Rest ice compression elevation | Rice Therapy and Price Therapy
Rice and Price
- The RICE Protocol is Rest, Ice, Compression and Elevation
- The PRICE Protocol adds Protection (brace or cast), 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 June 22, 2020)
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. 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.
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 – 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:
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.
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?
There was a 1992 study from Duke University (3). 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
A study was performed in 2013 and published in the Journal of Strength Conditioning Research. (4) 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.”
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.” (Updated June 22, 2020)
Ice Reduces Strength, Speed, Endurance and Coordination
Another study Mirkin cited was in Sports Med, Nov 28, 2011 which stated, “Ice is often used as short-term treatment to help injured athletes get back into a game. The cooling may help to decrease pain, but it interferes with the athlete’s strength, speed, endurance and coordination.”
This wasn’t the first study demonstrating that just 5 minutes of icing could be problematic. Ho et had already published articles in 1990 on the negative effects of ice, where they showed that as little as five minutes of icing a knee could decrease both blood flow to the soft tissues and skeletal metabolism. “This effect is time-dependent and can be enhanced three to four fold by increasing the ice application time to 25 minutes.”8
Ice hinders healing by decreasing blood flow
Healing is hindered by a decrease in blood flow and metabolism to the area. Icing increases the chance of incomplete healing by decreasing blood flow to the injured muscles, ligaments and tendons. This increases the chance of re-injury or the development of chronic pain. Did you ever wonder why almost all athletic trainers and therapists ice a limb for 20 minutes? In 1980, at the American Orthopedic Society meeting for Sports Medicine in Big Sky, Montana, and then again in 1981, physicians from the Louisiana State University School of Medicine reported on five athletes who obtained nerve palsies (nerve injuries usually to the peroneal nerve that moves the foot up) from too much ice around the knee. The conclusion of the article was, “Applying ice for more than 30 minutes, and preferably for not more than 20 minutes, should be strictly avoided.”9 They reported that one of the athletes still had nerve palsy at nine months. Here is our answer to the 20 minute question. You are iced for 20 minutes because the athletic trainer or therapist does not want to give you nerve palsy! The next time the trainer comes toward you with an ice pack, tell him, “Thanks, but no thanks. I want my injury to heal.” Interestingly Mirkin still recommends “ten minutes of ice application, removing it for 20 minutes, and repeating the 10 minute application once or twice.”2
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.
Anti-inflammatories delay healing
Mirkin states, “Anything that reduces inflammation or the immune response will also delay healing. This includes cortisone, NSAIDS, immune suppressants, and cold packs/ice.”2
We agree with this statement. Anti-inflammatory medications have been proven to be harmful. However, most people will continue to receive instructions to take anti-inflammatory medications after an injury or for musculoskeletal pain. “Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX) activity and are widely used as anti-arthritics, post-surgical analgesics, and for the relief of acute musculoskeletal pain.
Recent studies suggest that non-specific NSAIDs, which inhibit both COX-1 and COX-2 isoforms,10 delay bone healing. NSAIDS such as ketorolac and parecoxib delay fracture healing, but the daily administration of ketorolac, a non-selective COX inhibitor had a greater effect on this process.”
NSAIDS are commonly recommended because injuries such as ligament sprains are sometimes accompanied by quite a bit of inflammation and swelling, called edema. The premise is that the inflammation or swelling and edema are harmful to the tissue. Again, we have already established that inflammation is necessary for healing of the tissue. NSAIDS are used because they relieve pain; however they are also stopping the healing mechanisms of the body. Any technique or medication that stops the normal inflammatory process that helps heal the body must have a long-term detrimental effect on the body.
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. What happened in the 1970s, unfortunately for the athletes of the world, is that sports medicine doctors and trainers started treating every injury as if it was going to turn into compartment syndrome.
Ice applications and ligaments
We have discussed how the fluctuation in blood supply from applications of ice can affect muscle recovery. Now let’s consider what it might do to ligaments. 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.
