Authors: Domenic Scialoia & Adam J. Swartzendruber

Corresponding Author:
Domenic Scialoia
Saint Joseph’s College of Maine
278 Whites Bridge Road 
Standish, ME 04084
Email: [email protected]
Phone: 617-922-0309

Domenic Scialoia is a recent graduate of Saint Joseph’s College of Maine, where he obtained a Bachelor of Science in Exercise Science with concentrations in Pre- Physical Therapy and Sport Performance.

Adam J. Swartzendruber is an Assistant Professor of Sport and Exercise Science at Saint Joseph’s College of Maine.

The R.I.C.E Protocol is a MYTH: A Review and Recommendations

ABSTRACT

The RICE (Rest, Ice, Compression, Elevation) protocol has been the preferred method of treatment for acute musculoskeletal injuries since its origin in a 1978 publication entitled “Sports Medicine Book” by Dr. Gabe Mirkin.  These guidelines have been used by coaches and healthcare providers for over four decades with the intent of expediting the recovery process and reducing inflammation.  Although popular, the implementation of this protocol to attenuate the recovery process is unsubstantiated.  There is, however, an abundance of research that collectively supports the notion that ice and rest does not enhance the recovery process, but instead delays recovery, and may result in further damage to the tissue. Research in regard to compression and elevation is inconclusive, diluted and largely anecdotal.  Definitive guidelines for their application have yet to be purported.  As a result of the subsequent research that examined the validity of the protocol, Dr. Mirkin recanted his original position on the protocol in 2015.  The objective of this article is to analyze the available evidence within the research literature to elucidate why the RICE protocol is not a credible method for enhancing the recovery process of acute musculoskeletal injuries.  In addition, evidence- based alternatives to the protocol will be examined.  These findings are important to consider and should be utilized by any healthcare professional; specifically, those who specialize in the facilitation of optimal recovery, as well as those who teach in health-related disciplines in higher education.

Key words: R.I.C.E, Active Recovery, Icing, Inflammation, Injury Rehabilitation

INTRODUCTION

Disclaimer:  The following information is intended for educational purposes only and not as medical advice.

On May 23, 1962, twelve- year- old Everett (Eddie) Knowles jumped on to a freight train in Somerville, MA resulting in his arm being completely severed from his body.  The young boy was taken to Massachusetts General Hospital (MGH) where Dr. Ronald A. Malt, a young chief resident, attempted to save Eddie’s detached limb.   Despite the fact that there had never been a successful reattachment of a major limb recorded in medical literature, Dr. Malt and a team of twelve doctors performed the first successful limb reattachment in history.

The operation’s success quickly became a global phenomenon.  Newscasters swarmed the team of doctors to obtain essential facts about the miracle limb reattachment touted as one of the most monumental operations in medical history.  However, the essential facts about the surgery were rather complicated and would not be understood by the general public.  Instead, reporters focused on the aspects of the story that would be intriguing to the reader.  As a result, the application of ice to preserve the severed tissue became the main focus of the story. (21, 33, 36)

The use of ice to treat injuries was never part of medical protocol prior to the events of May 23, 1962 and the notion to utilize ice for tissue preservation was quickly published by newspapers around the globe.  Subsequently, as the story was continuously retold by individuals not directly involved in the surgery, facts began to change.  Eventually, the general public was quickly accepting the notion that any injury should be treated with the application of ice, regardless of its severity or how it occurred (36).

In 1978, Dr. Gabe Mirkin released “Sportsmedicine Book” and coined the acronym “RICE” (Rest, Ice, Compression, and Elevation) to represent the four activities for treating acute athletic injuries.  The RICE protocol has been ingrained in academic curriculum as well as in public perception for over four decades.  In 2013, however, RICE was challenged by Gary Reinl in his book “Iced! The Illusionary Treatment Option.”  Reinl cited numerous studies and anatomical resources in support of the notion that resting an injury, while wrapping it tightly (compression) with ice, is ineffective in accelerating the recovery process and could also result in further damage to the affected tissues.

Following the release of Reinl’s book, Mirkin publicly recanted his original position on the RICE protocol in a 2015 publication on his personal website (31).  Mirkin even wrote the foreword to Reinl’s second edition of “Iced! The Illusionary Treatment Option”, and offered his revised opinion on the protocol he created;

Subsequent research shows that rest and ice can actually delay recovery.    Mild    movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress     pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury (36).

