The RICE protocol — Rest, Ice, Compression, Elevation — has been the most popular treatment method for acute musculoskeletal injuries since Dr. Gabe Mirkin coined the term in his popular 1978 Sportsmedicine Book. Ubiquitous amongst healthcare and athletics alike, RICE works well to quickly reduce symptoms so we can get back to whatever we were doing before we were injured. But is this our best course for optimal healing? It might be more appropriate short-term if you’re an athlete who needs to get back on the field for an important game. But for most of us, the goal should be to heal optimally and completely. The RICE protocol (and the sports medicine paradigm that has followed) has been further researched by many (see Iced! The Illusionary Treatment Option by Gary Reinl) to reveal that rest and ice can actually delay and diminish healing. When presented with this new information in 2015, Dr. Mirkin publicly recanted his original stance on RICE (and even wrote the foreword to Reinl’s 2nd edition of Iced!), yet the RICE protocol remains widely used today.
How did we get here?
The use of ice to treat medical injuries first appeared in the 1960s after it was used to help preserve the tissue of a severed limb. A 12-year-old boy became a “medical miracle” after he was the first individual to have a major limb successfully reattached to his body. The procedure’s success story spread quickly and soon became a global phenomenon. As this story was told and retold to the public, mostly by those not directly involved in the surgery, some details were changed and complex ideas were distilled into tidbits more palatable to the general public. Soon enough, the use of ice for tissue preservation prior to limb-reattachment surgery somehow transformed into using ice for any and every injury, and this philosophy remains obviously prominent to this day.
Understanding Inflammation, Swelling, and Tissue Repair
One of the main issues with RICE is that it aims to delay, reduce, or halt inflammation and swelling — which stems from another misinformed understanding of tissue healing. Inflammation is often publicly perceived as a threat or a negative process that needs to be curbed before it wreaks havoc on the musculoskeletal system. In actuality, inflammation is a necessary and vital part of the body’s initial reaction to injury healing, intending to control the injury on a cellular level while also preparing the tissues for the next phase of healing: tissue repair. Inflammatory chemicals cause blood vessels to dilate and increase permeability, which grants the necessary immune cells access to the damaged tissues they intend to repair. Attempts to limit or suppress inflammation can gum up this process and lead to chronic inflammation.
The inflammatory phase of healing ends as fluid waste products (AKA swelling) evacuate via the lymphatic system, and is subsequently followed by phases of tissue repair and then remodeling. Unlike arteries that contain musculature within their vessel walls to help propel blood, lymph vessels rely on voluntary skeletal muscle contractions to propel fluid along their pathways. Any motion in the tissues that intermittently compresses the lymphatic capillaries will propel the lymph fluid forward. In other words, to facilitate swelling reduction the muscles must be contracted; at least some movement is required. In contrast, complete immobilization of the injured area significantly inhibits the lymphatic system’s ability to reduce excess fluid and make way for continued healing. Inadequate drainage and functioning of the lymphatic system is the primary contributor to prolonged swelling, which delays tissue repair and creates opportunities for chronic inflammation.
Likewise, the main problem with inflammation isn’t that there’s too much of it, but that the process has been interrupted or delayed and there’s too little evacuation of it. Inflammation often doesn’t need to be suppressed, reduced, or delayed, especially when acute. Instead, inflammation is more appropriately viewed as a process that is to be encouraged to run efficiently to completion. Ideal inflammation is a swift and robust response that sets up the injury for repair. Once the excess inflammatory fluid has been cleared, the repair phase begins by forming a framework of granulation tissue and creating new blood vessels to transport oxygen and nutrients to the area. The remodeling phase follows and is dependent upon adequate blood supply to develop, organize, and strengthen the granulation tissue to new healthy tissue. Problems arise when we interrupt these processes, often leading to a sort of “smoldering” chronic inflammation that lingers.
Ice and Rest Interrupt Inflammation and Delay Healing
Topical cooling with ice causes vasoconstriction (narrowing) of the local blood vessels, which in turn diminishes blood flow and decreases vascular permeability, impeding the transport of inflammatory cells and their signals. Worse, this vasoconstriction can last well beyond the application of ice, resulting in a hypoxic (low oxygen) environment long after the icing has stopped. Additionally, icing also suppresses the release of IGF-1 (insulin-like growth factor), a hormone that helps muscles and other injured tissues to heal and regenerate. When you pause to think about it, it’s easy to see how cold application slows things down, delaying and diminishing the healing process.
Periods of rest (non-weight bearing) are often necessary following an acute musculoskeletal injury and can help to prevent further exacerbation of injury, but do not actually enhance or accelerate the recovery process. As previously mentioned, the lymphatic system requires muscle contraction to evacuate waste products from the injured area. So immobilizing the injured area actually enables congestion and stagnation, significantly reducing the capacity to drain excess fluid. This prevents completion of the inflammatory phase and thus progression to the repair and remodeling phases.
