Rest ice compression elevation RICE Treatment are rest and immobilization not good practice?
- The RICE Protocol is Rest, Ice, Compression and Elevation
For many athletes a doctor’s recommendation of the RICE protocol for healing their sports related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism from a surprising source, the doctor who created the RICE treatment guidelines, Gabe Mirkin, MD.
In a recent article on his own website, Dr. Mirkin admits that both ice and rest (key components of RICE) may delay healing. This insight comes nearly 40 years after Dr. Mirkin authored the The Sportsmedicine Book (1978), where he coined the acronym RICE for the four elements which became the standard of care in treating soft tissue injuries- Rest, Ice, Compression and Elevation. Coaches, physicians, physical therapists and the lay public have recommended and followed the “RICE” guidelines for decades, but as Mirkin states on his website:
- “it now appears that both ice and complete rest may delay healing, instead of helping.”(Updated May 9, 2021)
When stopping inflammation is NOT a good thing
Inflammation is necessary because it plays an important role in the healing and the recovery of muscle cells and soft tissue regeneration. Tissue that is damaged through trauma or vigorous exercise requires inflammation. When muscles and other tissues are damaged, your body sends inflammatory cells to the damaged tissue to promote healing. Inflammatory cells rush to injured tissue to start the healing. Immune cells called macrophages release a hormone called insulin-like growth factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal.
Dr. Mirkin states, “Applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1.”
The arguments against prolonged Rest – Immobilization: Cartilage starves and dries out
RICE generally involves resting or immobilizing the joint for some time because of an injury. Patients are often taped, braced, casted, or told to rest because their injuries will not heal otherwise. Research is showing that this can be very detrimental to the articular cartilage, the cartilage the cover the ends of the bones. How? The articular cartilage can only receive nourishment from the synovial fluid (the protective lubricant of the joint) when it is pushed into the joint by weight-bearing and loading. In other words, you have to move to get the lubricant into the joint properly. If you do not get the lubricant to surround the articular cartilage, the cartilage will “starve and dry out.” The cartilage has no blood supply of its own. It has no other way to get its food and lubricating fluids.
This is why there is a shift away from prolonged immobilization: Moving, exercising, and loading the joint will allow the nourishment to get into the articular cartilage and the waste products to get out.
Many of you reading this article may find a degree of comfort in seeing that maybe rest is not the best thing for your type of injury.
Many of you reading this article may find a degree of comfort in seeing that maybe rest is not the best thing for your type of injury. Simply because a) you need to be at work or on the job site b) you feel that you are wasting time waiting for a healing that may not happen and if you are an athlete, time may be of the essence in saving a season.
That resting may in fact not only delay healing, it may also prevent a good, solid heal. You must clear your desire to get mobile again with your doctor’s advice if you have an injury that you cannot put weight on or have a limited range of motion. You must also clear with your doctor any type of post-surgical guideline before resuming your desire to get resume mobility.
Immobilization, also known as stress deprivation, can be extremely detrimental to the joints and ligaments. Both intra-articular and extra-articular (inside and outside, respectively) ligaments and periarticular (joint soft tissue) connective tissue can be significant strength and function compromised by immobility.
A physical examination of “rested” ligaments after stress deprivation shows them to be less glistening and more “woody” on palpation. They are stiff and less flexible.
Rest and immobilization may prevent a “solid heal”
What did we mean above, “preventing a solid heal.”
As just mentioned, a physical examination of “rested” ligaments after stress deprivation shows them to be less glistening and more “woody” on palpation. They are stiff and less flexible.
- Random collagen
Under a microscope the collagen of the ligament (when a ligament is being naturally repaired, the body makes collagen to patch tears and damage in the ligament) is very random.
- Loss of ligament mass creates a much weaker structure
Chemically, the ligaments lose water and glycosaminoglycans (which help maintain structure) so there is a net loss of mass in the ligaments. There is also more degradation of the collagen with stress deprivation. These changes translate to a much weaker structure.
- Death of cartilage cells
What can be considered so what amazing is that the idea of prolonged rest and immobilization causing joint breakdown and poor healing is not at all a new idea. If we go back sixty years we will see that doctors were concerned then.
