be a good idea. Maybe the inflammation, the swelling, is our body's way of helping you, and by stopping it you're not helping yourself. So that's one theory that the ice actually doesn't work. In fact, it might make things worse. The second theory as to what's going on Well, maybe we just don't know. Because the studies are poor and you do a bunch of poor studies, you're really not necessarily going to know and you do a bunch of poor studies, you're really not necessarily going to know. Third theory is when people tout that ice is the way to go, it could be our famous placebo effect. If you want to learn more about that, listen to episode 28.
Speaker 1:And now, as I alluded to earlier, I want to bring you to Dr Bobby's law of large number of studies. Okay, so this is what the law is, or the theory is, or the hypothesis. If there are a large number of studies examining a treatment or an approach to taking care of something, and at the end of all these studies, if we look at them and we scratch our head and say I still don't know whether it works or not, my law, my hypothesis, is that it likely doesn't work. And, yes, the studies were poor. But because there are a lot of studies and they never show a clear, clear benefit, I'm guessing it doesn't work. Or if it does work, the actual benefit is probably really small. So that's my law. When you see lots of studies and you don't know, at the end of it all, I'm guessing if there's any benefit, it's not huge. So what do I take from the literature and evidence on ice. There's no need to rush to get ice. It might help the discomfort, but we don't know in the long run whether that reduction of inflammation is a good idea or not. And let me also re-point out that all of these studies not all, but most all of these studies on ice were done with people who either had an ankle injury or just had surgical repair. So again, we don't really know about routine muscle injuries like a calf strain or pulling a hamstring, but nothing that's clearly saying ice works All right.
Speaker 1:The second area that we think might help how about ibuprofen or naproxen or a non-steroidal anti-inflammatory Very commonly recommended? Well, there was an important review of the evidence, the Cochrane Collaboration, which are groups around the world that summarize evidence in very rigorous ways. They found 20 studies looking at this topic in over 3,300 people. And what do they find? That there was no difference between the patients who took ibuprofen or a non-steroidal and those that took an alternative drug called paracetamol, which is like Tylenol. It's like an acetaminophen, and they looked at whether pain was better at one to two hours, two to three days, changes in swelling and basically they found no difference. So if you are in pain, by all means do something. But Tylenol is probably just as good.
Speaker 1:Why not take the ibuprofen? Well, ibuprofen reduces inflammation, and just like ice. Well, ibuprofen reduces inflammation, and just like ice, reducing the inflammation may or may not be a good idea. Unfortunately, the studies haven't really been done well enough to say whether ibuprofen will help you return to exercise and function. It just didn't fully answer that, so we don't know. Okay, so ice doesn't seem to be a great idea. Ibuprofen doesn't seem to be a great idea.
Speaker 1:Now, should you rest? You've injured that muscle. You've injured your ankle. Should you rest or not?
Speaker 1:Now, before we get too far in this, I did not find any studies that compared rest versus gentle exercise for the typical leg muscle strain. So what am I going to do? I'm going to now tell you more about that low back pain set of studies, because a low back pain episode is kind of like pulling a muscle. You are feeling good, you move some furniture, you pull a muscle in your back and you are in pain. So I don't have an example on rest or not for some of these other parts of our body, but I do have some data on low back, and I did mention that study that looked at two days of rest versus seven days of bed rest. And again there were no differences. And there were no differences in getting back to work sooner, except that the people who were in bed longer, of course, didn't get back to work very soon at all, that the people who were in bed longer, of course, didn't get back to work very soon at all.
Speaker 1:Then in 1995, there was a randomized trial that compared two days of bed rest, back exercises or just continue your normal activities. And then they looked at people who had hurt their back Again an acute injury, not a chronic problem. They looked to see at three weeks and 12 weeks who did best. Well, it turns out it wasn't the people who had two days of bed rest, it wasn't the people who did the back exercises. The people who did best were the ones that continued their normal activity. The duration of pain was less, the intensity of the pain was less and their ability to work was better. And in fact the people who went to bed for a couple of days actually had the slowest injury resolution. So this was fascinating.
Speaker 1:Again, it's not in some of the other areas of your body it doesn't tell us necessarily for my buddy tim with his calf muscle. But in the area of back pain it looks like if you have an acute injury you really just want to continue normal activities. Obviously you don't want to do anything that's making it cause severe pain. But resting the other things didn't do better than just continuing normal activity, and in fact normal activity did even better. So well, what about other things you might do? Acupuncture or massage. Well, another day I may drill into those. I don't think there's great data for an acute injury to your hamstring for that, but we'll dive into it. And if any of you out there in listener land have some good studies, by all means send them my way. And if you're interested in where does red light therapy fit into all this, you can listen again to episode 31 of my podcast. Okay, so the obvious things people tell you to do don't seem to make a difference to get the injury to go away.
Speaker 1:But how about preventing an injury? That seems really important. How about stretching? Does it work? And what type of stretching? You might have heard of static stretching or dynamic stretching. When should you do the stretching? Before exercise, in the middle of exercise or after? Well, I went to a set of guidelines by the American Academy of Orthopedic Surgeons. This is a very well-recognized group of physicians and surgeons and I asked the question in their guidelines, do they say anything about ways to prevent sports injuries? And they basically say, well, stretching is the way to go to help reduce injury.
