Should I Use Rest, Ice, Crutches or Heat?

Ice or heat has been a debate in musculoskeletal medicine for a very long time. Traditionally the idea was that you ice an acute injury to reduce swelling and relieve pain. Heat was believed to be more appropriate for chronic injuries, where there was no longer an inflammatory response and the tissue was ‘stiff.’ Over the last decade (or more), there has been more and more literature published on this topic challenging these long-held beliefs. It seems that there’s not a strong body of scientific evidence that gives us an exact right or wrong when it comes to ice or heat. It has been somewhat accepted though that we don’t rest injuries as much as we did in the past.

R.I.C.E. is an acronym that has been around for a very long time. It stands for rest, ice, compress and elevate. Some people also use the acronym P.R.I.C.E, which adds protection at the front of the plan. Typically, R.I.C.E. is recommended for acute injuries to reduce the swelling. The ‘rest’ allows the tissue to recover and avoid further aggravation. The ‘ice, compress and elevate’ are thought to reduce swelling, which has often been considered an overreaction of our body.

M.E.A.T. is an acronym that hasn’t been around as long as R.I.C.E. and stands for movement, exercise, analgesics and treatment. The thought behind this idea is that swelling is a good thing and is a necessary component of tissue repair and injury recovery. Movement helps facilitate blood flow and proper collagen synthesis. Exercise is essential for restoring the function of the area as quickly as possible. Analgesics reduce pain but don’t necessarily interfere with the natural cellular responses involved with inflammation, and they allow you to tolerate some movement and exercise. Treatment refers to the various treatment modalities and guidance offered by suitable professionals (like chiropractors, physiotherapists and athletic therapists).

P.O.L.I.C.E. refers to protection, optimal loading, ice, compression and elevation. Obviously, this is a tweaked version of P.R.I.C.E., except we now use the term ‘optimal loading.’ There is no question that most of the rehabilitation literature now promotes early activity and movement of injured areas (within reason, under the guidance of a professional).

As mentioned above, there really isn’t an exact right or wrong way to go. If we’re allowing the literature to sway us in a direction, it would make sense to use R.I.C.E. or P.R.I.C.E. with acute muscle injuries. The reason for this is that muscles have a good blood supply, so if cooling the tissue reduces blood flow, the tissue will still likely heal well. (Keep in mind that icing may not even alter the swelling). For acute ligament and tendon injuries, this might be different. These tissues have a poor blood supply, so if cooling a tissue reduces the blood flow healing may be delayed. This might be an excellent time to utilize the M.E.A.T. principle. As you can see, tissue type is a major player in the decision-making process. The time of the injury is also a factor. Acute injuries are new injuries, and chronic injuries are ones that have been around for a while. We wouldn’t usually use ice on a chronic injury as additional blood flow is likely helpful at that point.

The idea of optimal loading (P.O.L.I.C.E.) and movement and exercise (M.E.A.T.) is an important distinction. In the past, many injuries were believed to be better served with immobilization and rest. We don’t do that as often anymore. For example, we don’t keep patients on crutches for too long after an ankle sprain any more. Obviously, there are many variables that are at play here, but the general idea is that we get tissues moving as soon as it’s reasonable as the overall recovery time is shorter with this approach. It also allows healing tissue to be remodelled in the appropriate way so that the joint or tissue functions correctly with time.

Evidence-informed treatment is an approach that considers scientific evidence, patient preference and practitioner experience. P.R.I.C.E. / M.E.A.T. and P.O.L.I.C.E. are great examples of where the science doesn’t give us a clear fool-proof template to follow. A practitioner needs to use their judgement and experience to decide when it is appropriate to allow relative rest, loading of a tissue, exercise, treatment or ice/heat. In my personal experience, I don’t find that I recommend compression too often because I haven’t really seen it make a measurable difference. That doesn’t mean I disagree with it. On the other hand, I’ve seen the value of using ice (slowing nerve conduction rates and reducing pain) to allow a patient to exercise and move easier. This may contradict the M.E.A.T. principle, although I would sometimes question whether icing alters swelling in an area to an appreciable level. Regardless, the idea of loading tissue that may be damaged is a change from traditional beliefs but has now become well recognized and understood by practitioners. You never see whiplash patients wearing neck collars anymore.

In short, it’s not easy to navigate this, and the literature hasn’t given us a true right or wrong. Perhaps the closest we have to ‘right or wrong’ in this realm is that we don’t completely immobilize injuries for as long as we used to. I would recommend that anyone who is injured and unsure to consult with a suitable health professional who can help them safely load the tissue, return to function as soon as appropriate and then consider things like ice /heat/compression and elevation based on a health professionals experience with that situation.

By Dr. Kevin McIntyre
Chiropractor and Clinic Director – Burlington Sports Therapy

References

• Bleakley CM, Glasgow PD, Philips P et al. Management of acute soft tissue injury using Protection Rest Ice Compression and Elevation. London: ACPSM, 2011.
• Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med 2012;46(4):220–1.
• Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly KD, Struijs PAA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database of Systematic Reviews 2002, Issue 3.