If you search online for advice about sprains and strains, you'll find the traditional prescription — rest, ice, compression, and elevation (RICE) repeated over and over. But now some researchers think it needs updating — especially the "rest" part.
"This RICE construct doesn't necessarily reflect modern science," according to Eric Robertson, a spokesman for the American Physical Therapy Association. He says the same goes for the PRICE variation where "P" stands for "protection."
Too often patients and even doctors treat sprains by immobilizing their joints in casts, slings, and "walking boots," says Robertson. But immobility reduces circulation and can cause muscles, nerves, ligaments, and tendons to weaken from disuse. Instead, Robertson counsels patients to work with healthcare providers to find exercises that will speed healing.
Past Treatments Based on Guesswork
Even without medical attention, sprains and strains usually improve over time. But in the United States alone, some 28,000 ankle injuries occur every day. And the damage can linger. One study showed that only 35 to 85 percent of sprained ankles heal completely within three years.
So researchers have been questioning the way these injuries are treated. They've found that the RICE advice came about more from educated guesswork than actual research.
What happens when you actually put these ideas to the test? As far back as 1994, randomly divided 82 patients with sprained ankles into two groups. One group wore an elastic wrap for two days, and then switched to braces that allowed for movement. They exercised their ankles under the supervision of the physicians, gradually putting more weight on the injured joint.
The other group wore plaster splints for 10 days, preventing motion in their ankles. Then they started the same exercise and weight-bearing program.
Ten days after their injuries, 57 percent of the early mobilization group had fully returned to work, compared with only 13 percent of the plaster splint group. Three weeks after their injuries, 57 percent of the early mobilization group still experienced pain, compared with 87 percent of the plaster splint group.
The Value of Early Exercise
Similar studies have since confirmed the value of early exercise for all but the most severe sprains. They have also shown benefits for balance training — for example, standing on the injured foot with your eyes closed — which improves the function of nerves in the joint and can increases stability.
Citing evidence like this, a 2012 editorial in the British Journal of Sports Medicine suggested replacing RICE and PRICE with POLICE — protection, optimal loading, ice, compression and elevation.
But the “ICE” part of the treatment also remains poorly tested. In some trials, patients who received cold treatments did better than those who did not. In others, there was no difference.
"We do know it's a good pain reliever," says Thomas Kaminski, who helped devise the National Athletic Trainers' Association's official guidelines on ankle sprains, published last year. Most experts continue to recommend some kind of cold treatment, with the reasoning that people can start moving their sprained joints more quickly if they hurt less.
(To avoid frost bite, they caution against icing for more than 20 minutes at a stretch, however, and recommend using some sort of insulation like a wet towel, especially when applying chemical cold packs that get below freezing temperature.)
The same problem applies to compression and elevation. Tightly wrapping a sprained wrist or ankle reduces swelling. A less swollen joint is easier to move, and theoretically the pressure can reduce internal bleeding. But hardly anyone has actually compared healing in patients who receive this sort of compression with those who don't.
Fewer studies still have examined the effects of elevation. Putting your foot up might reduce swelling in your ankle, , but the swelling comes right back when you stand up again.
Treating a Sprain
So what else can you do about a sprain? Heat treatments might do more harm than good, Kaminski's team concluded. Electrical stimulation, an experimental treatment some clinics offer, has gotten mixed results.
Drugs can temper the pain. But all have potential side effects. And some of them, non-steroidal anti-inflammatory drugs (NSAIDS) like ibuprofen, could theoretically interfere with the healing. Kaminski recommends using acetaminophen if you need a pain killer for the first 48 hours, with use of NSAIDs safe after that.
With so few other options — and little risk — most experts are advising patients and doctors to stick with ICE until further notice.
"I think nobody would make the argument that if you get a musculoskeletal injury you should just let it swell," says Stephen Rice, a pediatric sports medicine doctor and former chair of the Health and Science Policy Committee for the American College of Sports Medicine. "[I] don't have the hard science, but I have nearly 40 years of experience that if you can control the swelling people can return faster."
Barbara Bergin, a fellow with the American Academy of Orthopedic Surgeons agrees. "You just can't beat rest, ice, compression and elevation," she says.
But she adds that you should only follow this prescription until you are able to consult with the appropriate healthcare provider, for example when "you sprain your ankle and it's a Sunday afternoon and you don't want to have to go to the emergency room [because] you'll have to wait in line for hours, and you'll have to pay a lot, and your doctor will be in on Monday."
Even critics of the RICE formula are willing to go along with that, for now. "RICE by itself is not necessarily too dangerous," says Robertson. "But you should know that there is a better way."