Based upon the available evidence, the only plausible conclusion is that the use of the RICE technique to accelerate the recovery process is unequivocally a myth.  Its validity was unequivocally compromised in 2015 when Dr. Mirkin publicly recanted his original position from 1978.

There is an abundance of scientific evidence purporting proven methods to accelerate the healing of muscle, ligament, and tendon injuries that do not include extended periods of rest used in conjunction with ice, compression, and elevation.  To debunk the RICE myth, it is prudent to explore the physiological responses to injury and the effect ice, compression, elevation and inactivity have on those processes.  The ultimate conclusion is that there are more optimal techniques to accelerate the recovery process that do not include a period of inactivity in which compression and topical cooling (ice) is simultaneously applied to the affected area.

Physiological Response to Tissue Trauma

When the homeostatic structure of any of the body’s tissues are compromised due to trauma, the same sequence of physiological events will occur regardless of whether the compromised tissue is a muscle, tendon, or ligament (43).  Additionally, each phase of the repair process must successfully occur to allow for the initiation of the next phase (43).  When disruptions form in tissues, the body responds with three sequenced phases of recovery: 1) inflammation, 2) repair, and 3) remodeling (2).  This sequence means that the process of inflammation must successfully occur in order for the body to shift its focus to the repair phase which must also be completed before proceeding to the remodeling phase.  The magnitude of the inflammatory response is dependent upon the severity of the trauma, as well as the degree of vascularization of the tissue (29).

Inflammation is commonly misunderstood and generally believed to be synonymous with swelling.  However, the two are entirely different. Inflammation is the first phase of a three-phase sequence of tissue repair, while swelling is “the accumulation of waste at the end of the inflammatory process that is not yet evacuated” (36). Inflammation is not an undesired outcome that needs to be reduced or delayed, but rather an instantaneous defense mechanism with the primary objective of controlling the extent of cell injury and preparing the tissue for the process of repair (24).  As noted by Leadbetter (23), “inflammation can occur without healing, but healing cannot occur without inflammation.”

 The rapid process of inflammation is caused by necrosis, or accidental cell death (34), and begins with a brief period of vasoconstriction and hemostasis which restricts blood flow and allows for a blood clot to form (7).  The formation of the blood clot prevents substantial blood loss.  Immediately after this transitory period of vasoconstriction, damaged tissue mast cells degranulate, releasing inflammatory chemicals such as histamine, which cause local vasodilation and an increased permeability of the lining of the blood vessels (34).  Local vasodilation is the process in which the blood vessels in the immediate area begin to widen in an effort to enhance blood flow.  This increase in vascular permeability and vasodilation allow neutrophils, which are white blood cells that have been attracted to the area of trauma by the inflammatory chemicals, to enter the interstitial space where they can optimally interact with damaged tissues (34).  Macrophages, which are cells that are essential for tissue development and repair, simultaneously enter the interstitial space to clear debris and produce growth factors (51).  Specifically, macrophages are responsible for the release of insulin-like growth factor (IGF-1), which is an essential hormone required for muscle regeneration (31).

As the waste products produced by macrophages and neutrophils begin to accumulate around the damaged site in the form of fluid, the body relies on the lymphatic system to drain the area (36).  The lymphatic system is a passive, one-way mode of transportation for excess fluid that relies on the voluntary contraction of the body’s tissues as a method of propulsion.  “When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system” (12).  Therefore, to ensure the lymphatic’s system functionality, the muscles must be actively contracted to facilitate the efficient flow of lymph throughout the body.  The inadequate functioning of the lymphatic system is the primary contributor to the accumulation of waste products, excess swelling, and the inability to allow for the optimal recovery of damaged tissues (36).  As noted by Reinl (37), “there’s not too much inflammation, there’s too little evacuation.”

When the body is able to successfully clear the damaged site of excess fluid via the lymphatic system, the process of repair is enabled (phase two of the recovery process).  An essential aspect of this phase includes angiogenesis, the division of endothelial cells that add blood vessels to portions of tissues that did not previously have them (1).  This addition of blood vessels is an essential process because the remodeling of damaged tissues (phase three of the recovery process) is dependent upon the body’s ability to reestablish a vascular network for optimal oxygen and nutrient exchange.

