RICE (Rest - Ice - Compression - Elevation) therapy after acute soft tissue injury

The examination and treatment of overload and injuries of the musculoskeletal system, and particularly of the soft tissue, i.e. muscles, tendons, ligaments, fasciae, and joint capsules, is provided by emergency and primary health care physicians, physiotherapists, and orthopedic and trauma surgeons.

For many of these health care specialists, rest, ice, compression, and elevation (RICE) therapy is a widely accepted, popular, easily accessible, and probably the most preferred method and modality for the treatment of posttraumatic pain, inflammation, and edema, all of which can increase tissue damage, delay healing in the rehabilitation process, and eventually result in some degree of chronic disability.

When used appropriately the RICE approach can improve recovery time, reduce discomfort, and decrease the probability of resulting chronic dysfunctions.

Rest

Rest is required to reduce the metabolic demands of the injured tissue. It also is needed to avoid any activity that induces stress or strain to the injured area and thus can compromise the healing process.

A short period of immobilization is beneficial but should be limited to the first few days after injury. By restricting the length of immobilization to a period of less than a week, the adverse effects of immobility can be minimized.

Ice

Ice therapy, also known as cryotherapy, is used to limit the injury-induced damage by reducing the temperature of the affected tissues and consequently reducing metabolic demand, inducing vasoconstriction (blood vessel constriction), slowing down and/or preventing further swelling, and limiting the bleeding. It can also promote analgesia by increasing threshold levels in the free nerve endings and at synapses, and by enhancing nerve conduction latency.

However, applying cryotherapy for an extended period can be detrimental to the healing process. Damage can be worsened if blood flow is excessively reduced. The risk of skin burns and nerve damage increases with prolonged ice application. There is limited evidence regarding appropriate ice therapy dosage on different body parts in acute injury. However, systematic reviews suggest that intermittent applications are most effective (10-minute ice treatment alternating with 10-minute periods without ice). Have in mind that on smaller areas, like the hands, you should not exceed 3-5 minutes of ice treatment, whereas bigger areas, i.e. the thighs, can take up to 10-20 minutes of ice therapy.

Cryotherapy should be used with caution in people who are hypersensitive to cold, such as patients with Raynaud’s syndrome (a medical condition in which spasms of the small arteries cause episodes of reduced blood flow, typically in the fingers, less commonly in the toes, and rarely in the ears, nose, and lips), diabetes, or cold urticaria (a disorder where hives or large red, itchy welts form on the skin after exposure to a cold stimulus), and patients who have a circulatory insufficiency.

It is recommended that the ice is wrapped in a damp towel or cloth to minimize the risk of superficial nerve or skin damage.

Compression

Compression serves to stop hemorrhage (bleeding) and prevent further edema (swelling) caused by the exudation of fluid from the damaged capillaries into the tissue because of the inflammatory process. Controlling the amount of inflammatory exudate also helps to control the osmotic pressure of the tissue fluid in the injured area, which consequently reduces pain.

An elasticated bandage should be used to provide a comfortable compression force without causing pain or constricting blood vessels to the point of occlusion. Bandaging should begin distal to the injury and move proximally, overlapping each previous layer by one half. It can also serve to provide minimal protection of the injured body part from excessive movement, although this is not its primary purpose.

Elevation

Elevation of the injured part lowers the pressure in local blood vessels and helps to limit the bleeding. It also increases the drainage of the inflammatory exudate through the lymph vessels, reducing and limiting edema and its resultant complications.

Elevation will prevent swelling by increasing venous return to the systemic circulation and reducing hydrostatic pressure thereby reducing edema and facilitating waste removal from the site of injury. In case the lower limb is involved, ensure it is elevated slightly above the level of the pelvis. If the upper limb is affected, it is recommendable elevating it slightly above the shoulder girdle level.

Science-based vs empirical data regarding RICE

Though science suggests that more sufficiently powered, high-quality, and appropriately reported randomized trials of the different elements of RICE therapy are needed, and concludes that there is moderate or even limited evidence to determine the relative effectiveness of RICE therapy, the empirical data, however, and clinical experience of most sports coaches, athletes, health care professionals, particularly physiotherapists – including myself being a physical therapist, personal trainer and health coach with more than 25 years of experience in my profession – and patients who suffered from soft tissue injury show a different picture.

RICE seems to work very effectively, especially when combined with the immediate intake of NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen, aspirin, or diclofenac during the inflammatory phase (especially in the first 48-72 hours after injury) and additionally being treated with well-dosed orthopedic manual therapy and low intensity passive, assistive, and even active posttraumatic mobilizations (2-3 sets of 15-20 repetitions), as well as isometric muscle contractions (2-3 sets of 15-20 static contractions) as a means of avoiding beginning atrophy (muscle degradation or breakdown) in the surrounding areas, but also in the injured area, if it happens in a range of motion (ROM) which does not add any additional pain or stress that potentially worsens or inhibits the healing process.

If applied appropriately under the professional supervision of an experienced health care specialist, the RICE approach can conclusively reduce discomfort, improve recovery time, and avoid possible resulting chronic disorders.

References

1. JAT Journal of Athletic Training – What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Michel P.J van den Bekerom, MD; Peter A.A Struijs, MD, PhD; Leendert Blankevoort, PhD; Lieke Welling, MD, PhD; C. Niek van Dijk, MD, PhD; Gino M.M.J Kerkhoffs, MD, PhD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/

2. JAT Journal of Athletic Training – Does Cryotherapy Improve Outcomes with Soft Tissue Injury? Tricia J Hubbard; Craig R Denegar. https://pubmed.ncbi.nlm.nih.gov/15496998/

3. BMC Musculoskeletal Disorders – The PRICE study (Protection Rest Ice Compression Elevation): Design of a randomized controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain. Chris M Bleakley, Seán O'Connor, Mark A Tully, Laurence G. Rocke, Domnhall C Macauley, Suzanne M McDonough. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2228299/

4. RICE – Physiopedia https://www.physio-pedia.com/RICE