Monday, May 12, 2008

Ice and Musculoskeletal Injuries

Musculoskeletal injuries are a common part of competitive soccer. Ankle sprains, muscle pulls and bruises all occur over course of a season. Some of these injuries are minor some are more serious. In either case, immediate treatment is perhaps the most important step in limiting the extent of injury and beginning the recovery process. The prevailing acute treatment for muscle and joint injuries is the RICE protocol. RICE stands for Rest, Ice, Compression and Elevation. Ice (or superficial cryotherapy) has been used for years as an immediate treatment for injury. Typically athletic trainers apply ice packs to the injured area for 15-30 minutes in an effort to reduce both pain and swelling. Surprisingly, there is very limited scientific evidence favoring ice as a treatment for acute injury. Clinical studies assessing RICE treatment are few and far between. Nevertheless, an understanding of the injury process and how the individual RICE components affect injury does lead to a few solid recommendations regarding the use of ice and compression to treat acute musculoskeletal injuries.

The use of the RICE protocol is almost entirely based on subjective evidence and an understanding of the biology of muscle and ligament injury. Injury to a muscle or ligament is not limited to the initial mechanical damage. That is, a muscle pull involves more than just tearing to the tissue. Acute damage to a muscle or ligament initiates a cascade of events that can last for several minutes, even hours. Once injured, various enzymes and other co-factors are activated and released by the damaged cells. The enzymes quickly begin to degrade proteins and membranes in the injured area causing tissue necrosis. The result is what many refer to as “secondary injury” which causes further damage to the injured area. The co-factors released into the injury area initiate an inflammatory response. Both injury and inflammation cause increased blood flow and movement of fluid into the injured area. The result is pain and swelling. If not arrested, secondary damage, inflammation and swelling can aggravate the injury and delay to recovery process. Thus treatments for acute injury are directed towards preventing secondary injury and inflammation as well as reducing pain and swelling

Well designed clinical studies on the effectiveness of RICE are very limited. This is a difficult area to study given that RICE is the prevailing method of treatment. Many researchers are unwilling to compare RICE treatment to a control condition (no treatment). However, there is solid biological evidence of how each component affects the injury and recovery process. First, Rest, or immobilization, limits further damage to the area by preventing unwanted movements. Movement of an injured joint or muscle can cause additional tearing of the injured tissue and increase the pain sensation. Second, Ice is known to accomplish two goals. Cold application decreases cellular respiration. This, in turn, limits the activation of degredative enzymes and release of pro-inflammatory factors. Both effects reduce the extent of secondary injury. Ice also causes constriction of blood vessels which reduces blood flow and prevents swelling. Third, Compression seems to speed the rate of cooling of the injured area. It also mechanically reduces the blood flow into the injured area. Compression can also act to brace and limit unwanted movements. Finally Elevation decreases hydrostatic pressure to the injured limb reducing the accumulation of fluid and preventing further swelling

From a clinical standpoint, a handful of well-designed research studies do allow trainers to arrive at some overall conclusions regarding ice treatment and injuries:

  • Ice is more effective than no treatment in reducing pain, swelling and secondary tissue damage.


  • The combination of ice and compression may be more effective than ice alone.


  • Ice applied immediately after injury may speed the return to participation.


  • Intermittent application of ice may be somewhat more effective than continuous.


  • These studies also allow trainers to make a few recommendations the application of RICE to muscle and joint injuries:

  • Quickly immobilize the injured joint or limb. Unless a trained clinician, do not attempt to diagnose the injury by moving the joint or stretching the muscle.


  • Wrap an ice pack onto the injured area as quickly as possible. This provided both cooling and compression. Crushed ice in a zip-lock bag works well, wrap with a bandage or plastic wrap.
    Elevate the injured area.


  • Apply ice in intervals - 10 minutes on / 10 minutes off every two hours. Alternatively, place a cloth or other material between the ice pack and the skin


  • Continue with the RICE treatment until the injury can be diagnosed by a clinician.


  • Despite limited clinical evidence concerning ice and injury, one can confidently conclude that rest, ice, compression and elevation (RICE) to injured areas can reduce pain and swelling and speed recovery to participation. As with all injuries, it is most important, however, to seek a medical evaluation as soon as possible.