Another key aspect of the repair phase is the construction of a temporary extracellular matrix, which is accomplished by fibroblasts.  Fibroblast are collagen producing cells, which create weak granulation tissue composed of collagen and fibronectin that will provide the framework for the development of new tissue (10).  Immediately after the body reestablishes a vascular network and produces the framework for tissue reconstruction, the process of remodeling is initiated (phase three of the recovery process).  The granulation tissue that was laid down during the repair phase is gradually remodeled into stronger tissue and the recovery process is completed.

Icing’s Effect on the Physiological Response to Tissue Trauma

The general premise of applying ice to damaged tissues is reducing inflammation. However, it is important to note that anything that reduces inflammation also delays healing (31) because the process of inflammation is an essential aspect of recovery.  When topical cooling (ice) is applied to damaged tissues, it acts as a vasoconstrictor (the narrowing of local blood vessels) (20).  This physiological response impedes the transport of inflammatory chemicals and neutrophils to the site of trauma.  Khoshnevis (20) purported that icing can produce further damage to the body’s tissues due to the prolonged period of vasoconstriction that “is not directly dependent on the continuing existence of a cold state.”  In other words, the blood vessels will remain constricted after icing regardless of whether or not the ice is being actively applied.  As a result of the reduced blood flow, the tissue is subjected to a hypoxic (low oxygen) environment, which can result in tissue death and permanent nerve damage (20).  

Although ice seems like a beneficial option to reduce swelling according to decades of assumptions about the R.I.C.E. technique, clinical research indicates that its utilization does not reduce the accumulation of fluid and can actually result in a greater degree of swelling.  According to Meeusen and Lievens (27)

When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability.  As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics in the wrong direction, increasing the amount of local swelling and pressure and potentially contributing to greater pain. 

A study conducted in 2013 examining the effect of cryotherapy (“ice therapy”) on muscle recovery and inflammation found that subjecting the tissues to 20 minutes of cooling was “ineffective in attenuating the strength decrement and soreness seen after muscle damaging exercise” (9).  The authors concluded “these results do not support the use of cryotherapy during recovery.”

Not only has topical cooling (ice) been proven to be an ineffective method for recovery of tissues, it has also been proven to delay the healing process and produce additional damage.  Tseng et al. (49) concluded that topical cooling does not enhance, and seems to delay, the return to normal concentrations of muscle damage markers and subjective fatigue after eccentric exercise.  Consequently, participants experienced an increased perception of pain and fatigue, as well as no change in their elevated levels of muscle damage markers, even after ice was applied to the site of trauma (49).

Icing also prevents the release of IGF-1 from macrophages during the process of inflammation. Lu (25) examined this phenomenon in mice.  One group of lab mice were genetically altered and unable to carry out the normal inflammatory process.  The second group, which was not subjected to the genetic alterations, possessed the ability to carry out the normal process of inflammation.  Both groups of mice were injected in their right quadriceps muscle with 100 microliters of barium chloride in order to produce an acute skeletal muscle injury.  The mice who were genetically unable to produce the inflammatory response experienced a reduction in the amounts of IGF-1 present in their tissues and did not successfully recover (25).  On the other hand, the control group of mice had very large amounts of IGF-1 present in their tissues after being subjected to trauma.  These findings suggest that the inflammatory process is essential for tissue regeneration since it produces IGF-1.  Further, the results of this study suggest that the use of ice, which has been proven to delay the inflammatory process (9, 27, 49), will directly suppress the production of IGF-1 from macrophages and may result in suboptimal tissue regeneration.  A more recent study explored this phenomenon as well. Miyakawa et. al (32) applied ice to the skeletal muscles of rats for 20 minutes shortly after an injury. The authors found that “accumulation of macrophages was inhibited until 12 hours after the injury.” Considering the findings from Lu (25), we can infer that IGF-1 production was also inhibited for 12 hours after injury as a result of applying ice to the damaged tissues, ultimately delaying the recovery process. 