Speaker 1:Well, I looked at the evidence and I wanted to figure out is that true? Well, there was an article that reviewed four randomized control trials and they looked at static stretching. Now, what is static stretching? That's the kind of typical stretching you usually think 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 of stretching that's called static. And what these four studies found was there was really no significant difference between the people who did the static stretching or didn't to prevent injury. And if there is some suggestion that maybe there's a tiny bit of benefit and we're going to come back to what a tiny bit of benefit means in just a little bit Well, there was another study.
Speaker 1: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 studies were really poorly done, except for the four, and those four were kind of atypical, meaning three of them were in military recruits, who do get injured regularly, and one was in soccer players. Now, what they tested was a pretty significant regimen of stretching, so 20 seconds at a time, one to two sets for each of the key muscle areas, and they followed up at 12 weeks to see whether stretching before vigorous activity and obviously military recruits are doing vigorous activity and also the soccer players. What did they find? The stretching did not prevent tendon injuries. Now, it did seem to reduce muscle injuries and in fact they had what's called an odds ratio of 0.37, meaning that it reduced the rate of muscle injuries by two-thirds.
Speaker 1:That sounds fantastic, but, as Mark Twain said well over a century ago, there are lies, damn lies and statistics. So in these studies of 1,300 people the people who did nothing, no stretching only 65 muscle injuries. In the people who did the static stretching, there were fewer muscle injuries. There were about 33. So the rate of injury went from about 5% to 2.6 or 7%. Now, what does this mean? It seems like it made a difference, but 95% of the people had no injuries whatsoever. So a whole lot of people were stretching to reduce the number of injuries by a very small number, and there's something called the number needed to treat and basically it would take 33 people stretching for 12 weeks to prevent one injury.
Speaker 1:Now, this isn't one person dying or having a heart attack you're trying to avoid. It's just a muscle sprain or strain. So even if you think the data are compelling, the impact isn't huge at all. And these studies were in young people, you know, military recruits and such. What does it tell us about stretching for people who are 40 or 50 year olds more like my listeners? We just don't know.
Speaker 1:Okay, what about dynamic stretching? Dynamic stretching has been something that's gotten a lot of attention. Now, what is dynamic stretching? Dynamic stretching is things like, you know, shoulder rotation or trunk rotation or hip flexion or lifting your knees up high, so it's basically stretching while you're moving the joint, as opposed to just holding a stretch for a significant period of time. Now, there weren't many studies. They were small, they weren't well done. But what about dynamic stretching? There's conflicting evidence Now.
Speaker 1:Stretching may increase your range of motion, it might make you feel better, it might even improve performance. So if you can move your muscles in your leg better, maybe you'll run faster. But that isn't the question on the table. The question on the table is not whether it feels better, not whether you'll run a little bit faster, but does it prevent injury? Turns out, not much evidence to support it. Okay, I talked with you earlier about the law Dr Bobby's law of the large number of studies.
Speaker 1:You know, when something works, it's often quite clear and not all prevention efforts fail. Now this is a less sexy area and might not apply to you, but the reason I want to explain this to you is that when something works, it can be pretty clear and pretty obvious. So old people fall. About a third of people will fall each year who are older than 65. And people who fall leads to disability and death. So we want to help our elderly folks 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 was there was a meta-analysis of 66 clinical trials, 47,000 people who are about 77 years old. So they did strength training. Would strength training and balance-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's pretty clear and it's reproducible. So again, dr Bobby's law of a large number of studies. When it works, it's usually not that hard to show, and if you can't find evidence, probably if there's any benefit, it's pretty small. All right, let's wrap things up.
Speaker 1:Injuries are common. We're all going to get them. Too many experts, even real experts, tell you you need to do this approach, or that it's what I call eminence-based medicine. They're promoting their approaches and usually there's not evidence to support it, not just in the injury space but more generally. Ice ibuprofen definitely can help your pain, but there's no real evidence it will get you back to your activities any sooner.
Speaker 1:Rest Well, strict rest of that area of your body probably isn't a good idea. Gentle return to activities seems like a good idea. But again, the only real data is on low back pain. Well, dr Bobby, shouldn't I just do one of the famous N of 1 studies and see what works for me? Maybe by stretching I can avoid problems?
Speaker 1:Here's the difficulty. You don't have an injury that often, so it might be once a year and you might do your stretching. And to be statistically significant, you know, you might have to try stretching for years and years to see whether it works and then if you stop stretching, you might have to wait years and years to see if the problems come back. So a little hard to do the N of one here come back. So a little hard to do the N of 1 here. I wish there were a magical approach, but sadly there is no magical approach to avoid injuries. There are some approaches that seem to work or don't, when you have some discomfort from an injury, but again, no magic approach.
Speaker 1:I hope you all can live long and well and be as active as much of the time as possible. Take care Until next time. Thanks so much for listening to Live Long and Well with Dr Bobby. If you like this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at that's drbobblivelongandwellcom. That's doctor, as in D-R Bobby livelongandwellcom.