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Is R.I.C.E. Good For Acute Musculoskeletal Injuries?

What Is R.I.C.E?

If you've ever had a sprained ankle, the chances are someone has suggested you apply R.I.C.E. These aren't the white grains that you might often have for dinner, but rather a protocol to follow after you've had a minor injury. It stands for:

  • R - Rest
  • I - Ice
  • C - Compression
  • E - Elevation

R.I.C.E. is one of the most common first aid treatments for acute musculoskeletal injuries, and its aim is to try and provide pain relief and reduce the amount of swelling. Healthcare practitioners of all kinds have used this protocol to aid the healing process for decades, whether that be delivering first aid to someone who has tripped over and hurt their ankle, to elite level athletes in an attempt to get them fit and back into training. Each protocol has a logical reason behind it. Rest is to take the pressure off the injury and prevent further injury from taking place, as well as potentially inducing more pain. Ice aims to reduce the amount of blood flow to the area and numb the pain, and compression and elevation aim to reduce the amount of swelling.

The problem with this approach however is that our bodies are fantastic at healing themselves, and R.I.C.E. may actually impact on the quality of the healing process. To understand this a little better, it may help to understand what actually happens when we have an acute musculoskeletal injury and the resulting inflammatory and healing process.

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What are the signs of inflammation?

When we suffer a trauma, various tissues at the site of injury are damaged. You will know when this happens due to the cardinal signs of inflammation. They are:

  • Redness
  • Heat
  • Pain
  • Swelling
  • Reduced Range of Movement

Redness (rubor) occurs when the small blood vessels around the site of injury dilate. Heat takes place due to the increased blood flow to the area. Pain is associated with the release of the chemical mediators of inflammation (which we will talk more about later). Swelling, also known as oedema, and resulting reduced range of movement, occurs primarily due to the accumulation of fluid outside of the blood vessels,

What causes the cardinal signs of inflammation?

The cardinal signs occur due to chemicals that are released when the tissues are damaged. There are lots of different chemicals, but some of the most common are histamine, bradykynin, serotonin and prostaglandin.

Why might R.I.C.E. impair the healing process?

As soon as the damage to the tissues occurs, the body immediately sets about trying to heal itself. The first part is the inflammatory response, which we've discussed already. The second part is called the regeneration and repair stage. This stage usually starts around 48 hours after injury takes place and can last up to six weeks, but varies depending on the severity of the injury. A type of cell called fibroblasts secrete collagen and allow the formation of scar tissue. As this is happening, the process of remodelling occurs. This is where the final aggregation, orientation and alignment of collagen takes place. What's important to note here, is that if the site of injury remains completely motionless during this phase, the fibres of connective tissue will begin to be laid down in a haphazard manor, potentially clumping together local tissue to the site and generally decreasing the range of movement in the area. If however, there is gentle movement and exercise applied to the injured sit that is done within pain free ranges of movement, the collagen begins to remodel along the lines of mechanical stress, meaning it becomes more organised and functional and closer to the strength of the original tissue before injury. It's important to note that the new tissue will never be as strong as before the injury, but careful movement and exercise can help with the alignment of collagen and therefore increase the functional capabilities of the new tissue. It's because of this that rest might not be as helpful as first thought.

The next part of the R.I.C.E. protocol refers to the application of ice. There are a number of reasons for this, but the primary two are its ability to numb the injured site and reduce pain, and promote vasoconstriction, which reduces the amount of blood flow to the area and limits the amount of swelling. We often consider swelling to be negative and want to limit it, however we should try to remember that this is the bodies response to healing itself. The blood that rushes to the injured site is rich and full of the cells and ingredients needed to help the healing process. By applying ice, we're reducing the areas metabolism, reducing enzyme activity and preventing oxygen from getting to the site of jury. Even if the reduction of swelling and pain was the outcome we wanted to achieve, is ice even the best way to achieve this result? After all, as soon as ice is taken away from the site, the temperature of the site returns to normal, blood blow returns along with the swelling, and the numbness will dissipate. It's also important to remember that there are some people who may have adverse reactions to ice application, especially those with a hypersensitivity to cold such as those with Raynaud's syndrome, diabetes, cold urticaria and other circulatory conditions.

However, gentle articulation through pain free ranges of movement, acts as a pump to the area and can be applied continuously. The reduction of pain can be very important as bad strains can hurt a lot, but we shouldn't forget why pain is there. It's to prevent further damage from taking place.

Compression is also suggested as part of R.I.C.E. and is done to protect and immobilise the area, as well as reduce the amount of swelling. Protection and immobilisation can be very important, especially if the injury is more severe, or the injured area is weight bearing such as the ankle. However, the body provides it's own form of protection and immobilisation through swelling, whilst also bringing nutrients to the area. Whilst there are occasions that compression and support can be very useful, it may be more appropriate, depending on the injury, to allow the body to continue unaided.

Elevation is the final stage of the R.I.C.E. protocol and is perhaps the most useful, especially at night when the bodies healing process is at full flow. Elevation, preferably above the heart, helps excess fluid leave the area, reducing pressure in the area and in turn reducing pain.

What could you do instead of R.I.C.E.?

So if you're not going to use R.I.C.E., what should you do? Well one of the recommended protocols instead of R.I.C.E. is M.E.A.T. It stands for:

  • M - Movement
  • E - Exercise
  • A - Analgesics
  • T - Treatments

Both movement and exercise are aimed at making sure the alignment of connective tissue that is laid down is as strong as possible. Movement will also provide a pump like effect, changing pressure within the area and helping reduce the amount of swelling. Analgesics can be useful if you are in a lot of pain, but you must always consult a pharmacist or medical practitioner before taking any sort of pain medication. As has been mentioned above, trying natural analgesics such as pineapple may be enough to reduce the pain in certain cases. The final letter is perhaps the most important, and that's having a treatment. Seeking out a trusted medical practitioner, such as an osteopath who can diagnose exactly what is wrong, and can offer both treatment and a rehabilitation routine.

It's important to remember that the above is just information on different approaches, and speaking to a medical practitioner should always be your first port of call. Both R.I.C.E. and M.E.A.T. protocols have their advantages and disadvantages, and speaking to a professional will help you decide what the best course of action should be.

Andrew Terry

Registered Osteopath