There are several studies that suggest the cyclical application of ice is beneficial with the pain management of soft tissue injuries (3, 8, 16, 19, 26).  Kellett (19) suggests “cryotherapy for 10 to 20 minutes, two to four times per day for the first two to three days is helpful in promoting early return to activity.”  MacAuley (26) and Bleakley (3) had similar findings.  MacAuley (26), which was a literature review exploring the evidence in support of ice therapy, concluded “ice is effective but should be applied in repeated application of 10 minutes to be most effective, avoid side effects, and prevent possible further injury.”  Bleakely (3) explored the difference between the standard 20-minute icing protocol and an intermittent protocol and found that “intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.” Collins (8), which is the most recent publication of this group, also purported that “cryotherapy seems to be effective in decreasing pain.”  However, “the efficacy of cryotherapy has been questioned.  The exact effect of cryotherapy on more frequently treated acute injuries has not been fully elucidated” (8).

The authors of these studies have merely supported the notion that ice therapy may be beneficial in pain management, but not one could definitively prove that ice decreased swelling or attenuated the recovery process.  In some cases, the authors suggested that evidence in support of icing is insufficient and more studies are warranted (8, 16, 47).  There is no evidence in the available literature that definitively supports the notion that ice belongs in a rehabilitation protocol for an acute musculoskeletal injury, unless pain reduction is the only desired outcome.

Compression and Elevation

Compression is commonly used with the objective of stopping hemorrhage and reducing swelling (50).  Although popular, research on the validity of compression for recovery enhancement is limited (4, 35, 51) and most support for its application is anecdotal.  Pollard and Cronin (35) concluded there is little evidence available that supports compression for all soft tissue ankle injuries.  The authors could not suggest a definitive recommendation regarding the level and type of compression.  Van der Bekerom (50) had similar findings, concluding that “evidence to support the use of compression in the treatment of ankle sprains is limited. No information can be provided about the best way, amount, and duration of compression or the position in which the compression treatment is given.”  

There is also a lack of definitive evidence that supports compression used in conjunction with ice therapy when treating an acute musculoskeletal injury. Block (4) completed a literature review regarding the cold and compression management of musculoskeletal injuries and found that “the studies are not uniform in their choices of experimental and control groups, study duration, sample size or surgical procedure, rendering the evidence diluted.”  Until we can definitively prove the validity of utilizing compression with ice in clinical trials, we cannot assume it expedites the recovery process.

Elevation is commonly used in an effort to reduce swelling in the extremities by increasing venous return (50).  However, “no evidence based on studies with high levels of evidence is available for the effectiveness of elevation” (50).  Bayer et al. (2) concluded that elevation, along with the rest of the RICE protocol, “is well tolerated by patients, but there is no evidence that these methods enhance tissue repair.”

It is difficult to assert that compression and elevation are always advantageous when utilized in a recovery protocol, as clinical research has not yet provided definitive guidelines on their usage.  However, besides the possibility of applying too much pressure to the limbs and reducing circulation, there are no adverse side effects associated with applying compression.  Consequently, if the application of compression or elevation creates a placebo effect and makes the athlete, patient, or client feel better during the recovery process then it may be justified to continue their use.  However, prioritizing the application of compression or elevation over another therapeutic approach is unsubstantiated.

Rest’s Effect on the Physiological Response to Trauma

Periods of rest following an acute musculoskeletal injury does not enhance the recovery process.  As previously mentioned, the lymphatic system is responsible for draining the accumulation of waste products from the damaged site.  In order to do so, this passive system relies on the voluntary contraction of the tissues surrounding the site of trauma in order to produce a propulsive force.  Therefore, a period of stillness will not adequately evacuate the damaged site and the area will remain congested with metabolic waste.  This congestion can delay the completion of the inflammatory process, which will result in an inability to progress to the processes of repair and remodeling (43).

The process of angiogenesis, which occurs during the phase of repair (phase two of recovery process), is strongly dependent upon the concentration of VEGF-A, a key proangiogenic growth factor that is primarily located within skeletal muscle (1).  In fact, clinical studies have shown that revascularization is reduced in the skeletal muscle of animals as a result of the inhibition of VEGF-A (14). Gustafsson (10) found that “VEGF is upregulated in human skeletal muscle by a single bout of dynamic exercise.”  Consequently, we can infer that active contraction of the skeletal muscles surrounding the site of trauma will enhance the body’s ability to revascularize the damaged tissue.