Basic animal research has shown that in as little as six days of immobilizing a joint, pressure necrosis of the articular cartilage (death of cartilage cells) can occur with subsequent degenerative arthritis. In a landmark study from 1960 (1) doctors noted: “The lesions (damage) produced by simple immobilization of a joint in a forced position were similar in nature to those produced by clamp compression. The extent of the lesion varied directly with duration of continuous compression. The articular lesion has been designated pressure necrosis of cartilage, and it has been concluded that it is the result of interference with the diffusion of nutritive fluid through the intercellular substance of the cartilage. Pressure necrosis of cartilage is probably an irreparable lesion and may interfere with growth of the epiphysis (the bone end plate or in younger patients the growth plate). It may also act as the starting point in the development of degenerative arthritis.”
What is being said:
- You have an injury that requires immobilization.
- Your ankle or elbow or neck for example is now put in a cast or a brace.
- Even short-term immobilization can create a surface pressure in the joint in part by swelling. This swelling or inflammation, can exert the same pressure as a clamp (simply a lot of pressure).
- This pressure is killing cartilage cells (necrosis).
- Immobilization and continued immobilization can lead to osteoarthritis.
The problem in the knee
How important was this study? Enough so that we used it as a reference more than 60 years after publication. Most recently this research (2) was cited in a 2020 study suggesting that patient need to move their knees following a knee replacement so they could avoid some of the problems we just noted.
When rest works – broken bones and complete ruptures – when rest may not – ligament injury
We get many emails from people asking about their chronic joint pain. Many of these emails will describe to us a sports injury or a fall. Many of these emails will come from skiers, skateboarders, or cyclists. People who in a fall can suffer from multiple injuries to multiple joints.
Their stories can go something like this:
My broken bones healed okay but I am having a lot of problems with my knee and ankle.
I took a really bad fall, I broke my arm (both forearm bones) and my leg (both shin bones). I also tore up my knee and ankle but I did not need surgery as I had only stretched out the ligaments. My broken bones healed okay but I am having a lot of problems with my knee and ankle. I have been to twelve sessions of physical therapy working on both but the are very weak.
My ankle can get very puffy. I am putting ice on it, I am wearing ankle braces and I have orthotics in my shoes, its not helping. I feel that I am in a state of chronic ankle and knee sprain.
Later in this article we will discuss aspects of ligament healing. In this next section we will discuss the problems of icing and anti-inflammatories.
When RICE causes more problems – a paper on ankle sprains
What are we seeing in this image. Two types of ankle injuries – Ankle rolled in eversion force and ankle rolled out – inversion force.
A paper in the Pomeranian journal of life sciences (3) discussed problems of post-traumatic scar tissue formation in the ankle. Here is what the researchers of this paper wrote: “Most (ankle sprains) are inversion-type (ankle rolled outwards big toe points inward) traumas which could harm soft tissues like lateral collateral ligaments, capsule and peroneal tendons. The vast majority of these injuries are grade 1 sprains where there is no clinical instability.”
Because immobilization leads to formation of inelastic scar tissue caused by ligamentous adhesions.
- “Very often treatment is based on conservative protocols, i.e. RICE (rest, ice, compression, elevation), immobilization and avoiding weight bearing. Besides the above procedures, in the following period of time some modalities are planned, and there is not enough attention paid to regaining function after the acute stage. Such a conservative approach over a longer period of time should be reserved for fractures and (worsening grade sprains) because immobilization leads to loss of proprioception (an awareness of balance and stability – for instance you do not look down at your feet to know you are walking) and the formation of inelastic scar tissue caused by ligamentous adhesions.”
Let’s move on to the discussion on ICE.
Icing can cause muscle and nerve damage, fatigue, and delayed recovery in elite athletes
We know, for many people ice is almost like a drug. It can make a painful joint feel good. That is what some patients tell us. Their ice is their best painkiller. So many people are not that enthusiastic to hear that we want them to stop icing. Why would we ant them to stop icing?
Topical cooling with a cold pack or ice is frequently used therapeutically to reduce acute pain and inflammation of injured tissues. Topical cooling has also been used in an effort to boost recovery after athletic exercise. But does ice help recovery?
Should cold therapy be stopped?
