RICE (rest, ice, compression and elevation) revisited.

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“Rest, Ice, Compression and Elevate” has for years been the accepted and oft quoted way to address injury. You roll your ankle and quickly you run for the ice/peas, sit down and place it on the injured ankle. However, what if current research is starting to challenge the accepted norm? At this point, I know what you’re thinking: can the guys who wear lab coats for a living just stop moving the goalposts, changing our collective common knowledge and stop stuffing with our psyche?

I hear your gripes, moans and interjections but it is progression like this in science that ensures we keep advancing to a greater understanding of the body. Even with the advance in available technology, there is still much to learn when talking about the human body, with technology arguably helping us to pose more questions and then the answers it seemingly provides.

So, back on topic. I recently attended a junior sports science symposium and had the benefit of hearing about interesting research regarding the latest developments to emerge regarding soft tissue injury and the widely accepted practice of RICE (rest, ice, compression, elevate) post trauma. A university professor was discussing some new research pointing to the effect of practices to the contrary, which was a veritable slap in the face, especially considering my extensive history with injuries (compared to the everyday individual) and my reliance on this method as standard practice. However, the professor was intimating that new research suggests the body’s normal response to trauma, which is needed to help rebuild new tissue and excrete the damaged cells, is prohibited from doing so when the RICE method is used. The conversation finished without a defined conclusion; however, this piqued my interest to the point that I have been investigating it ever since, in order to determine what views and practices are now in this area concerning soft tissue trauma and treatment. Learning what I have, consider this blog as my report on the early conclusions, which will hopefully open your eyes as wide as mine were.

So let’s go back to when you roll your ankle (for arguments sake in this instance, it’s just a minor sprain); when you do this you damage ligaments and soft tissue, ultimately causing internal bleeding to that area. At this point, your body responds by initiating its inflammatory response, which to most of us means a big, fat (c)ankle. It is at this point that we usually go grab an ice pack, whack it on the area that’s swollen, put our ankle on a couple of pillows and lay down, watching telly with a tea towel or bandage tightly holding it together.

So why do we RICE? What does it do?

Let’s start with R; R stands for rest, which seemingly explains itself – when you hurt something usually the pain experienced will mean that this stage is taken care for you. You stay off the area injured to minimise any further injury and aid scar tissue formation. “I” stands for ice; by cooling the area of trauma, blood flow to the capillaries is restricted, thereby reducing the total volume of swelling and bleeding as well as slowing nerve transmission from shunting the pain response. “C” stands for compression; this works in a similar way to ice, in which the compression increases the intramuscular pressure around the area of trauma, thereby reducing the volume of fluid and blood. “E” stands for elevation; when you elevate the injury area above your heart the blood flow to that part slows. It decreases hydrostatic pressure, reducing blood flow to the damaged area which in turn reduces the prevalence of interstitial fluid. In essence, all these modalities achieve the same effect, but by acting through different mechanisms.

So usually the quicker the swelling goes down, the quicker the bleed dissipates, the quicker the pain subsides and the quicker we can return to weight bearing and strengthening the area affected. This is what we have been led to believe, the norm, the accepted practice for all our life – myself especially. This all sounds logical and still not necessarily wrong. (Knight. K et al 2000)

Just like in my previous blog about stretching, there’s no conclusive evidence that the RICE process actually speeds up the recovery process. Hubbard and Denegar in 2004 found that it reduced pain and swelling acutely but critically, gave no conclusive effect on recovery. Isabell et al 1992 found the therapeutic use of ice, combined or used separately, was not effective in reducing the symptoms of swelling. Though not statistically significant, disparity in the data suggests that ice application may be contraindicated in the treatment of inflammation. Bleakley et al (2004) reported that the application of cold seemed to be more effective in limiting swelling and decreasing pain in the short term (immediately after application to 1 week post injury). However, the long-term effects of cryotherapy and the effect on the tissue repair are not known. Bleakley et al also found ice didn’t seem to be more effective than compression after surgery. In that study, only 2 of the 8 groups reported significant differences in favour of ice and compression. However, in all 8 studies, postsurgical dressings or socks were used to separate the injured area of the body and the cooling agent (e.g. like the tea towel around the ice-pack). Such a barrier may have mitigated the cooling effect of the cold compress. As such, additional research with larger sample sizes is needed before we can know conclusively how effective ice and compression is on acute or chronic injury. Based on reviews by Bleakley et al and a similar review by Hubbard et al (2004), the quality of methodology used in clinical trials of cryotherapy is poor. Further, most of these studies were conducted years ago. Despite the general acceptance of cryotherapy as an effective intervention, evidence on which to base these conclusions is limited. Only with strong randomized, controlled clinical trials will we know the true efficacy of RICE.

Returning to the now, some scientists are saying that the natural reaction of swelling and pain experienced after trauma is maybe the most effective way to treat the problem. The thing is swelling comprises many cells, including detrimental cells such as pathogens, damaged cells or irritants. However, swelling also carries cells that are essential in the remodelling, repairing, clearing and strengthening of the traumatised area. Therefore, the view now being populated is that there is a reason why the body responds this way to trauma, as it aids recovery quicker than the RICE method due to the introduction into the affected area with repairing, remodelling and cleaning cells. A study by John M. Beiner, MD and Peter Jokl, MD found that soft tissue injuries are the leading cause of morbidity from sports-related injuries. Severity depends on the site of impact, the activation status of the muscles involved, the age of the patient, and the presence of fatigue. The diagnosis has traditionally been one of clinical judgment and RICE; however, newer modalities, including ultrasonography, magnetic resonance imaging, and spectroscopy, are becoming increasingly important in both identifying and delineating the extent of injury. Although controlled clinical studies are scarce, animal research into soft tissue injuries has allowed for a description of the natural healing process to propagate, which is seemingly a complex balance between muscle repair, regeneration, and scar-tissue formation. This suggests that treating these injuries with RICE decreases the flow of beneficial cells that assist in the remodelling and recovering of the injury.

At this point, I am not advocating either over the other – however, it is an interesting concept that has piqued my interest and is a developing area of research that perhaps we should all keep aware. At this point, there is no doubt that the RICE method assists in the reduction of acute swelling and pain; however the question remains unanswered as to whether the RICE method is, in the long term, a benefit or a hindrance? Smarter people then I will have to spend a lot more time to conclusively answer this interesting hypothesis – a hypothesis that could see a monumental shift in the paradigm of soft-tissue injury treatment.

So after all that, have you got more questions than answers? Unfortunately, you are going to have to join the queue.

Beiner. John M, MD. Jokly, P Muscle Contusion Injuries: Current Treatment Options American Academy of Orthopaedic Surgeons MD 2001

Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004;32:251–261.

Hocutt JE Jr, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. Am J Sport Med. 1982;10:316–319

Hubbard TJ, Aronson SL, Denegar CR. Does cryotherapy hasten return to participation? A systematic review. J Athl Train. 2004;39:88–94.

KENNETH L. KNIGHT, PhD, ATC; JODY B. BRUCKER, MS, ATC; PAUL D. STONEMAN, MPT; and MACK D. RUBLEY, MS, ATC Muscle Injury Management With Cryotherapy. Brigham Young University. Human Kinetics 2000




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