Myostatin, a growth factor responsible for inhibiting muscle growth, has been hypothesized to play a role in muscle regeneration (40).  Hittel et al. (13) concluded that “aerobic and resistance exercise reduces muscle and circulating myostatin levels in human subjects.”  Therefore, activity following a musculoskeletal injury will inhibit myostatin and may reduce the possibility of muscular atrophy (muscle loss).

Sandri et al (39) states “maintaining muscle size and fiber composition requires contractile activity.”  Consequently, a period of inactivity will cause the muscles to undergo atrophy because the circulatory system cannot sufficiently provide nourishment or move waste from the affected area as a result of the inactivity (35).  As a result, “the tissue will become weaker, less functional, and more susceptible to injury” (35).  Therefore, continuing to activate the musculature surrounding the site of trauma is required in order to maintain muscle mass and avoid the possibility of reinjuring the tissue.

 A More Optimal Approach: Active Recovery

There is an abundance of available information that suggests moving early in the recovery process is more beneficial than extended periods of stillness (5, 6, 36, 37, 38). Reinl (36) proposed his own acronym for recovery, ARITA, which stands for “active recovery is the answer.” Active recovery is a broad term that can include any activity that involves the contraction of skeletal muscle tissue that was previously subjected to trauma (30).  Active recovery can include activation/mobility exercises or low intensity physical activity that utilizes pain free movements through a full range of motion.  If an injury is minor, rehabilitation can begin as early as the next day, assuming there is no pain associated with the desired movements. However, if the injury is severe, it is best to follow a physician’s advice on rehabilitation (31).

The validity of performing bouts of active recovery has been examined in multiple studies.  Buckwalter (5) advocated the importance of imposing a load on damaged tissues to enhance the recovery process stating that “although new approaches to facilitate bone and fibrous tissue healing have shown promise, none has been proven to offer beneficial effects comparable to those produced by loading healing tissues.”  A study in 2016 compared the implementation of active recovery to canoeist and football players in an effort to demonstrate the importance of loading the tissues previously subjected to trauma.  One group performed active recovery sessions targeting the muscles involved in a bout of exercise while the second group performed activities targeting muscles that were not utilized during a training session.  Based on the findings, the authors concluded that “20 minutes of post- exercise active recovery by working the same muscles that were active during the fatiguing exercise is more effective in fatigue reduction than active exercise using those muscles not involved in the fatiguing effort” (30).  These findings support the idea that contraction of utilized tissues facilitates recovery from a training session.  The recovery can likely be attributed to the fact that contraction of the tissues previously subjected to trauma enhances blood circulation and lymphatic drainage, which facilitates the successful evacuation of metabolic waste products from the affected area.  As a result, the process of inflammation can be completed, and the next two phases of recovery (repair and remodeling) can begin.

MEAT (movement, exercise, analgesia, treatment) has been proposed as a more optimal alternative and effectively addresses the discrepancies surrounding the RICE protocol.  Instead of resting an injury, this acronym suggests moving the damaged area through a range of motion that is pain free in an effort to provide the propulsive force required to adequately move lymph throughout the body.  Exercise with resistance should be the next step beyond simple movements. Campbell (6) suggests that eccentric loading should be prioritized when rehabilitating a tendon injury.

Analgesia, the inability to feel pain, is the third aspect of the MEAT protocol. Pain limits one’s ability to efficiently move the injured area through a full range of motion.  It is quite common for people to rely on the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain management. Common brand names of NSAIDs include Ibuprofen, Motrin, Aleve, or Advil.  However, it is important to note that the use of NSAIDs will not accelerate, and may actually delay, the recovery process (44).  NSAIDs inhibit the synthesis of prostaglandins, which initiate inflammation (44).  Campbell (6) suggests Tylenol as an alternative, as it is not an NSAID and will not disrupt the inflammatory process.  However, Tylenol can damage the liver and recommendations on a proper dosage should be followed.

The final aspect of the MEAT protocol is treatment.  This is a broad category that consists of treating the individual injury using a variety of therapeutic approaches that are utilized on a patient to patient basis.  Campbell (6) suggests the consumption of certain supplements/nutrients that reduce inflammation, as well as the application of rehabilitation modalities such as kinesiology taping or acupuncture.