A June 2021 paper presented by the School of Sports Medicine and Rehabilitation, Beijing Sport University in the World journal of clinical cases (4) makes a bold statement. Maybe it is time to stop using cold therapy in soft-tissue injury. Here is the opinion:
“Cold therapy has been used regularly as an immediate treatment to induce analgesia following acute soft-tissue injuries, however, a prolonged ice application has proved to delay the start of the healing and lengthen the recovery process. . . (the authors do however suggest) Traditional cold therapy still has beneficial effect especially when injuries are severe and swelling is the limiting factor for recovery after soft-tissue injuries, and therefore no need to be entirely put out to pasture in the rehabilitation practice.”
While the idea is not to end icing or cold therapy all together, especially in controlling acute swelling, the concept of prolonged icing continues to meet with disfavor.
The Duke University Study
There was a 1992 study from Duke University (5). Let’s point out that Duke University’s men’s basketball team won the 1992 NCAA National Basketball Championship. This followed up a 1991 NCAA National Basketball Championship. So you would have to imagine that peak athletic performance is an important aspect of the Duke athletic program. Academics is also very important, so in 1992, researchers at Duke University tested whether applications of ice were helpful in physical recovery after strength training- a type of eccentric exercise where muscle damage is induced as a result of the exercise. Eccentric training is defined as active contraction of a muscle occurring simultaneously with lengthening of the muscle.
- When the tissue is cooled through icing, peripheral blood perfusion can be reduced, in other words the blood vessels constrict and shut off the blood flow that brings in healing cells.
- After the ice is removed, the blood perfusion may then return, but the blood vessels may not open for many hours after the ice application.
This research team found that this fluctuation can cause the tissue to die due to lack of blood flow. It can also lead to temporary or permanent nerve damage and disability in the individual or athlete. Therefore, ice application does not boost recovery after exercise and can instead cause tissue and nerve damage.
Obviously we are not going to rely solely on a 1992 study, certainly there have been updates in the last thirty years.
Twenty year-old baseball players – ice and delayed recovery 48 and 72 hours later
A study was performed in 2013 and published in the Journal of Strength Conditioning Research. (6) The study involved eleven 20 year old male baseball players to examine the effects of topical cooling on recovery after eccentric exercise. Muscle damage markers and hemodynamic (the way blood moves) changes were checked.
- Topical cooling caused a significant increase in muscle damage markers during recovery from eccentric exercise over the controls at 48 and 72 hours, as well as increased fatigue at 72 hours.
- The researchers noted: “This data suggests that topical cooling, a commonly used clinical intervention appears to not improve but rather delay recovery from eccentric exercise-induced muscle damage.”
Ice during athletic performance does not help soft tissue
The idea of icing after pitching a game has been the subject of great debate. Many players and trainers no longer suggest wrapping the pitching arm up. Studies are also showing that icing during a competition is not likely to increase athletic performance but rather decrease performance. A paper published in May 2021 in the International journal of environmental research and public health (7) sought to “verify the effectiveness of three minute applications of acute local cooling to the lower extremities between sets of a repeated vertical jump exercise.” How was this done?
- Twelve subjects performed a total of 3 sets of 30 consecutive maximal vertical jumps and were allowed a recovery period of 5 minutes after each set.
- In the recovery period, subjects rested with or without a cooling suit worn on their lower legs.
- Results: Vertical jump performance steadily decreased during 30 consecutive vertical jumps in all 3 sets
- Conclusion: The current study provides evidence that acute local cooling recovery after a vertical jump exercise may not add any performance benefits but may provide a psychological benefit.
Being careful when icing during athletic performance
In August 2021, doctors at the Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital European journal of applied physiology.(8)
“Cryotherapy is utilized as a physical intervention in the treatment of injury and exercise recovery. Traditionally, ice is used in the treatment of musculoskeletal injury while cold water immersion or whole-body cryotherapy is used for recovery from exercise. In humans, the primary benefit of traditional cryotherapy is reduced pain following injury or soreness following exercise. . . following exercise, cryotherapy is indicated when rapid recovery is required between exercise bouts, as opposed to after routine training. Ultimately, the effectiveness of cryotherapy as a recovery modality is dependent upon its ability to maintain a reduction in muscle temperature and on the timing of treatment with respect to when the injury occurred, or the exercise ceased. “
The main difference between muscles and ligaments is that muscles are massively strong structures with a tremendous blood supply, both outside and inside the muscle (this is why steak is red). Ligaments, on the other hand, are small tissues that have a poor blood supply both inside and outside of the ligament (why they appear white). Muscles, because of their good circulation, can heal more quickly, whereas ligaments, due to their poor blood supply, often heal incompletely. If muscles which have good circulation have healing issues due to the ice application causing a fluctuation in blood supply, it is understandable that it would be even more difficult for ligaments to recover or heal after ice applications. Ligament injuries are the cause of most chronic sports injuries and pain.
