By: Chris Ecklund, MA, CSCS
For: SB Independent
Roll an ankle? Ice it.
Pull a muscle? Ice it.
Jam a finger? Ice it.
Research over the past couple decades has brought the therapeutic effects of R.I.C.E (rest, ice, compress, elevate) for soft tissue injury into question. Does it actually help? Is it worth the time and discomfort? Are there other therapies (i.e. e-stim or ultrasound) that are more appropriate or better yet, more efficacious in bringing about the tissue healing process for acute soft tissue trauma? Some studies have even gone so far as to say that cryotherapy has a negative impact on tissue healing and can actually slow or negate some of the body’s natural healing processes for recovery.
The truth, not surprisingly, lies somewhere in the middle.
Local Physical Therapist, Tom Walters, DPT, CSCS notes that “for acute musculoskeletal trauma (due to surgery or injury), the practice of R.I.C.E. still holds value. Numerous studies are available that show the positive effects of RICE, particularly with regard to ice and compression during the inflammatory phase of healing (first 24-72 hours after injury).” Further, he describes that the exact application technique, total icing/compression time and number of applications per day does vary depending on the size and severity of the aforementioned injury. As a rule, however, 15-20 minutes of application (particularly that of crushed ice) several times daily with at least an hour between applications are still sound advice.
Where does the confusion lie, then? Why are some arguing against it? Primarily in the research evaluating cryotherapy effects past the inflammatory phase. Here the information is equivocal at best. Certainly there are enough studies to suggest (and most likely add credibility) to the theory that icing beyond this initial phase of 24-72 hours may actually limit the body’s natural healing response. However, Walters points out “one must remember that if [he/she does] not rest the injured area, the inflammatory process may be lengthened beyond 72 hours.” In this situation, further icing therapy may be warranted.
In short, E-stim and Ultrasound appear to offer very little, if any, additional benefit to tissue repair and the healing process.
Where does that leave us? R.I.C.E. Still good advice according to the literature…at least for the first 72 hours.
One stone remains unturned, however: how long is it going to take the tissue to heal beyond the 72 hours and what should we do until then?
We find many of the clients in our performance center struggle to simply allow tissue repair to take place and often reengage in activities beyond tissue capacity far too soon thinking, “it doesn’t hurt anymore so it must be healed.” Understanding that injuries are unique and blanket statements can’t be made about healing processes, I asked Walters to offer a general time line and plan of action for a typical ankle sprain based on the latest research. Here’s what he suggests:
2. Begin RICE ASAP (assuming no fracture) and continue for 24-72 hours (depending on severity).
3. Keep ankle as inactive as possible to avoid re-injury.
Phase 2: Fibroblastic Healing Phase (approximately 4 weeks)4. Increase Range of Motion, Strength and Proprioception (balance and neuromuscular control) using pain as guide (if pushed into pain, the tissue will regress into the Inflammatory Phase again).
Grade I sprains (least severe) may be healed and allow regular sports participation between 2 weeks – 2 months.
Grade II usually require between 3-6 months to be pain-free with all activities.
Grade III sprains (most severe) may require >6 months to heal and may ultimately require surgery if instability remains.
1. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Hubbaard TJ, Denegar CR. J Athl Train. 2004 Sep; 39 (3):278-279
2. Cooling Efficiency of 4 Common Cryotherapeutic Agents. Kennet, Jane; Hardaker, Natalie; Hobbs, Sarah; Selfe, James. J Athl Train. 2007 Jul; 42 (3):343
3. The role of physical agents in modulating pain. Fedorczyk J. J Hand Ther 10: 110-121, 1997.
4. Effectiveness of Interferential Current Therapy in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis. Fuentes J, Olivo S, Magee D and Gross D. Physical Therapy. 2010 Sept; 90; 1219-1238.
5. Thermal Agents in Rehabilitation, 2nd ed. Michlovitz SL. Philadelphia. 1990. FA Davis.
6. The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction. Okoshi Y. Am J Sports Med 27:357-362, 1999.