Another acronym has been proposed in replace of the RICE protocol.  Robinson (38) suggested the application of MOVE (movement, options, vary, ease).  The movement aspect of this protocol mirrors the message from Reinl (36) and Campbell (6), as it emphasizes the need to move early in the recovery process (38).  The other three aspects of the MOVE protocol place an emphasis on utilizing a variety of treatment options that “vary rehabilitation with strength, balance and agility drills” (38). Additionally, the protocol suggests that returning to activity early can help athletes cope with the emotional cost of the injury which “may be moderated by permission to move immediately” (38).

CONCLUSIONS

The theory of resting an injury while wrapping it tightly with ice to accelerate the recovery of damaged tissues seems to be completely predicated upon unsubstantiated reports dating back over four decades.  The original support for the argument to ice musculoskeletal injuries was recanted in 2015 by the founding father of the RICE protocol (31).  In otherwise healthy individuals, the body is well equipped with the means to adequately remove any accumulation of fluid from the damaged site, as it contains the lymphatic system that primarily functions to perform such duties.  However, it is important to note that the success of the lymphatic system depends on the body’s ability to provide a propulsive force that facilitates the movement of lymph through active skeletal muscle contraction.  In other words, movement of the body’s voluntary tissues is vital to the adequate functioning of this system.  Therefore, an extended period of rest following an injury to a tendon, ligament, or muscle is not the most optimal way to accelerate the process of tissue regeneration. The notion of moving as much as possible following an injury is supported by the literature (5, 6, 30, 35, 38).

In addition, the application of ice, or cryotherapy, has been found to not only delay recovery, but to also damage tissue in the process (9, 20, 27, 49). The evidence suggests that the application of ice is only necessary if pain reduction is the desired outcome (3, 8, 16, 19, 26). Evidence in support of compression and elevation is lacking, as most studies are inconclusive (4, 35, 51) and fail to establish definitive application guidelines that are supported by research. These findings, along with the public recant from Dr. Gabe Mirkin in 2015 (31), support the premise that the RICE protocol, which is a generally preferred method of immediate treatment for acute musculoskeletal injuries, is a myth.

Based on the available literature, a rehabilitation protocol for an acute athletic injury should prioritize pain free movement through a full range of motion as early as possible and gradually progress to higher intensities and more complex movements.  In addition, the healthcare professional should evaluate the individual injury and work with the patient or athlete to decide which therapeutic modalities are most appropriate.  If a patient or athlete believes that compression or elevation is beneficial to their recovery process then the two modalities can be used, as it has been purported that there are no adverse side effects associated with their application.  The method and duration of the compression should be at the discretion of the healthcare professional, as no definitive guidelines have been purported.  However, there should be little to no utilization of ice or NSAIDs, unless the only desired outcome is pain reduction.

ACKNOWLEDGEMENTS

None

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FIGURES AND TABLES

Table 1: Summarization of publications that support the use of any aspect of the R.I.C.E. Protocol

Author Major Findings
Icing
Kellett (1986, October) “Cryotherapy (crushed ice) for 10 to 20 min, 2 to 4 times/day for the first 2 to 3 days is helpful in promoting early return to full activity.”
Swenson, Sward & Karlsson (1996, August) “The application of cold has also been found to decrease the inflammatory reaction in an experimental situation. Cold appears to be effective and harmless and few complications or side-effects after the use of cold therapy are reported. Prolonged application at very low temperatures should, however, be avoided as this may cause serious side-effects, such as frost-bite and nerve injuries.”
MacAuley (2001) “It is concluded that ice is effective but should be applied in repeated application of 10 minutes to be most effective, avoid side effects, and prevent possible further injury.”
Hubbard, Aronson & Denegar (2004, Jan-Mar) “Our review of the 4 randomized, controlled clinical trials suggests that cryotherapy may be effective in reducing the time to return to participation; however, the extremely low quality of the studies reviewed is of concern. Despite the extensive use of cryotherapy in the management of acute musculoskeletal injury, few investigators have actually examined the effect of cryotherapy alone on return to participation.”
Bleakley, McDonough & MacAuley (2006, August) “Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.” However, “there were no significant differences between groups in terms of function, swelling, or pain at rest.”
Singh et al. (2017, March) “In conclusion, although icing disrupted inflammation and some aspects of angiogenesis/revascularization, these effects did not result in substantial differences in capillary density or muscle growth.”
Compression
Hansrani et al. (2015, August) “Compression may be an effective tool in the management of ankle injuries and has been shown to reduce swelling and improve quality of life in single studies. Definitive conclusions are hampered by the poor quality of evidence and the variety of treatments used. The most effective form of compression to treat ankle sprains or is yet to be determined. Adequately designed randomized control trials are clearly needed.”

