RICE | Should we still be using this treatment for soft tissue injury?

It’s time for an alternative to RICE (Rest, Ice, Compression, and Elevation). It’s Time for PEACE and LOVE for soft tissue injury instead.

RICE is the most commonly advised treatment for acute soft tissue injuries. It is so common that it very rarely needs repeating. Anyone that has taken part in any sport or a form of structured exercise, would have come across this acronym. However, despite its popularity and relative success, science might be pressing us for an alternative.[1]

Karl Meiring, Musculoskeletal & Sports Physiotherapist at City Physiotherapy gives us the latest evidence & advice for the best management of soft tissue injuries.

Here is the problem.

RICE is mainly focused on the immediate care following injury, without giving attention to the injury as it progresses through the stages of healing.[2] There is no convincing evidence that implementing the RICE strategy will do any harm, however, there might be different strategies that offer more benefits when recovering from injury.[2] The rest component would be an obvious initial treatment, but how much rest is enough? Too much rest might be leading us down a path of avoidance behavior when it might be time to return to graded activity. Too much-unwarranted rest can lead to deconditioning and a reduced ability to manage the physical demands of exercise. The second component (ice) can certainly numb the pain for short term pain relief but is this the best course of action. There may be some evidence suggesting adverse effects in the long term from removing pain and swelling too quickly.[3]

Lastly, the overall view of inflammation has changed significantly in the last few years. We are now starting to understand the benefit of inflammation in acute injuries. Our obsession with removing all pain and swelling associated with inflammation might be detrimental.[4] Removing some pain is often necessary, but pain can be a useful guide and it allows us to know when to rest and when to move. Swelling can be similarly useful in stabilizing an area during the healing process. Inflammation is an integral part of the healing process, removing it may disrupt this and delay recovery.[4]

An alternative acronym for acute/immediate management is PEACE.

[1] P (Protect) – This would replace rest as protection can still occur while being active. E (Elevate) – Unchanged. A (Avoid anti-inflammatories) – Respecting the acute inflammatory process. C (Compression) – Unchanged. E (Education) – Talking to your Physiotherapist about your injury and what exercise might be safe to take part in. Understanding your injury can also help with pain management. [7]

After the first few days following an injury, the acronym LOVE can then be applied.

[1] L (Load) – Early loading can be very beneficial. It can stimulate tissue healing and recovery. [6] O (Optimism) – A positive mental state can certainly help you through the recovery process. [7] V (Vascularisation) – Moving more, loading early if appropriate and exercise can all improve blood flow to the injured area. [5] E (Exercise) – Has a wide variety of benefits and if the injury is something that might take time to heal it’s important to find out how you can continue enjoying these benefits. [5,6]

In summary, I believe poor early management can often lead to chronic pain and long-term dysfunction. It is important for you to address injuries early and appropriately. If you’ve suffered an acute injury or struggling with recovery, make an appointment with City Physio to help guide you through the healing process.

1) Dubois, B. and Esculier, J. (2019). Soft tissue injuries simply need PEACE & LOVE | BJSM blog – social media’s leading SEM voice. [online] BJSM blog – social media’s leading SEM voice. Available at: https://blogs.bmj.com/bjsm/2019/04/26/soft-tissue-injuries-simply-need-peace-love/ [Accessed 25 Jun. 2019].

2) van den Bekerom MPJ, Struijs PAA, Blankevoort L, et al. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train2012;47: 435-43.

3) Singh DP, Barani Lonbani Z, Woodruff MA, et al. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol2017;8: 93.

4) Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. Br J Sports Med2018;52: 956.

5) Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ2010;340: c1964.

6) Khan KM, Scott A. Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med2009;43: 247-52.

7) Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. Br J Sports Med2019; Epub ahead of print

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