Why is the RICE (Rest, Ice, Compression, and Elevation) protocol no longer recommended for managing acute sprains in patients, such as a young male with an acute left foot sprain?

Why RICE Protocol Is No Longer Recommended

The RICE protocol alone has no role in treating acute ankle sprains because rigorous scientific investigation has shown no evidence that it improves pain, swelling, or patient function. 1

The Evidence Against RICE

The 2018 British Journal of Sports Medicine guideline explicitly states that RICE is a conservative treatment method that has not been rigorously investigated, and its efficacy is questionable. 1 When examining the individual components:

Ice (Cryotherapy) Shows No Benefit Alone

• Isolated ice application does not improve function, decrease swelling, or reduce pain at rest in acute ankle sprains, based on 27 RCTs involving 1,670 patients (Level 2 evidence). 1
• The efficacy of cryotherapy for reducing injury symptoms is unclear, even when examining 33 RCTs with 2,337 patients (Level 1 evidence). 1
• Ice only shows benefit when combined with exercise therapy, where it reduces swelling more than heat and improves short-term ankle function. 1

Compression Has Inconclusive Evidence

• Evidence for compression therapy effectiveness is inconclusive, based on only 3 RCTs with 86 patients (Level 2 evidence). 1
• RICE plus multimodal physiotherapy provides no additional benefits compared to RICE alone for pain reduction, function, or swelling. 1

Rest and Elevation Have No Evidence

• No scientific evidence exists regarding the individual effects of rest and elevation after ankle sprains. 1

What Actually Works Instead

The shift away from RICE reflects understanding that early mobilization and active treatment produce superior outcomes:

Functional Treatment Is Superior

• Lace-up or semi-rigid ankle bracing for 4-6 weeks combined with immediate supervised exercise therapy is the evidence-based approach. 2, 3
• Functional treatment leads to return to sports 4.6 days sooner and return to work 7.1 days sooner compared to immobilization. 2, 4

Exercise Therapy Has the Strongest Evidence

• Supervised exercise therapy should begin within 48-72 hours after injury, focusing on proprioception, strength, coordination, and function (Level 1 evidence). 2, 4, 3
• This represents the treatment with the strongest scientific support for ankle sprain rehabilitation. 2, 4

NSAIDs for Pain Management

• Oral or topical NSAIDs effectively reduce pain in the short term (<14 days) based on 26 RCTs with 4,225 patients (Level 1 evidence). 1
• Options include ibuprofen, naproxen, diclofenac, or celecoxib, with acetaminophen equally effective if NSAIDs are contraindicated. 2

The Evolution to PRICE

While some sources mention PRICE (Protection, Rest, Ice, Compression, Elevation) as an evolution, 2 the critical distinction is that protection through functional bracing and early active mobilization are the effective components, not the passive rest and ice elements. 2, 3

Common Pitfalls to Avoid

• Prolonged immobilization beyond 3-5 days leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits. 2
• Using RICE alone without exercise therapy delays recovery and provides no functional improvement. 1
• Inadequate rehabilitation leads to chronic problems in 5-46% of patients at 1-4 years, with up to 40% developing chronic ankle instability. 2

Clinical Bottom Line

The abandonment of RICE reflects evidence-based medicine: passive treatments don't work, active rehabilitation does. The modern approach prioritizes immediate functional support with bracing, early weight-bearing as tolerated, and supervised exercise therapy starting within 48-72 hours, with NSAIDs for pain control as needed. 1, 2, 3