Most people are familiar with the RICE (Rest, Ice, Compression and Elevation) principle for treating sports injuries. It is widely advocated and commonly used for the treatment of acute injuries such as ankle sprains. However some of the medical community are moving away from this principle as it is now thought that this protocol may delay recovery from tendon/ligament injuries. Tendons and ligaments are naturally avascular structures meaning that they have poor blood supply in comparison muscle fibres. Further reducing blood and nutrient supply with the use of the RICE principle may cause delayed healing.
The doctor who invented the RICE treatment protocol in the 1970s has now stated that the use of ice and rest may delay healing and has recanted its use.
- Rest (no movement): Movement is required to promote lymphatic drainage (drainage of fluid and waste products) and bring fresh oxygenated blood flow and nutrients to the injured tissue.
- Ice: There is also a lack of evidence for the use of ice or cryotherapy for soft tissue injuries and Bleakley et al (2004) found that it may delay or slow healing by decreasing the metabolic rate.
Researchers tested whether applications of ice were helpful in recovery after strength training. When the tissue is cooled through icing, peripheral blood flow can be reduced. 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 found that these fluctuations can cause the tissue to die due to lack of blood flow. It can also lead to temporary or permanent nerve damage.Therefore, ice application does not boost recovery after exercise and can instead cause tissue and nerve damage.
Tseng et al (2013) found that topical cooling significantly increased the levels of muscle damage markers in elite athletes as well as causing muscle fatigue.
The new injury protocol mnemonic that some practitioners are now in favour of is MEAT. Meat stands for:
- Movement: It is thought that early movement stimulates healing, promotes nicely aligned collagen fibres and leads to faster recovery times. Kerkhoffs et al (2002) Cochrane review showed that patients improved quicker and had a faster return to activities with functional treatments versus their immobilised counterparts.
- Exercise: The reasons behind this are the same for movement but establishing an exercise program after the acute injury is important to prevent long term joint instability and improve functional outcomes.
- Analgesia: Is the use of pain relieving drugs that do not cause delay in healing. Some medications such as NSAIDs have been show to delay or inhibit healing. Acetaminophen can help with pain relief but not block the inflammatory cascade/process, although it does come with risk factors (liver toxicity). Natural pain relieving treatments such as acupuncture/dry needling and low level laser therapy have shown to be very effective at providing pain relief.
- Treatment: Treatment includes any form of manual or electro-therapy modalities such as myofascial release, ultrasound, low level laser therapy, acupuncture/dry needling and mobilisations. These all promote blood flow, tissue healing and pain relief.
The RICE/ICE principle should still generally be used for acute muscle injuries as there is risk of developing compartment syndrome. Ligaments and tendons are not at risk of developing this pathology.
There are elements of both protocols that are beneficial – e.g. compression from the RICE principle is beneficial for lymphatic drainage and reducing oedema but without immobilising the joint. It is important to consider the type of injury and the symptoms that the patient presents with before implementing a treatment plan.
Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.
Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly KD, Struijs PAA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database of Systematic Reviews 2002, Issue 3.
Malone T, Engelhardt D, Kirkpatrick J, Bassett F. Nerve injury in athletes caused by cryotherapy. J Athl Train. 1992; 27(3): 235–237.
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. doi: 10.1519/JSC.0b013e318267a22c