Should We Ice Injuries?
I’ve said this before, but inflammation is a necessary response to injury. It’s the inflammatory response that increases blood and lymphatic flow to and from the injured tissues, bringing healing nutrients and inflammatory mediators and removing damaged refuse. It’s the inflammatory response that makes injuries hurt, which prevents us from using and re-injuring the injured area. And yeah, the inflammatory response can get out of hand and do more damage than the initial insult, but it’s ultimately how our bodies heal damaged tissues and recover from injuries. If we didn’t have an inflammatory response, we’d never get anywhere. This was the crux of a very interesting blog post by Kelly Starrett in which he questioned the typical use of ice after injury. In short, Kelly says that putting ice on a healing tissue is counterproductive because it halts or at least disrupts inflammation, which is really how we heal.
Do we want to use ice in order to reduce the inflammation incurred after a soft tissue injury?
Let’s establish what we mean by “inflammation” after an injury. We’re really talking about the inflammatory process, which includes pro-inflammatory and anti-inflammatory processes. It begins with the release of inflammatory mediators that cause vasodilation, or widening of the bood vessels, at the injury site. This allows more blood to arrive, and with it leukocytes and macrophages (types of white blood cells) to clean up the site and moderate the inflammation. More fluid at the site also means swelling, or edema, which, along with the increased sensitivity to pain, restricts movement and allows the inflammatory process to progress. But once that fluid is filled with waste products from cellular cleanup, it needs to be drained. That’s where the lymphatic system comes in. The lesser-known circulatory system, the lymphatic system removes all the waste products and excess fluid buildup caused by the inflammatory process. When the waste fluid is drained, healing can commence.
Since the lymphatic system doesn’t have a big multi-valved muscle in the center of the chest controlling the flow of fluid through its vessels, we need to get the lymph draining smoothly through other means, like elevating, compressing, or moving the tissue. What about icing? Kelly and his guest in that video above say that icing an injury promotes fluid build-up and restricts lymphatic flow. To reduce swelling, they like compression over icing, because the former doesn’t affect the lymphatic flow in a negative way.
How do these claims play out?
Icing a specific areas definitely disrupts the overall inflammatory process, lowering both inflammatory and anti-inflammatory cytokines. Icing muscles after a sprint workout, for instance, seemed to reduce levels of IGF-1 (an anabolic marker that usually increases after injury/exercise and improves healing/recovery), IL-1ra (an anti-inflammatory cytokine), and IL-1β (an inflammatory cytokine) while increasing levels of IGFBP-1 (a catabolic marker that breaks down tissue). Those are just markers, though, and an ankle sprain is not a sprint workout. But still – the responses to exercise and injury are based on the same inflammatory and anti-inflammatory mediators. If one’s affected, the other likely is, too.
As for lymph flow, it’s been shown (albeit in a reference I can’t fully access) that prolonged application of ice to tissue enhances the lymphatic vessels’ permeability, causing “backflow” of waste fluid back into the injured area, worsening edema, and potentially extending healing time.
So, is that that? Icing is bad?
Not so fast. With some injuries, it’s been shown to help. Clinicians are actually using cold therapy to induce hypothermia and reduce brain injury and mortality while improving the outcome in patients who’ve just had a stroke. Or after something like pelvic surgery (which is a traumatic controlled injury of sorts), cold therapy can improve erection function and reduce incontinence. Following “primary injury” (the stroke) the application of cold is preventing “secondary injury” (brain damage) to the surrounding tissues originally uninvolved in the initial injury. Though this secondary injury phenomenon also exists with soft tissue injuries, and ice therapy seems to work in its prevention, the window of opportunity for intervention is pretty small – perhaps just the first thirty minutes after the initial trauma.
Icing your ankle right after a really bad sprain to prevent secondary injury seems to make sense, but does it help with swelling and overall healing?
