RICE or MEAT Protocol for Acute Ligament Sprain Treatment

Some Food For Thought

The RICE protocol is widely advocated in the treatment of acute soft tissue injuries, and is therefore frequently utilised in the acute phase following most sports injuries. Whilst RICE should still be used in the case of acute muscle strains, given the potential for adverse consequences such as compartment syndrome, there are some who are suggesting that the RICE protocol has reduced efficacy in the management of acute ligament (and even tendon) sprains.

Why is this so? Read on to find out.

Unlike muscle tissues which have a large vascular supply, ligaments (and normal tendons) are largely avascular. Reduced blood and nutrient supply means that ligaments are more prone to delayed or incomplete healing, and may frequently cause chronic problems in the athlete. This is the proposed reason why RICE is effective in the management of acute muscle injuries, yet MEAT is more effective in acute ligament sprains.

RICE, Rest, Ice, Compression, Elevation

It may be suggested that use of the RICE protocol could inhibit healing and therefore delay recovery in those with an acute ligament sprains. How each component may be disadvantageous to rehabilitation is discussed:

REST – Whilst rest should more accurately be taken as ‘Relative Rest’, some take this to the extreme. Complete rest would be disadvantageous for the treatment of most acute soft tissue injuries. The issue with complete rest or immobilisation is discussed later in the post.

ICE – now this is a tough one. The use of ice following acute soft tissue injuries is a staple of the sports medicine world, and I for one am not going to disagree with its use. However, I will say this. The research regarding the clinical effectiveness of ice/cryotherapy is significantly lacking, and icing acute ligament injuries may not be as cool as everyone thinks (Bleakley et al. 2004). It is possible that the decreases in metabolic rates secondary to cryotherapy will slow rates of healing, leading to a slower recovery and RTP.

COMPRESSION – I can see no feasible reason why those who strongly advocate the MEAT principle for acute ligament injuries would not want to utilise compression, given that  the compression used does not lead to immobilisation.

ELEVATION – whilst elevation could reduce oedema and oedema associated issues (e.g. chemically mediated pain), elevation of an injured limb will reduce the circulation of blood to the limb. It is possible that this could slow the rates of healing, effectively prolonging recovery.

Overview Of RICE vs MEAT

Acute Ligament Sprains

MEAT – Movement, Exercise, Analgesics, Treatments

MOVEMENT – controlled movement of the affected limb can stimulate blood flow, reduce the formation of inappropriately aligned collagen fibres (scar tissue), and effectively improve recovery. This is shown by Cochrane review which displayed the improved recovery in patients with ankle ligament sprains treated with functional treatments rather than immobilisation (Kerkhoffs et al. 2002). These patients had improved satisfaction, less swelling, and quicker RTW or RTP.

EXERCISE whilst exercise is a broad term, this is closely linked to movement (as above).  Controlled and appropriately prescribed exercises, I am sure all sports physiotherapists would agree, have the potential to enhance recovery. This is also research backed, Bleakley et al (2010) showed that the addition of ankle AROM, strength and sensorimotor exercises to standard RICE treatments improved function and weight-bearing in patients following acute ankle sprain.

ANALGESICS – these should be utilised to control acute pain. This however does not include the use of anti-inflammatory medications, which inhibit the normal process of healing. It is suggested that natural analgesics, such as proteolytic enzymes, can assist with recovery (Rathgeber, 1971; Deitrick, 1965). Athletes with high levels of pain could also use narcotics (i.e. codeine) or other pain relievers.

TREATMENTS – this suggests that the athlete should seek treatments such as physiotherapy (or physiotherapy) who may also utilise other modalities with the aim of stimulating blood flow and healing. I doubt I have any challenge selling the role of PT in this case. Physiotherapy may include various forms of EPA, despite their frequent lack of evidence basis. In the elite athlete with strict return to play time-frames, you may decide to utilise additional treatments like prolotherapy.

Conclusion

It is important to state that there is no decent research comparing the two treatment protocols, and both have clear positives and negatives. This is just ‘food for thought’. I would think that the majority of sports physiotherapists would never blindly follow the RICE or MEAT protocols in the treatment of any acute soft tissue injuries. Furthermore, I would suggest that the ‘Gold-Standard’ or universally accepted management of many acute conditions would utilise components of both the RICE and MEAT protocols.

What are your thoughts? Comment here, or catch me on Twitter or Facebook.

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References

Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.

Bleakley CT, O’Connor SR, Tully MA, Rocke LG, MacAuley D, Bradbury I, et al (2010). Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 340

Caring Medical and Rehabilitation Services (2010). MEAT vs RICE Treatments. Retrieved from http://www.caringmedical.com/symptoms/meatvsrice.asp

Deitrick RE. Oral Proteolytic Enzymes in the treatment of athletic injuries: a double-blind study. Pa Med.1965;68:35-37.

Rathgeber WF. The use of proteolytic enzymes (Chymoral) in sporting injuries. S Afr Med J. 1971;45:181-183.

