Is There a Better Way to Use RICE for Your Injury?

If you’ve ever pulled your hamstring or jammed your finger, your doctor may have recommended treating the injury with RICE, which stands for rest, ice, compression, and elevation. It has long been a commonly recommended at-home treatment plan for soft-tissue injuries, including those affecting muscles, tendons, and ligaments.

Few experts question the wisdom of compression and elevation for treating soft-tissue injuries, but there has been debate over the years about the value of rest and ice. Some researchers and health experts have made calls to revise the recommendations, and the physician who developed RICE even changed his position in 2015, saying that rest and ice can possibly delay healing.

Below, we talk with Elizabeth Gardner, MD, a Yale Medicine orthopaedic surgeon and sports medicine specialist, about how you should treat a soft-tissue injury amid conflicting advice on rest and ice, as well as on the use of heat and pain relievers.

The RICE protocol was developed by sports medicine physician Gabe Mirkin, MD, and outlined in The Sports Medicine Book in 1978.

The principles behind RICE are as follows:

• Rest (avoiding use of the injured area)
• Ice (applying ice packs to the affected area to cool the tissue, relieve pain, and reduce swelling)
• Compression (wrapping the injured area with an elastic bandage to reduce swelling and provide support)
• Elevation (keeping the injured area raised above the level of the heart to drain fluid away from the injury and reduce swelling)

Typically, people are advised to use RICE on soft-tissue injuries for the first 48 to 72 hours following the injury.

Soft-tissue injuries usually appear as bruises, sprains, strains, and even tendinitis (when a tendon becomes inflamed, swollen, or painful). These injuries are common in athletes but can happen in regular life, too, whether you lose your footing on a slippery surface and twist your ankle or accidentally hit your finger with a hammer.

Experts have gravitated toward the concept of “load or activity management,” based on the idea that a gradual return to exercise and activity is preferred over pure and sustained rest, which some say can lead to deconditioning and muscle weakness.

“We’ve learned that we need to protect an injury but also incorporate some activity or load,” Dr. Gardner says. “The old-school recommendation was to avoid any weight-bearing activity and to use crutches. But there’s good agreement at this point that we instead want some light, modified mobility that moves the joints and muscles, but not in an intense way or in a manner that exacerbates pain. You’re not trying to strengthen them, just move them, which can accelerate their function. This can include body-weight exercises done at home like squats, lunges, or slow marching steps.”

Current wisdom also emphasizes the importance of movement not only during the acute (immediate) phase of injury but also during the subacute (more than three to five days after injury) healing stage.

Immediately following an injury, you may need to restrict movement for one to three days to reduce aggravation, but not rest so much that tissue strength is compromised. Pain should be your guide as to how much activity to do, Dr. Gardner says.

Then, after the first three days of recovery, you can try to resume normal activities—if they do not increase pain. If you experience pain, you can instead try pain-free aerobic exercise to increase blood flow to the injured areas, Dr. Gardner says. Some examples include walking and/or biking (initially with low or no resistance) at an intensity and duration that doesn’t aggravate your symptoms.

You can also try introducing body-weight activities (mentioned above) to restore mobility and strength. “For mobility, it’s smart to start with a familiar exercise, but at a low intensity and duration, and then you can slowly increase,” says Dr. Gardner.

Some recent studies suggest that ice—especially when used during the acute phase of an injury—reduces blood flow and can, therefore, end up delaying the healing process.

The conventional wisdom behind using ice on soft-tissue injuries was that doing so would reduce pain and swelling. But the body’s inflammatory response to an injury is a built-in mechanism to help the tissue heal. The pain, redness, and heat you experience where the injury occurred are signs that this is happening. Swelling is part of this process, too, as your body rushes more blood to the area to help with healing.

“Blood is how your body delivers everything that it needs to heal,” says Dr. Gardner. “The increased blood flow contributes to the swelling, but so does the local tissue damage.”

So, should you ice a soft-tissue injury or not?

“There isn’t one right answer, and much depends on the severity of the injury, the patient, and their goals,” says Dr. Gardner. “If it’s a low-grade athletic injury, such as an ankle sprain or muscle strain, or any mishap that could happen around the house like slamming your finger in the door, the priority is going to be to return to basic function. In those cases, I’m still a fan of icing—it provides pain relief and improves immediate function.”

On the flip side, a professional athlete may choose to prolong the process in order to allow maximum inflammation and, potentially, with that, optimal healing, she adds.

She also points out that the average person isn’t likely to ice the way people do in studies, meaning they probably aren’t doing so in such a way that it interferes with the body’s inflammatory response. “The studies on icing are super regimented and have very consistent protocols. I don’t know that most people are keeping up with 20 minutes ‘on’ with ice and 20 minutes ‘off’ every four hours for X number of days,” she says. “More realistically, someone is throwing ice on their injury for 15 to 20 minutes a couple of times a day. The dosing of ice that most people do has not been shown, in any studies I’ve seen, to delay healing or alter your final healing.”

“Yes, those absolutely still work and fall into the very low to zero risk category of delayed healing,” says Dr. Gardner.

Heat should not be used in the first couple of days after a soft tissue injury because it increases blood flow to the area, which can cause more swelling, notes Dr. Gardner. However, once you are a few days out from the initial injury, using heat, including a heating pad, can help warm up an injured area before you move it, she says. Dr. Gardner recommends using heat for 5 to 10 minutes once per day at a comfortable temperature (meaning there shouldn’t be a burning sensation).

“In general, you want to warm up an injured area before you move it by using gentle movements, such as gentle stretches, or dynamic movements to get the blood flow going—or by using a heating pad. Light stretching and dynamic movements are extra important as you start to move after an injury,” Dr. Gardner says.

And then you want to cool it down after, which could mean using ice, adds Dr. Gardner. “You want to both warm up and cool down,” she notes.

There is debate on whether or not nonsteroidal anti-inflammatory drugs (NSAIDs) delay healing. Advice to avoid them is based on the idea that the natural phases of inflammation help repair damaged soft tissues and that using medications to reduce inflammation can be detrimental to that process.

“The studies, though only in animal models, show delayed muscle regeneration, and that, when the muscle does regenerate, there is decreased strength and size in the first few weeks following injury,” Dr. Gardner says. “We also know there is some effect on bone healing with the use of NSAIDs. However, we also know very clearly that there is significant pain relief from NSAIDs. And this is where you need to weigh the pros and cons of an individual’s situation. Ultimately, talk with your doctor to discuss your options.”

Another option for pain relief without compromising the healing process is to take acetaminophen (Tylenol). “Tylenol has not been shown to inhibit healing, so that may be a good place to start,” Dr. Gardner says. “But you need to be careful not to exceed the daily dose limits because then you might damage your liver.”

Ultimately, the decision to employ strategies from the RICE method is one you make in partnership with your medical provider.