A 2004 literature review on the ability of cryotherapy to affect soft tissue injury healing looked at 22 eligible randomized controlled studies to determine if ice was actually helping, and the results were mixed at best:
- Ice alone was better for pain after knee surgery when compared to no ice, but swelling and range of motion were not affected.
- Ice was no more effective than rehab in reducing swelling, pain, and range of motion.
- Ice and compression were better than ice alone at pain reduction.
- Of eight studies that compared the two, there was little difference between ice and compression and compression alone.
And that’s the big problem: there simply isn’t a lot of real, hard research on how icing affects the types of commonplace injuries people actually get. And why would there be? “Everyone knows” that you ice a sprained ankle. That’s just what you do. What’s there to study? Thus, most of the research on “soft tissue injury” either preemptively accepts icing as efficacious or uses surgery patients with open soft tissue injuries when what we should really be looking at are people with ligament, tendon, and muscle strains and sprains.
One thing to consider is that ice is rarely used in isolation. RICE, the acronym that everyone seems to follow after an injury, stands for “rest, ice, compression, elevation.” It’s the standard advice you’ll hear from most PTs and docs: rest the affected area, apply ice, compress it, and elevate the tissue. Thus, many studies that seem to show efficacy for cryotherapy also use compression, making it difficult to disentangle the two. Is it the ice or the compression, or the combo of both doing the work?
Indeed, some evidence suggests that compression is key. I was unable to find many studies that compared compression alone, icing alone, and doing nothing, but there are several studies showing major benefit for compression and icing over icing alone. Most recently, subjects recovering from recent ACL surgery received either icing or compression+icing. The compression+icing group had better pain relief and a marked reduction in pain medication usage when compared to the icing group. However, an earlier meta-analysis found that while cryotherapy after ACL surgery seemed to help with pain, it did not improve range of motion or drainage. In other words, it was good for pain but did nothing to actually speed the healing process or get patients back to action. And in the one study I did find that isolated compression and icing, compression bested both types of icing – continuous cryotherapy and intermittent ice pack application – in the reduction of post-foot-or-ankle-injury swelling.
The problem with RICE, as I see it, isn’t that icing is in there, it’s that people focus way too much on the icing and do it way to the exclusion of compression, while totally misinterpreting the rest and elevation recommendations. You’re not supposed to stay completely immobile and sedentary with your iced leg up on the couch for weeks while watching bad TV. After the initial downtime, you need to move! As soon as you’re able to move without pain, you should be mobilizing the affected tissue. Don’t go hiking on a broken leg or swollen ankle or anything, but don’t assume inactivity is best. Keep your movements pain free and unloaded to begin with. Rotate that sprained ankle. Flex and extend that hurt elbow. And so on. If you’re going to ice, keep it short and sweet and immediately after the initial injury. Err on the side of moderation. Most studies indicate that the coldest temperatures are less effective at reducing swelling and may even increase it, while the “cooler” temperatures were better at reducing swelling.
So, to answer the initial question: it depends.
Clearly, people aren’t losing limbs and whittling away their connective tissue despite the prevalence of icing after injury, so I don’t think the situation is that dire. It goes both ways, of course; people aren’t going to turn into shattered husks of their former athletic selves just because they neglected to ice an injury or two.
Ultimately, I don’t think icing is as unequivocally detrimental to the healing process. It can certainly reduce pain and, if that’s the only way for you to get the tissues moving, that’s a good thing (as long as you don’t move too much too fast and end up re-injuring the weakened tissue). And it can likely prevent secondary tissue damage, particularly if you apply it shortly after an acute injury. But the extended, constant, day-in day-out cryotherapy that some of us feel is absolutely necessary anytime a tissue feels less than perfect? No. It seems clear to me that compression and mobilization of the injured area are likely more important and effective than ice.
I don’t want anyone to subject themselves to a laboratory limb contusion or anything, but I’d be real curious as to how you Primal folks handle your injuries. Do you ice them? Do you let the inflammatory cards fall as they may, confident that the composition of your tissue fatty acids will provide a suitable inflammatory response?
