The latest evidence in treating soft tissue injury
For more than 40 years, RICE (Rest, Ice, Compression, Elevation) has been the default first-aid response to soft tissue injury. It is taught in undergraduate courses, printed on first-aid posters, and quoted quoted across allied health and primary care. The problem is that the evidence underpinning two of those four letters has quietly collapsed. Compression is still a pillar!
In 2014, Dr Gabe Mirkin, the physician who coined RICE in 1978, publicly walked back his original advice, conceding that ice and prolonged rest may delay rather than aid recovery. Elevation also shows limited impact in recent studies, but another ‘E’ (as in exercise) is increasingly recognised as critical.
In 2020 Dubois and Esculier published their now well-known editorial in the British Journal of Sports Medicine, Soft-tissue injuries simply need PEACE and LOVE, drawing together the primary evidence into a framework spanning acute care through to long-term rehabilitation. A more recent narrative review in the Orthopaedic Journal of Sports Medicine (Marinta 2025) reaches the same conclusion: PEACE & LOVE represents a more comprehensive and evidence-based strategy than RICE, even as some debate continues over the role of ice in specific clinical scenarios.
We think there is a simpler bridge for clinicians and clients who already know RICE – one that retains the familiar four-letter shape but updates the contents to reflect current evidence.
We call it PACE.
P – Protect
Rest still matters in the first 1–3 days as protection from activities that increase pain or risk re-injury. After that, the evidence is clear that prolonged rest is harmful. Bleakley and colleagues have argued that immobilisation compromises tissue strength and quality, and that a shift toward optimal loading rather than rest produces better outcomes (Bleakley et al. 2012). Pain (not the calendar) should guide the cessation of protection. Rest is a short window, not a treatment plan.
A — Avoid Anti-inflammatories and Ice
Inflammation is not a bug – it is the first phase of tissue repair. Macrophages clear damaged tissue and signal regeneration. Anything that suppresses this response, including non-steroidal anti-inflammatory drugs (NSAIDs) and ice, may impair long-term healing even where short-term symptoms feel better. The international consensus on ankle sprain management (Vuurberg et al. 2018) flags that while anti-inflammatories show short-term benefits on pain and function, their potential to disrupt optimal tissue repair argues against routine use.
This concern has only strengthened in subsequent years. A 2024 systematic review of NSAID use in athletes (Pham & Spaniol 2024) found that NSAIDs do not improve athletic performance and may impair the body’s adaptive response to exercise – specifically by suppressing prostaglandin-mediated satellite cell activity and collagen synthesis, both essential for tissue recovery and remodelling.
The ‘I’ is dropped as the case against ice has only grown stronger to support Mirkin. Singh et al. (2017) showed that topical icing in a skeletal muscle contusion model disrupted inflammation, impaired angiogenesis and revascularisation, delayed neutrophil and macrophage infiltration, and led to redundant collagen synthesis and slower and lower-quality healing. We made a parallel case in our earlier blog The end of the ice age and start of the space age?
It is worth noting that the picture is not entirely binary. Fousekis and Tsepis (2021) propose that moderate-to-severe injuries with significant swelling may still benefit from short-window cryotherapy to limit secondary hypoxic injury. We agree that ice retains narrow utility — short-duration analgesia, end-of-day recovery during congested competition schedules, or significant acute oedema — but it does not belong in a default soft tissue injury protocol. Replacing “Ice” with “Avoid Anti-inflammatories” captures both the NSAID and the cryotherapy evidence in a single letter.
C — Compression
Significantly, compression is the one instruction of RICE that has not only held up, but has arguably grown stronger. Hansrani et al. (2015), in a systematic review of compression in soft tissue ankle injury, found that it reduces swelling and improves quality of life. Unlike ice or NSAIDs, it does so without suppressing the underlying healing process.
In rehabilitation and musculoskeletal recovery, compression garments are widely used to support tissue repair by improving blood flow and the delivery of oxygen and nutrients to working tissue, while supporting clearance of metabolic by-products (Broatch et al. 2018; Coza et al. 2012; Rimaud et al. 2010).
Compression garments also enhance joint stability and proprioception. Light, consistent pressure improves neuromuscular control by increasing afferent feedback from joint and muscle receptors, with measurable improvements in lower-limb stability during functional tasks (Angelakos et al. 2020). This property is especially valuable for clients undergoing rehabilitation from soft-tissue injuries and for chronic joint presentations, where proprioceptive deficits and perceived joint instability may delay functional recovery (Bryk et al. 2011; Cudejko et al. 2017; Bennell et al. 2016).