The cells that make up ligaments, tendons, and organs are extremely temperature-sensitive. The metabolic rate at which these cells function is directly proportional to the temperature in their environment. For each 10 degree Celsius change in the temperature, there is a more than two-fold increase in the cell metabolism. In other words, in order to increase cell metabolic rate by more than 100 percent, the temperature of the tissue must increase by 10 degrees. Conversely, cooling tissue will decrease that cell’s metabolism. It is obvious that ligaments require improved circulation to the area in order to heal after an injury, since the blood supply to ligaments is normally so poor. Yet ice is arguably the most widely used therapeutic agent in medicine today, which most definitely decreases circulation. Ice has been shown to be one of the most efficient forms of cryotherapy, and is often the first line of treatment for traumatic injuries.
RICE treatment is totally inappropriate for healing 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.
Athletes are often confused when it comes to therapies that will help them return to play. Doctors from Rutgers University sought to help them understand. In a 2014 paper published in the journal Physical medicine and rehabilitation clinics of North America (1) they wrote:
- Traditional treatment of sports injuries includes use of the PRICE principle (Protection, Rest, Ice, Compression, Elevation), nonsteroidal anti-inflammatories, physical therapy modalities, and corticosteroid injections.
- Recent evidence has raised concerns over this traditional treatment.
- Evidence about regenerative medicine, including platelet-rich plasma and stem cell therapy’s effectiveness in treating a variety of sports injuries has emerged, ranging from tendinopathy and muscle tears to ligament and chondral (cartilage bone) injuries. 1
RICE protocol or treatments surrounding Prolotherapy applications
For many years doctors have questioned the legitimacy of the RICE protocol. As far back as 2001, in our book, Prolo Your Sports Injuries Away, we dedicated large sections to talking about the deleterious effect RICE had on patients. As opposed to RICE we talked about how Prolotherapy and later Platelet Rich Plasma Therapy and Stem Cell Therapy treatments and “MEAT” (Movement, Exercise, Analgesics and Treatment) , in our opinion, healed the athlete faster and made weakened tissue stronger without the need for surgical intervention.
1 Salter RB, Field P. The effects of continuous compression on living articular cartilage. An experimental investigation. J Bone Joint Surg Am. 1960;42:31–39. [Google Scholar]
2 Buttacavoli FA. Gravity-Assisted Passive Flexion in Total Knee Arthroplasty Recovery. Orthopedics. 2020 Aug 6;43(5):e431-7. [Google Scholar]
3. Malone T, Engelhardt D, Kirkpatrick J, Bassett F. Nerve injury in athletes caused by cryotherapy. J Athl Train. 1992; 27(3): 235–237. [Google Scholar]
4. Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. J Strength Cond Res. 2013;27(5):1354-61. [Pubmed]
1 Malanga G1, Nakamura R. The role of regenerative medicine in the treatment of sports injuries. Phys Med Rehabil Clin N Am. 2014 Nov;25(4):881-95. [Pubmed]
2 Mirkin G. Why Ice Delays Recovery. March 16, 2014.
6. Nemet D, Meckel Y, Bar-Sela S, Zaldivar F, Cooper D, Eliakim A. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. European Journal of Applied Physiology. November 2009, Volume 107, Issue 4, pp 411-417.
7. Ho SS, Illgen R, Meyer R, et al. Comparison of Various Icing Times in Decreasing Bone Metabolism and Blood Flow in the Knee. Am J Sports Med. 1995; 23(1): 74-76. doi: 10.1177/036354659502300112.
8. Drez D, Faust DC, Evans JP. Cryotherapy and nerve palsy. American Journal of Sports Medicine. 1981; 9:256-257.
9. Gerstenfeld L, Thiede M, Seibert K, Mielke C, Phippard D, Svagr B, Cullinnane D, Einhorn T. Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. Journal of Orthopaedic Research.2003;21(4):670-675.Article first published online: 1 JAN 2006. DOI: 10.1016/S0736-0266(03)00003-2.
10. Van den Bekerom M, Struijs P, Blankevoort L, Welling L, Van Dijk C, Kerkhoffs G. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train. 2012; 47(4): 435–443.