Revisiting ice after injury

By Dev K. Mishra, M.D.

The acronym RICE -- which stands for Rest, Ice, Compression, Elevation -- has been around since Dr. Gabe Mirkin introduced it in 1978. Since then, healthcare professionals have viewed it almost as gospel that immediately after an acute sports injury you apply ice and light compression. I've never encountered a single athletic trainer or team doctor that wouldn’t recommend this, and I also recommend it for young athletes in the first few days after a joint injury.

Interestingly though, Dr. Mirkin and others have recently raised questions about whether we should actually be applying RICE after injury. Dr. Mirkin states that inflammation after injury is a necessary part of the body’s healing response after injury, and that by reducing inflammation you are actually slowing down the healing process. He has changed his stance and no longer recommends RICE.

Let’s briefly have a look at a few sides of this problem:

Authors from the National Athletic Trainers Association wrote a very nice review article about management of sports-related ankle sprains, in which they devote several paragraphs to the use of RICE.

They note importantly that injury recovery can be divided into several phases.

Immediately after injury (the first hours to maybe 3 days) can be called the “acute phase” in which the goals are to reduce pain, reduce swelling, and protect the injured area from further injury.

After this comes the “subacute phase” in which inflammation is less of a factor and the focus is more on tissue and joint recovery.

Finally, athletes would go through training for return-to-play.

They write that in those first few minutes or hours after injury: “Sports health care professionals, athletic trainers in particular, advocate the application of RICE immediately after injury and are arguably the only health care professionals who can consistently apply these interventions within minutes because they are often on site at the time of injury.”

To be clear, we are talking about the very early phase after an injury and I think this should be emphasized.

Once an injured person gets in to the “subacute phase” after a few days, then the emphasis changes more toward mobilization and improved function. This will vary on the type of injury, whether surgery was needed, etc. -- but the point is that once you get in to this phase then ice is likely less useful.

Interestingly, there isn’t a lot of high-quality scientific evidence to support either position -- for or against use of ice in the immediate post injury phase. Much of what we advocate is based on decades of clinical experience with athletes and other injured individuals, but we should recognize that evidence might someday appear that challenges our current beliefs.

Until then, I’m still a believer that application of RICE for about 20 minutes out of every few hours in the first few days after a sports related injury to a joint or extremity is the correct thing to do; decades of experience has established this method as the standard of care.

Understand also that not all injuries can fit neatly into boxes and there will be a lot of individual variability. When in doubt, seek qualified evaluation from a healthcare practitioner and have them assist you with an individualized treatment plan.

Key Points:
• RICE -- Rest, Ice, Compression and Elevation is widely recognized as the most appropriate immediate treatment for many sports injuries in the first hours to few days after injury.
• The recommendation is mainly based on several decades of experience from athletic trainers and team physicians but there is a surprising lack of high level scientific evidence to support the use of ice, especially in the later phases after injury.
• I still recommend RICE for young athletes in the first hours to few days after common sports injuries.

(Dr. Dev K. Mishra, a Clinical Assistant Professor of orthopedic surgery at Stanford University, is the creator of the online injury-management course, now a requirement for US Club Soccer coaches and staff members. Mishra writes about injury management at Blog, where this article first appeared.)

1 comment about "Revisiting ice after injury ".
  1. Bob Ashpole, August 24, 2016 at 7:09 p.m.

    Good article, doctor. My experience has been treating my own soft tissue injuries over a lifetime. I believe RICE works, but there is definitely a point where cold therapy no longer reduces swelling. I have also learned the hard way that switching to heat therapy too soon aggravates the swelling. I found that 48 hours is not always the right time. The advantage to giving yourself first aid is that you have first hand feedback as to what works or not. I have read about other people's concerns with suppressing the immune system/healing response. It has lead me to not use ibuprofen as much and increase the use of light exercise and coverings to promote circulation. By coverings I mean anything from a wool sox or sweat pants to a neoprene sleeve. The covering is such a simple thing, but in my case I think it works, although that is a purely subjective opinion. I feel that this improved circulation merely speeds recovery. I generally only use ibuprofen only on very mild injuries. I judge the need to seek medical treatment partly on the degree of pain experienced which I feel is an indicator of the amount of soft tissue damage. I say soft tissue, because lack of pain doesn't mean I don't need medical treatment. (Twice I sought treatment for broken bones and the doctors didn't believe me until they saw the x-rays. One even sent me home before seeing them. Collarbones both times.) As a youth coach I always left treatment to the child's parents. Other than putting pressure on a nosebleed once, I fortunately never faced a situation where the parent was absent and immediate treatment was needed.

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