Compression therapy also helps modulate excessive inflammation following surgery, trauma, or strenuous physical activity. Mechanical support reduces the interstitial space available for fluid accumulation and inflammatory mediator activity, which is reflected in measurable reductions in limb oedema and post-operative swelling (Heiss et al. 2018; Damstra & Partsch 2009; Kim et al. 2013). At a circulating level, meta-analytic evidence shows that compression after exercise- or activity-induced muscle damage reduces creatine kinase (CK) and other markers of muscle damage, supporting faster functional recovery (Hill et al. 2014; Kraemer et al. 2010; Kim et al. 2017).
The caveat for clinicians is fit. Compression only delivers consistent therapeutic pressure when the garment matches the client’s anatomy, and off-the-shelf sizing routinely under- or over-compresses, particularly across asymmetric or post-operative limbs (Hill et al. 2015; Brophy-Williams et al. 2020). Custom-fit, scan-derived garments resolve this — and are now achievable in clinic in minutes rather than weeks.
E — Exercise
This is where PACE absorbs the entirety of the LOVE half of Dubois and Esculier’s framework. Once the acute phase passes, the single most important thing a client does is move.
Progressive mechanical loading restores tissue strength and tolerance. Khan and Scott’s work on mechanotransduction (2009) describes the cellular pathway: physical loading is converted into biochemical signals that drive tissue repair and remodelling – the rationale for prescribing exercise rather than rest.
Cardiovascular work drives the vascularisation that delivers nutrients and clears metabolites from the injured site. Sculco et al. (2001) demonstrated that aerobic exercise improves physical function and reduces pain medication requirements in musculoskeletal conditions, supporting earlier return to work. Exercise and rehabilitation progress also strongly promote beneficial psychological factors such as positivity and optimism.
Doherty et al. (2017), in an overview of systematic reviews and meta-analyses on ankle sprain, concluded that exercise-based rehabilitation is the most evidence-supported intervention for both treatment and prevention of recurrence – findings since reaffirmed by Vuurberg et al. (2018) in the international consensus guideline. All four LOVE letters collapse cleanly into a single ‘E’.
A graded return-to-load active exercise programme, communicated with confidence, does more for long-term outcomes than any passive modality.
Elevation is conspicuously absent from PACE. Dubois and Esculier note that the evidence supporting elevation is weak, and they retain it in PEACE only on the basis of a low risk-to-benefit ratio rather than demonstrated efficacy. Where compression and exercise is being used appropriately, elevation adds little. We have chosen to use the ‘E’ for exercise for the intervention with the strongest evidence base rather than the one with the weakest.
Summary
| RICE (1978) | PACE (current evidence) |
| Rest | Protect |
| Ice | Avoid Anti-inflammatories and Ice |
| Compression | Compression |
| Elevation | Exercise |
PACE is a convenient shorthand that evolves RICE using the latest evidence into a four-letter shape clinicians and clients already know. For a four-decade-old protocol, that is overdue.
Next step: We’re real, we’re local, and we’re here for you. Contact us to learn how easy, effective and lucrative CAPE custom-fit compression can be for your clinic.
CAPE produces medical-grade compression garments, individually sized from a 3D scan, for rehabilitation, post-operative recovery, oedema and lymphoedema management, venous insufficiency, and MSK injury recovery. The Cape Health app turns any iOS device into a clinic-ready scanner, with garments produced in Australia and delivered in a week.
References
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Bennell KL, et al. Effect of knee sleeve on self-reported knee instability, pain, and function in knee osteoarthritis: a randomized trial. Arthritis Care & Research 2016;68(5):611–618.
Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med 2012;46:220–1.
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.
Broatch JR, Bishop DJ, Halson S. Lower limb sports compression garments improve muscle blood flow and exercise performance during repeated-sprint cycling. International Journal of Sports Physiology & Performance 2018;13:882–890.
Brophy-Williams N, Fell JW, Halson SL, Kitic CM, Driller MW. Pressure gradient differences between medical grade and sports compression socks. The Journal of the Textile Institute 2020.
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CAPE Bionics. The end of the ice age and start of the space age? 2020.
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