Let us know how it’s been working out for you in the comment section! If there are any physical therapists or coaches out there, I’d be particularly interested in your take on this.
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Posted By: Mark Sisson
Interesting, I had never thought about how icing an injury might slow down healing but it makes sense. Just like taking cold medicine treats the symptoms but not the problem. The symptoms of the cold are what treat your cold so by removing them you slow down your recovery. Next time I sprain an ankle I’ll be sure to not ice it and I’ll let you know how it heals.
As a Massage Therapist and learning hydrotherapy and injury recovery, the common mistakes with icing an injury is that people leave the ice on too long, 10 min at a time is recomended! Ice is a vasoconstrictor which pushes the fluid and edema away from injured area, after 10 min, removing the ice allows the vessles to dialate and the healing cells come back in. Think of it more like circulating something that would otherwise stay stagnant, speeding up the healing process.
When I started Crossfit,ice didn’t help a lot but upping my Omega 3′s helped a ton.
So are you saying that the omega 3 helped you recover from lifting faster? That would make sense, the extra omega 3 would reduce inflammation.
But isn’t THAT inflammation you are referring to necessary for healing?
interesting point. maybe teams should O3 together rather than ice bath, or whatever_____ insert tradition ____here, they think is helping their team do well
Two weeks ago, I had lateral meniscus surgery and have been told to ice my knee as much as possible, so this article is of particular interest to me right now. The ice makes me feel better, and along with compression, improves range of motion. Is this fooling my body?
you might only be increasing your range of motion beyond a safe level due to numbed pain receptors.
I try to avoid any painkillers at all because I want to know what activity is safe and what makes it feel worse. Advil doesn’t make it better it makes it FEEL better.
Me too! I just had medial meniscal surgery yesterday and have been searching for the answer to this very question. This was excellent timing.
What my research found, though, was that inflammation is by and large a much better response to OPEN wounds because it works so hard to prevent bacteria and infection. Modern sterile arthroscopic surgeries are their own class. I also learned that without ice, the swelling rapidly leads to scar tissue, which can be awful to try to breakdown later on and resume full range of motion. I’m at least cooling and compressing for the time being.
I’ve badly sprained both of my ankles before. On one occasion I iced it straight after. One the other I didn’t. Interestingly, it wasn’t so bad the time I didn’t ice it. Something i’ve never really thought about before…I’m going to look into this a bit more!
Did you sprain them both at the same time? If so, you should have iced one and not iced the other to see which one heals faster. The first clinical test.
If he managed to sprain both at once, I am more interested in the story about HOW.
I once sprained both ankles at once. I was playing lacrosse and running down the field. It hadn’t rained in weeks so the ground was so hard that I sprained both ankles.
Snowboarding can cause dual ankle injuries.
I have always been an athlete and NEVER believed the current concept of ice on an injury. I was delighted to read that someone actually believed the same and for the same reasons.
I find that the correct pressure points do a much better job and stop it (especially a sprain) before it gets started.
My experience… I’ve had tendonitis a few times and I’ve tried ice because I was convinced it had to work. And it didn’t. I didn’t notice any benefit from it, and I suspect it may have slowed my healing.
I’ve had a lot of sprained ankles over the years due to an inherited structural problem called varus heels. Long story made short: The bottoms of my heels are slightly rounded rather than flat, which can result in a supination problem that contributes to spraining (according to the podiatrist).
Anyway, I’ve never much bothered with icing a sprain. I’ve used ace bandages for a day or so for added support and to help reduce the swelling, but as soon as it didn’t hurt to walk I was up and about, usually within minutes after the injury.
