Rest. Ice. Compression. Elevation. This treatment protocol has been used for over four decades by healthcare professionals, trainers, athletes and lay people alike to treat acute injuries. But what does the research say? Is this an appropriate method to treat acute tissue injuries?
Dr. Gabe Mirkin coined the acronym R.I.C.E in 1978, however, in 2013 the notion of resting an injury while simultaneously elevating and compressing with ice was challenged causing Dr. Mirkin to rescind his opinion in 2015. “Subsequent research shows that rest and ice can actually delay recovery. Mild movement helps tissues to heal faster, and the application of cold supresses the immune responses that start and hasten immune recovery” (Scialoia & Swartzendruber, 2020).
When injury occurs, whether to ligament, tendon or muscle, our cells respond in three phases: inflammation, repair, and remodeling. Inflammation is often mistakenly viewed as a negative consequence of injury that needs to be reduced or delayed with the application of ice; however, inflammation is actually an important part of the body’s defense mechanism. The purpose of inflammation is to control the extent of cell injury and prepare tissues for the process of repair. Not only does delaying inflammation delay healing, but it also damages tissues. “Inflammation can occur without healing, but healing cannot occur without inflammation” (Scialoia & Swartzendruber, 2020).
The generally accepted use of compression is to control swelling. However, there is little evidence to support these assumptions. Further, there is no evidence on the best way, amount, duration or position in which the treatment should be given. Elevation is also used in an effort to control swelling in the extremities by promoting venous return, but again, there is no evidence to suggest it enhances tissue healing. However, the use of compression and elevation is generally tolerated well by most individuals. Other than the possibility of restricting circulation by too much compression, these treatments do not have negative effects on outcome.
Lastly, resting following acute injury is not associated with enhanced recovery. In fact, movement will evacuate the site of injury of metabolic waste which is an important factor in tissue healing (think ankle alphabet exercises following an ankle sprain). Multiple studies have provided evidence to support active recovery in the treatment of damaged tissue noting that “…although new approaches to facilitate bone and fibrous tissue healing have shown promise, none has been proven to offer beneficial effects comparable to those produced by loading healing tissues” (Scialoia & Swartzendruber, 2020).
So is there anything you can do following injury to promote tissue healing? Rehabilitation should include pain free movement within the available range of motion early on following injury with a gradual progression to more complex movements and resistance. The application of ice may be used to reduce pain; however, this should be based on the advice of your physiotherapist to avoid delaying recovery. Post injury, talk to your health care professional about the best course of action for you.
Scialoia, Domenic & Swartzendruber, Adam J. (2020, October). The R.I.C.E Protocol is a MYTH: A Review and Recommendations. The Sport Journal Vol 24.
By: Maryann Fabrizio, Registered Physiotherapist