Table 2: Summarization of publications that refute any aspect of the R.I.C.E Protocol

Author Major Findings
Icing
Meeusen & Lievens (1986, Nov-Dec) “When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability.  As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics in the wrong direction, increasing the amount of local swelling and pressure and potentially contributing to greater pain.”
Thorsson (2001, March) “Experimental studies, however, show no effect of cryotherapy on muscle regeneration, and no controlled clinical study has shown a significant effect in emergency treatment of soft tissue sports injuries.”
Hubbard & Denegar (2004, Jul- Sep) “Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated.”
Collins (2008, February) “There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.”
Takagi et al. (2011, February) Icing applied soon after a muscle crush injury could have retarded proliferation and differentiation of satellite cells at the early stages of regeneration through retardation of degeneration and macrophage migration, which play a crucial role in muscle regeneration, and could have induced not only a delay in late stages of muscle regeneration but also impairment of muscle regeneration along with a thicker collagen deposition around the regenerating muscle fibers. Judging from these findings, it might be better to avoid icing, although it has been widely used in sports medicine.
van den Bekerom et al. (2012, August) “Based on our review, evidence from RCTs to support the use of ice in the treatment of acute ankle sprains is limited.”
Tseng et al. (2013, May) “Topical cooling, a commonly used clinical intervention, seems to not improve but rather delay recovery from eccentric exercise- induced muscle damage.”
Crystal, Townson, Cook & LaRoche (2013, October) “20 min of cryotherapy was ineffective in attenuating the strength decrement and soreness seen after muscle-damaging exercise but may have mitigated the rise in plasma CCL2 concentration. These results do not support the use of cryotherapy during recovery.”
Yamane, Ohnishi & Matsumoto (2015, July) “Regular post-exercise cold application to muscles might attenuate muscular and vascular adaptations to resistance training.”
Khoshnevis, Craik & Diller (2015, September) “The condition of reduced blood flow persists long after cooling is stopped and local temperatures have rewarmed towards the normal range, indicating that the maintenance of vasoconstriction is not directly dependent on the continuing existence of a cold state. The depressed blood flow may dispose tissue to NFCI (non- freezing cold injury).”
Tomares (2018, February) “R.I.C.E. therapy should strive to avoid sub-0°C conditions when possible” due to the potential risks of injury and exacerbation of inflammation associated with such conditions.
Bayer et al. (2019, February) “The application of ice, compression, and elevation is well tolerated by patents, but there is no evidence that these methods enhance tissue repair.”
Miyakawa et al. (2020, April) “Numbers of the neutrophils at 3 h after the injury and the MCP-1+ cells at 6 h and later after the injury in the icing group were significantly lower than those in the non-icing group, suggesting that these phenomena contribute to the retardation of macrophage migration.”
Rest
Buckwalter & Grodzinsky (1999, Sep- Oct) “Although new approaches to facilitate bone and fibrous tissue healing have shown promise, none has been proven to offer beneficial effects comparable to those produced by loading healing tissues.”
Campbell (2013, December) “RICE does have a place at the table for injury management, but it should be used sparingly and in very specific injury situations. In general, for most injuries, the MEAT approach should make up the majority of the treatment.”
Robinson (2017, October) “Ice is out. I reserve anti-inflammatories for inflammatory arthropathies. Patients can choose. Use compression if you believe it works, and elevate if you like, but I prefer calf pump exercises, walking and cross training. Light strength and agility exercises can start right away. I permit resumption of training and practices as soon as the patient is strong enough, with gradual easing back to full participation.”
Compression
Pollard & Cronin (2005) “Little evidence is available to support this type of treatment.”
van den Bekerom et al. (2012, August) “Based on our review, evidence from RCTs to support the use of compression in the treatment of acute ankle sprains is limited. No information can be provided about the best way, amount, and duration of compression or the position in which compression treatment is given (recumbent or elevated).”
Elevation
van den Bekerom et al. (2012, August) “No randomized trials were found and included in this review, so no evidence based on studies with high levels of evidence is available for the effectiveness of elevation.”

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