Injuries: Time to Stop Icing?


Most of us have been taught to treat injuries using the acronym RICE - Rest, Ice, Compression, and Elevation.  In fact, this advice has become so common that it enjoys an almost mythical infallibility.  Of course you put ice on injuries, right?  That’s what we’ve done for years!  All the research shows that icing injuries…wait.  Did you know that there actually is very little evidence to support RICE?  Even more, there is mounting evidence that some components of RICE treatment might slow healing.  A 2018 consensus statement in the British Journal of Sports Medicine stated, “RICE is a conservative treatment method that has not been rigorously investigated, and the efficacy of this combination is questionable.”  That’s a very political way of saying maybe we should look for something better.

So what is wrong with RICE? 

Rest can be a decent initial strategy for 48-72 hours, but we know that soft tissue ultimately heals better when used.  We call this “loading”.  The type and intensity of loading is important, but simply resting an injured tissue can slow healing.

Ice may help decrease pain and swelling immediately after an injury, but it also inhibits many necessary aspects of healing.  The technical term for icing an injury is “cryotherapy”.  Cryotherapy decreases inflammation, which might seem good.  But inflammation is the signaling mechanism used by the body to initiate healing responses.  If it is suppressed, healing will not happen as quickly.

Compression and Elevation are likely quite useful, as we’ll see below.

If not RICE, then what?

The body’s response to a soft tissue injury occurs in stages, and our treatment protocol should be similarly staged.  The acute or immediate management will look a bit different than the sub-acute or later stages of management.  Two Canadian physical therapists have proposed a new protocol, complete with its own cheesy acronym.  It’s a great way to think about this process though.  Blaise Dubois and Jean-Francois Esculier have submitted that proper treatment consists of PEACE & LOVE.  This is a sensible protocol which is consistent with how I’ve practiced in recent years, but they lay it out very well.

The acute injury is managed with PEACE for the first few days.

Protect - ovoid overuse or overextension of injured tissue.

Elevate - to limit swelling and improve lymphatic drainage.

Avoid anti-inflammatories - that’s right!  As with cryotherapy, we do not want to inhibit the inflammatory process.  Such a strategy may actually slow healing.

Compression - pressure applied from taping or compression sleeves may limit swelling.

Educate - it is argued that clinicians should spend more time educating patients about their injury and what is to be expected.  It is important for patients to understand that using the injured body part is a good thing and that there are no magic treatments.  Setting an appropriate timeline is key as well.

As the first days of injury pass and the subacute phase begins, the injury is ready for a little LOVE.

Load - movement is a good thing for most soft tissue injuries.  Appropriate exercise and mechanical stress will trigger healing responses.  This should be guided by a doctor or physical therapists, but simply resting the injured body part is not the best way to proceed.

Optimism - the mental approach to healing is often overlooked, but mindset can be incredibly important.  It is understandable that injuries can lead athletes to disappointment and even depression, but they can also cause a fear of re-injury and an avoidance of activity.  It is important to remain optimistic, engaging in appropriate therapy and understanding the natural timeline.

Vascularization - encouraging blood flow is important, as blood caries all of the building blocks needed for healing.  Studies show that cardiovascular exercise can improve healing.  This should be exercise which does not exacerbate the injury though.  A patient with an ankle sprain can benefit from a swimming regimen, for instance, but running is probably best avoided.

Exercise - whether formal physical therapy or a prescribed home exercise program, it is well documented that exercises help improve strength, range of motion, and coordination around injured tissue.

As mentioned above, ice may be useful immediately after injuries as a means of pain relief. You don’t want to sacrifice healing though. For this reason, I’ll often recommend contrast baths for my patients in the hours and days after an injury. This is the alternation of heat and cooling, allowing for some of the analgesia of cold temperatures while continuing to encourage blood flow with the warmth. It is a strategy that you should discuss with your doctor or physical therapist as an addition to the PEACE & LOVE treatment protocol.

Soft tissue injuries are an unfortunate but nearly inevitable part of an active lifestyle.  When they do occur, let’s agree to get rid of the passive and ineffective RICE treatment that is so engrained in our culture.  Instead, take a more active and well-rounded approach which will get you back sooner and stronger. 

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Kevin Sprouse