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.

Comments

  1. Hi, I think allone those two protocols are less effective. as a physiotherapist ithink combination of RICE and MEAT will mgive higher results to the pation.
    thankyou

    • Thanks for the feedback Charith. I tend to agree that clinically I will use a combination of the two protocols, often as the conditions move through the stages of acute through to sub-acute. I think I would find it very challenging to put a hot pack on a acute and swollen ligament tear!

      • I totaly agree that the evidence does not consistently support the RICE protocol. However, clinical experience is a very important factor to the learning procedure. I guess every one of us has witnessed how a swoolen area reduces its volume after 10 min of ICE application.

        The table RICE vs MEAT is misleading (if it is referred to an ACUTE injury).
        – Do you want to increase the ROM of a joint with injured ligaments???
        – Do you want to increase the blood flow to an injured-inflammed ligament???
        – Collagen formation occurs 7 days post injury!!

        People, think TWICE before you apply MEAT in an ACUTE ligament injury!!!

        CHEERS!!

        • Thanks for the comment Dimitrios! I agree with what you are saying, the anecdotal evidence for RICE certainly does stack up. However, I will just do a little to defend the authors of the work…

          The table you refer to is suggesting that the healing of the largely avascular ligamentous tissue may be impeded by reduced blood flow. With reference to ROM I agree that injured ligaments must go through a phase of protection (if we use a P(rotection)RICE paradigm), however, ultimately our main goals would be to return the athlete (and her joint) to normal function ASAP. With reference to collagen formation, you will find that it does not only begin at 7 days post injury (as you might expect from readings on the ‘Proliferative’ Phase of healing). Collagen synsthesis will begin in the ‘inflammatory’ phase, and will peak in the proliferative phase. Quick reference on tendons: http://bit.ly/e23KFY

          In saying all this, as clinicians it would be very challenging to follow the MEAT protocol. We are built (as is the world of sports med) to opt for RICE! This was just meant to be a sneaky little post with some food for thought! It clearly has generated some!!

          Thanks again for the comment Dimitrios!

          • Glad for your reply!

            Yes, in tendinopathy, things are quite different. There is no inflammation in most cases! So, this does not apply clearly to this general topic about acute injuries. So does the table!

            “..decreases in metabolic rates secondary to cryotherapy..”.
            I really doubt it that 10min of ice can do that! On the other hand, ice reduces pain, swelling, inflammatory “soup” etc.

            Also, MEAT is quite vague. There is no ”versus” between RICE and MEAT. Quite the opposite, we HAVE TO combine the elements of these approaches. And that’s what research must look for!

            I don’t think that anyone could disagree with the following example! Of course you give MOVEMENT to a sprained ankle (the appropriate movement!). Of course you EXERCISE a sprained ankle (the appropriate exercises!). Of course you give ANALGESICS in such case. Of course you give TREATMENT (physio, acupuncture etc) to a sprained ankle.

            RICE and MEAT are friends! And they give a very good and healthy meal when combined!

          • Agreed Dimitrios, absolutely. I love the metaphor, a healthy meal!! Thank you so much for your contribution!

          • I have looked both articles of Bleakley on acute ankle sprains.

            He uses participants with time since injury <7 days. 5, 6, 7 days post injury it is not acute I guess! The protocol for the control group is “10 minute applications of ice and compression interspersed with 10 minutes of rest (repeated three times daily for one week)”. That dosage is not what we do in clinical practise for RICE. Too much ice and too much time lost!!

  2. Glad for your reply!

    Yes, in tendinopathy, things are quite different. There is no inflammation in most cases! So, this does not apply clearly to this general topic about acute injuries. So does the table!

    “..decreases in metabolic rates secondary to cryotherapy..”.
    I really doubt it that 10min of ice can do that! On the other hand, ice reduces pain, swelling, inflammatory “soup” etc.

    Also, MEAT is quite vague. There is no ”versus” between RICE and MEAT. Quite the opposite, we HAVE TO combine the elements of these approaches. And that’s what research must look for!

    I don’t think that anyone could disagree with the following example! Of course you give MOVEMENT to a sprained ankle (the appropriate movement!). Of course you EXERCISE a sprained ankle (the appropriate exercises!). Of course you give ANALGESICS in such case. Of course you give TREATMENT (physio, acupuncture etc) to a sprained ankle.

    RICE and MEAT are friends! And they give a very good and healthy meal when combined!

  3. food for thought. i’ve found that icing my Achilles straight after a long run is incredible effective – more so than ibuprofen even. i usually do a bit of ice, rest and elevation straight after a long run for 10 mins then get active to stimulate blood flow. if it’s a one off soreness i just let nature take it’s course, but when you’re putting in loads of miles a week and things start to get really sore, you need to do something so you can continue to train. ice and ibuprofen definitely help the pain in a way that it feels like it’s healing. although i’ve been laying off it as much as possible as inflammation is part of the healing process. it’s a balance :)

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