It is our opinion that non healing ligaments are the number one cause of early retirement in athletes.
That ice can be detrimental to an athlete is an idea that has been around for a long time. In 1995 doctors at the Section of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Illinois published in The American journal of sports medicine (9) in which they expanded on previous research that showed “cooling a knee for 20 minutes with a standard ice wrap will decrease soft tissue blood flow by a mean (average) of 26%, and skeletal blood flow and metabolism by 19%.” In this updated study “the effects of shorter and longer icing periods to determine minimum cooling time for a measurable and consistent decrease, and time to produce maximal decrease within a safe period of icing (< 30 minutes).”
Less than 30 minutes of icing
- Thirty-eight people were studied.
- An ice wrap was applied to one knee for an assigned time (5, 10, 15, 20, or 25 minutes).
- Triple-phase bone scans of knees were obtained; average percentages of decrease in the iced knee for each of the five time groups at each of the three phases of the bone scan were calculated and compared.
- At 5 minutes:
- Mean decreases of 11.1% in soft tissue blood flow, and 5.1% in skeletal metabolism and blood flow were measured at 5 minutes;
- At 25 minutes:
- Maximum decreases of 29.5% in soft tissue blood flow and 20.9% in skeletal metabolism and blood flow, respectively, were obtained at 25 minutes.
It is this type of research which lead to the acceptance that ice should only be applied in 20 minute intervals to AVOID soft tissue damage.
Advising against RICE
We treat many types of musculoskeletal conditions in individual and athletes of all levels, every day. We recommend treating acute sports injuries, not with RICE, but with MEAT (Movement, Exercise, Analgesics and Treatment). We have already established that R.I.C.E. has been the conventional method of pain management and treatment of sports injuries for years, even decades. Even though the author of RICE has recanted its use, and research proves it can be injurious, you will most likely continue to see it utilized from the emergency room to the sports trainer. This is a good example of how something false can hold sway on even those who are considered professionals.
Exercise does not notably increase the blood supply to ligaments.
Exercise does not notably increase the blood supply to ligaments. This is probably because the ligament is not important in the fight-or-flight response. It is not involved in the defense of the body if attacked. Exercise does not have the profound stimulatory effect on ligaments that it has on muscles. Ligaments are made up primarily of type I collagen. This particular type of collagen is very resistant to stretching (has a high tensile strength). Collagen is a type of protein and is therefore made up of amino acids, building blocks of protein. What most people do not know is that the collagen in ligaments is thought to remain relatively metabolically inert, with a half-life on the order of 300 to 500 days. This means that the metabolism of collagen is very, very slow. It is a good thing this is true, because blood supply to ligaments is so poor. This is another reason ligaments heal so slowly and are so prone to injury. Anything that decreases the metabolic rate or blood supply to the ligaments will further promote the decline of the ligaments, and profoundly delay their healing.
Muscles, unlike ligaments and tendons, are encapsulated within a tight, compartmental, special tissue called fascia. These fascial sheaths only have a limited amount of space and in high-energy trauma, as can occur in sports, this limited space can be encroached upon by a hematoma (blood clot in the muscle) or be externally compressed by a hematoma in another compartment (or broken bone, etc.).This increased tissue pressure within the fascial sheath that contains the muscle causes a decrease in the blood circulation (malperfusion), causing further tissue damage. This further tissue damage causes an increase in the edema, which increases the pressure in the space even more, causing even less oxygen to get to the injured tissues (hypoxia), which causes the pH in the tissue to be decreased (acidosis) and a vicious cycle is set up. This continued increase in a specific muscle facial sheath is called compartment syndrome. Compartment syndrome, if not immediately taken care of, quickly progresses to permanent muscle, nerve, or circulation damage. RICE treatment is very effective at eliminating edema, so it could, theoretically, prevent a compartment syndrome situation from occurring. Compartment syndrome only occurs in muscles (and only those with a lot of damage) and never occurs in ligaments.
Questions about our treatments?
If you have questions about your joint pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated August 26, 2021