Elevation & Compression
There isn’t much strong evidence analyzing elevation alone as a post-injury measure, however, it may be useful for some and has a very low risk-benefit ratio. When it comes to elevating an injury, do it if it feels good but don’t force it if it doesn’t. The rationale behind both compression and elevation is mostly to reduce swelling which, as explained above, can be appropriate at times but isn’t necessarily a worthy goal by itself. Non-rigid braces and compression sleeves can help to temporarily physically reduce swelling. With less swelling fluid there is less pressure on the nearby nerves sending pain signals and joint mobility and range of motion are improved. For this reason, compression is especially useful during the rehab and strengthening portions of post-injury recovery to ease the transition returning to activity.
A Brief Word on Anti-Inflammatory Medications
Although not a part of the RICE protocol, anti-inflammatory medications like NSAIDs (Ibuprofen, Motrin) are also ubiquitously recommended for the management and treatment of musculoskeletal injuries. It’s important to know the mechanisms of these medications so you can better align their use with your own healing goals. NSAIDs block the synthesis of prostaglandins, which initiate inflammation, and thus can be effective in temporarily reducing inflammation as well as symptoms of pain and swelling. But as we’ve already learned, inflammation is an essential part of the healing process. NSAIDs can also inhibit the formation of bone callus during healing fractures and inhibit proper healing of tendons after tears. Acetaminophen (Tylenol) works slightly differently and can help to reduce pain and fever without necessarily interfering with the inflammatory process as much.
And yet masking pain signals can have its own downsides as well. Pain hurts, but it’s also a helpful sign to make us aware of when we may be damaging or injuring ourselves. By blocking pain, we take away this awareness and ultimately run the risk of further injury. NSAIDs, like many other medications, also can have a myriad of side effects—but that’s a discussion for another blog post.
Better Methods for Healing Injuries: HEAT, PEACE & LOVE
People love their acronyms, and if RICE won’t cut it, try “HEAT” or “PEACE and LOVE” on for size. HEAT stands for: Heat, Exercise, Analgesics, and Topicals. Ice can be useful immediately following an injury to help temporarily numb the pain and slow down any potential excess bleeding into the surrounding tissues, but for many injuries, the actual bleeding stops within minutes to hours after the initial injury. Starting within 24-48 hours after most injuries, heat alone or intermittent cold alternating with heat applications (5-10 minutes at a time) can be used to help reduce the potential for stagnation and congestion while encouraging adequate healthy blood flow. Good circulation is essential to healing, and often the structures of the foot and ankle we’re trying to heal aren’t well vascularized (think ligaments, tendons, joints, fascia), so maintaining adequate blood flow is vital. For some, heat can also be just as effective in temporarily relieving pain as ice.
The E of HEAT, Exercise, represents initial gentle movements and activity as tolerated, starting with static range-of-motion and isometric strengthening exercises. As the injury heals, it becomes more important to progress to dynamic movement exercises and actively strengthen the muscles surrounding the injured area. This helps us return to full function and prevent future recurrences of the injury. The stronger and healthier muscles are, the less stress is put on ligaments, bones, joints, and other structures.
Analgesia and Topicals can be one-in-the-same, both working to alleviate pain. Avoid NSAIDs and only use Acetaminophen if you must. Topicals with menthol, camphor, and capsaicin can help to reduce pain and promote more exercise. Topicals work great on the feet and ankles because most structures we are trying to reach are very superficial, just below the surface of the skin. At Northwest Foot & Ankle, we use Sombra.
PEACE represents a thoughtful approach for immediately following an acute injury and stands for Protect, Elevate, Avoid anti-inflammatory modalities, Compress, and Educate. Patient education is essential for long-term success. LOVE helps guide the more rehabilitative aspect of recovery and stands for Load, Optimism, Vascularization, and Exercise. When returning to activity, it’s important to manage load and not do too much too fast or risk re-injury. We’ve touched and blood supply and exercise already, but optimism (like Education) is an underrated factor to sustained treatment success. I hope more will realize that we are our own best healers—and instead of interrupting nature and suppressing our healing, we should learn to encourage and facilitate our healing processes. For more information about how to help heal your specific injury, please consult with your holistically-minded physician or reach out to us at Northwest Foot & Ankle.
Sources
- 1. Scialoia, D. The R.I.C.E Protocol is a MYTH: A Review and Recommendations. The Sport Journal. 2020. Vol. 22.
- 2. Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22-28. doi:10.1179/106698110X12595770849524
- 3. Su B, O’Connor JP. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol (1985). 2013;115(6):892-899. doi:10.1152/japplphysiol.00053.2013
- 4. Weerasekara RMIM, Tennakoon SUB, Suraweera HJ. Contrast Therapy and Heat Therapy in Subacute Stage of Grade I and II Lateral Ankle Sprains. Foot & Ankle Specialist. 2016;9(4):307-323. doi:10.1177/1938640016640885
Written by: Dr. Andrew Wojciechowski, ND
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