A runner is clutching their injured ankle

Originally published on 1 February 2016

One of the biggest mistakes I often see is with patients coming in who have had long term tendinopathies (e.g. Achilles Tendonitis). Their mainstay treatment has been anti-inflammatories but also icing and applying the old adage of using RICE which stands for Resting, Icing, Compression, and Elevation. This can be applied to a wide range of muscular injuries of the lower limb.

So just to define what each of those terms mean:

  • Rest is required to reduce the metabolic demands of the injured tissue and thus, avoid increased blood flow. It’s required to reduce stress on the injured tissues that may disrupt the repair process.
  • Icing is the most common means by which cooling is achieved, and the term is ice is used to apply a cryotherapy. So ice is used in this context to limit the injury induced damage by reducing the temperature of the tissues at the site of injury and consequently reducing metabolic demand. Applying ice can cause vasoconstriction and limiting the bleeding. Ice may also reduce pain by interacting with the free nerve endings at the injury site.
  • Compression is used to stop excessive swelling and haemorrhaging. It is applied to reduce the limit of swelling into the surrounding tissues. And it can ultimately reduce the amount of fibrin and scarring.
  • Elevation of the injured part lowers the pressure of the local blood vessels and can help limit the bleeding. It can also increase the drainage of the inflammatory exudate through the lymph vessels, reducing and limiting oedema and its resultant complications.

I have quoted those definitions from a recent article by van den Bekerom from the Journal of Athletic Training in 2012.

So why is this the biggest mistake?

As highlighted in this article, where is the evidence that these therapies work? What they did was look at the use of RICE in conjunction with ankle sprains to see if there was any merit in applying this therapy. What did they find? In summary, basically there was a low amount of high quality research trials that can advocate for the use of RICE. There was insufficient evidence available that RICE for the application of ankle sprains is useful. There is a small amount of evidence that supports mobilising post traumatic ankle sprains. There is no effect that ICE works in the treatment of ankle sprains. There is limited or no evidence to support the use of elevation and compression.

A recent trial stemming from this, is that icing may be detrimental when applied to local muscle or damaged tissues. It can cause reduction in the inflammatory cells, which are called macrophages which play an important role in degeneration or regeneration. When applying ice, you may be delaying this regeneration process, which may delay healing. I am not a big advocate of all components of the RICE paradigm. I do encourage rest in an acute injury, however there is some degree of mobilising and/or physical therapy that is applied to help the repair process and that resonates well with my clinical reasoning. Components of RICE may be applied to long term tendinopathies, however it should be under the guidance of a podiatrist or physiotherapist stemming from sufficient reasoning. I couldn’t find any decent research to support this though.


van den Bekerom, M PJ; What is the evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in adults? Athl Train. 2012; 47 (4): 435

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