Since Gabe Mirkin first coined the acronym R.I.C.E. (Rest, Ice, Compression, Elevation) in 1978, healthcare providers have been utilizing the therapy as a standard practice to treat soft tissue injuries throughout the subsequent decades. And though there have been some minor adaptations to the practice, as more knowledge has been gained by researchers, most of us will have been told at one time or another to use RICE when applying self-care to manage or treat soft-tissue ailments. That being said however, many are still uncertain exactly when to apply ice versus heat, and this can mean the difference between exacerbating an ailment or injury and speeding recovery from it. Follow us below as we review RICE as well as provide some general guidelines to help you better determine when to use which treatment.
Rest: Rest is critical for both repair of the body as well as prevention of continual strain which contributes to increased inflammation, pain, delayed healing, abnormal repair and possible further injury. Depending upon the degree of severity, an injury may require complete rest for a period of time, or it may require partial rest. The goal of applying rest is to allow the body adequate time to heal an injury, alleviate pain associated with that injury, and restore the majority of normal function.
Ice: Ice is well known for reducing the inflammatory response. It works to alleviate pain associated with heat generated by increased blood flow and/or blood loss. There are various methods of applying ice therapy. Many prefer to alternate ice with no ice for 15-20 minute increments; while others prefer to ice for 20 minutes every hour. The actual application can best be determined by the injury in question, however a good rule of thumb is to ice the affected area at least twice a day in no more than 20 minute increments until pain is reduced to a tolerable level and for the first 72 hours after an acute injury to help relieve inflammation as well as provide some relief of swelling. It is recommended that one never apply ice directly to the skin in order to prevent frostbite; use an old pillow case, or tea towel placed between the skin and ice pack. (Additional note: gel-packs in general do not get cold enough to address inflammation; specialists recommend using ice packs made with water and ice cubes or crushed ice in a zip-lock bag or specialized ice pack bag to reach a therapeutic temperature.)
Compression: Compression is mainly used to help minimize or reduce swelling that can result from a soft tissue injury. Some swelling can actually help to "splint" the injured area and help prevent further injury, however too much swelling may actually cause further harm to the affected soft tissues, increase pain, and decrease functionality to excessive levels. Compression may be applied in a variety of ways such as with an elastic bandage (the fit should be snug, yet not so tight as to inhibit movement or blood flow).
Elevation: Elevation is intended to help reduce swelling by allowing blood and lymph fluid to return to the system and leave the injured area.
So now that we better understand the reasons for RICE, let us take a moment to just focus on Ice. Why ice? Let's briefly recap. Ice is meant to reduce inflammation and relieve pain. So, a reasonable deduction then would be to assume that we should use ice whenever there is, or could be inflammation. When might there be inflammation? A great hint is in the fine print. The suffix "-itis" is used in medicine to indicate any disease characterized by inflammation. You've likely heard the term "tendon-itis"; tendonitis is, in effect the inflammation of tendons in a given area. Bursitis? You guessed it, bursitis is inflammation of the bursa. Colitis? Yep! Inflammation of the colon. Isn't this fun!? How about a bit more challenging one... Rhinitis? It's the inflammation of the sinuses. Ok, you get the idea.
Now it's time for a pop quiz! (Didn't know you'd be hit with that here did you?) Let's say Joe sprained his ankle this morning. Should Joe use ice or heat on his tender ankle? If you guessed ice, you guessed right! Why? Because Joe's injury is acute, and calls for the RICE technique. Jim is Joe's brother, and Jim also sprained his ankle, but it has been five days since his injury. Should Jim use ice or heat on his tender ankle? Knowing that the 72 hour mark has passed, Jim is at liberty to see which helps alleviate the discomfort in his ankle more effectively. Often, after the initial inflammatory process has passed, heat may actually help speed healing of a given injury; however, it is important to listen to the body and determine which helps or hinders. Sometimes the application of contrast therapy (3 minutes moist heat; 30 seconds moist cold/ice) can be even more effective still in aiding the recovery process.
Wait a minute though, we haven't discussed Jane. You say, "What about Jane?" Jane is Jim's wife, and has been suffering from chronic tendonitis for nearly seven months. Jane works in a packaging factory and has been diagnosed with a repetitive use injury; specifically, tendonitis of the elbow. Jane has been using NSAIDS (a form of anti-inflammatory medication) but has not found permanent relief, in fact, they don't seem to be helping much at all anymore. Should Jane use ice or heat? Let's look at Jane's situation a bit closer. It has been longer than 72 hours since the initial symptoms of injury came on. The pain comes and goes but is usually worse after a day's shift. Jane doesn't like the discomfort that ice produces and insists that heat helps her elbow feel better. But what is Jane's diagnosis? Tendonitis. There it is: "-itis". So what is Jane dealing with? An inflammatory condition, and one that is likely exacerbated by the use of heat. In order to facilitate healing, Jane really needs to apply the RICE technique and utilize icing to help reduce the inflammatory process that is taking place in her elbow. In addition, it would be beneficial for Jane to take some time off to rest her elbow, or adopt different movement patterns in order to provide some partial rest periods for the affected elbow during her daily shift. At this point, Jane might find contrast therapy beneficial as well, particularly in the morning before work (always ending with ice to combat the inflammation!), however, at the end of a day's shift after the area has been aggravated by repetitive motion, Jane's best option is to utilize ice as part of the RICE treatment technique. The most critical thing to remember is that as long as there is inflammation (or the possibility of inflammation) present in an area, particularly within the first 72 hours post-injury, ice is likely the best option.
In addition to RICE, therapies such as massage, gentle stretching and range of motion exercises, supplements such as bromelain with quercitin, and charcoal poultices may help facilitate healing depending upon the injury. If you have more questions regarding the proper application of RICE (and particularly Ice), talk to your healthcare provider, if you'd like to know more about how massage therapy can help alleviate chronic or acute pain and injury such as sprains, strains or tendonitis, give us a call and we'd be happy to visit with you. Happy icing to you!
Jerri W., LMT, CWC
Licensed Massage Therapist and Certified Wellness Coach with over 23 years of experience in pain management, relaxation techniques and lifestyle education.
Heather R., LMT, CWC
Certified Wellness Coach and Licensed Massage Therapist with a passion for helping others achieve optimal wellness through healthier living.
NOTICE: The information provided herein is meant for educational purposes only. We accept no liability for your use of the information provided. As always, use your best judgment and if in doubt, please consult your healthcare provider to determine the best course of action for your particular situation.