Most commonly people will know about Rest, Ice, Compress and Elevate when we get injured. But how long should you spend at each stage? What if you’ve been doing this for a few weeks but the pain hasn't improved or you still feel weakness around the site of injury?
ICE/RICE/PRICE focuses mainly on acute (the immediate) management and does not address the sub-acute and chronic stages of tissue healing. There is now an updated acronym that we as Sports injury specialists recommend and implement with our patients.
Starting with PEACE which addresses the acute and immediate care following injury and onto LOVE which progresses patients into the sub-acute and chronic phases. These updated acronym starts to address how to load back safely and optimise healing in injured tissue, as well as start to address the mental factors involved in injury to try and optimise recovery. We are starting to see the challenge of the use of anti-imflammatories and their role and function within injury recovery and whether they have any harmful effects on optimal tissue repair.(9)
Initially after injury - do no harm and let PEACE guide you!
P - Protect
Unload or restrict movement for 1–3 days to minimise bleeding and reduce the risk of aggravating the injury. We want this rest period to be as minimal as prolonged rest may compromise tissue quality and strength (1). Let pain be your guide - once this has started to settle - the protection level can drop.
E - Elevate
Elevate the limb higher than the heart to promote reduction in swelling. There is weak evidence to support the use of this method - the risk is low of implementing - and can help settle uncomfortable sensation around the injured limb.
A - Avoid anti-inflammatories
There are different phases of inflammation - and they help repair damaged soft tissue, therefore trying to reduce this inflammation using medication may negatively impact long term healing. Standard of care for soft-tissue injuries should not include anti-inflammatory medications. We also question the use of cryotherapy (ice). Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft-tissue injuries (2). Even if mostly it helps to reduce pain and numb the area, ice could potentially disrupt inflammation revascularisation, this may lead to impaired tissue repair and redundant collagen synthesis.(9)
C - Compression
External mechanical pressure using taping or bandages helps limit intra-articular oedema and tissue haemorrhage(2,4). Despite conflicting studies, compression after an ankle sprain for example seems to reduce swelling and improve quality of life.
E - Education
There are many benefits to an active approach to recovery (2), we are trying to move away from the idea that patients ‘need to be fixed by us’ and more about what they can start to do for themselves - and helping patients to understand more realistic expectations of the type of injury they have sustained and how to now load up safely during recovery and how long this will take.
After the first days have passed - your body is going to need a little LOVE!
L - Load
Most musculoskeletal disorders can benefit from movement and exercise, the loading should be introduced early into recovery and normal activities as soon as pain and symptoms allow (2,6). Optimal loading (1) promotes repair and remodelling of soft tissue and helps to build load tolerance in tendons, muscles and ligaments. However this needs to be achieved by not increasing any significant pain or symptoms.
O - Optimism
There are many barriers to recovery - such as depression, fear and catastrophization. Optimistic patient expectation, beliefs and emotions are associated with better outcomes and recovery. (7)
V - Vascularisation
The delivery of blood flow to injured structures is important in the management of injuries, as well as cardiovascular activity helps boost motivation, improve physical function and reduce the need to take pain medication. As well as supporting the return to work and daily activities. However, more research and better understanding is needed regarding dosage.
E - Exercise
There is a lot of supporting evidence to suggest that exercise helps reduce pain and reduces the risk of recurring injuries. Exercises are to help restore mobility and normal function, increase strength and improve proprioception early after injury. Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions. Managing soft-tissue injuries is more than short-term damage control. (8)
1 Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police? Br J Sports Med 2012;46:220–1.
2 Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 2018;52:956.
3 Singh DP, Barani Lonbani Z, Woodruff MA, et al. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol 2017;8:93.
4 Hansrani V, Khanbhai M, Bhandari S, et al. The role of compression in the management of soft tissue ankle injuries: a systematic review. Eur J Orthop Surg Traumatol 2015;25:987–95.
5 Graves JM, Fulton-Kehoe D, Jarvik JG, et al. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res 2014;49:645–65.
6 Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52.
7 Briet JP, Houwert RM, Hageman M, et al. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury 2016;47:2565–9.
8 Sculco AD, Paup DC, Fernhall B, et al. Effects of aerobic exercise on low back pain patients in treatment. Spine J 2001;1:95–101.
9 Blaise Dubois, and Jean-Francois Esculier. Soft tissue injuries simply need PEACE & LOVE. 2019