I’ve always found that using the hurt ankle helped it heal much faster, whereas babying and immobility (as with the RICE technique) just seemed to delay healing and cause increased stiffness in the joint. I’ve found this to be true of an injured meniscus as well. I think you want to support the injury with tape or compression wrap so you don’t reinjure it, but otherwise it’s best to return to normal usage as quickly as possible
This is very interesting. It would seem to confirm my instincts (once again!). I’ve never liked using ice, it just never felt right to me, often being more painful then the initial injury. But what I’d often do, after the initial swelling and pain were passed, was to gently massage the area – that seemed to release pressure and pain much more effectively – and I guess that was probably helping with draining. Then insisting on moving the affected body part gently but often to keep it mobile. Good to know my instincts were right!
instincts are great. a few years back i slipped on some ice while walking down cement stairs and landed on my back, slightly on my right side. easily the most excrutiating pain in my life. don’t know for sure, but probably did rib damage–didn’t see any point going to a doctor as pain was my only symptom. i pulled out some ice and put it on. soooo painful! i tossed the ice and found my zostrix. the pain had eased but it was very raw and my biggest fear was that it would stiffen (meaning more pain) up as i slept so slathered three layers of zostrix before going to bed. when i got up after four hours of sleep it certainly still hurt but no stiffness. after a few days and more layers of zostrix i was functional, though there was a horrific bruise. for a couple months it felt awkward, kinda like something was out of place, then one day i felt a pop and the discomfort went away. still not sure how much damage i did, but heat was the answer for me, not ice.
I read this article using movement, elevation, traction, and heat to treat and rehab injuries.
http://www.t-nation.com/free_online_article/most_recent/radical_methods_of_injury_rehabilitation
I was just going to link to that exact article. My husband and I have both treated ankle sprains very successfully using the METH protocol. I am a firm believer.
I suffered horrible back pain for years before I discovered icing. If I ice at the first twinge, it keeps my back from going into spasm. That and MDA and I’m good to go!
Yes I now use ice for bad backs, when I used to always gravitate towards heat packs. The ice recommended by my chiro, feels really wrong, but always if applied at first twinge, avoids full blow spasm.
I spray tight joints or my back with magnesium solution and make a point to have epsom salts in the bath.
I had bursitis in my ankle/heel once and the doctor told me to ice it, rest and elevate it and take it easy for 6 weeks. I did that for one day and could tell that was the wrong thing to do. Instead I did no ice, no elevation and I went for easy walks. The pain lasted only a few days. I also got metatarsal stress fractures once. I walked barefoot around my neighborhood and it went away in 6 weeks.
I would agree with this approach, though others might not. IMO, moving the injured body part as soon as it can be done without pain speeds the healing process because it promotes normal blood circulation, whereas icing probably does just the opposite.
After a dozen ankle sprains through the years, icing immediately afterwards for one day only and then afterwards lots of massaging and gently rolling my ankle in circles both ways, gets me back on good footing with the world. Sometimes I put a bit of heat on the injury after the first day to help with the foot rotations.
I’m a licensed Physical Therapist Assistant and they always taught us in school to ICE/RICE, I’ve always told my patients to ice also. I will certainly be researching this further. Thank you Mark for the interesting post
I’m not someone that likes to artificially influence the natural reactions the body has to injury or illness, but I do sometimes recommend ice for its pain relieving quality. I don’t necessarily like it. I would much rather a patient let the body heal on its own. But we are a pain treatment society, and I would rather someone use ice than go for the drugs. Lesser of two evils I think.
That makes sense to me.
Our baby girl just had back surgery (long story.) It was clear that surgeon vastly preferred working on infants and small children, in part, because they don’t play head games with pain meds, unlike the adults.
As for us, we felt any pain she was experiencing was necessary to keep her from moving too much. We let them do their “standard” pain treatment and when it was “on demand” we had no need to give her any more. She was sleeping and eating well so it was good enough for all of us.
As much as it sucks for people to suffer, there is a reason for pain and as long as the trend is right and someone is able to rest/recover there’s no reason to remove what is vital feedback. (And if anyone is wondering, I did in fact not use pain meds for any of my births. The standard applies to me, too
)
With so many people visiting your website it must be tempting to provide definitive answers to readers inquiries. I appreciate it when you relay the information you uncover in your research even when it means you were unable to find an answer. Thanks for that.
It’s very refreshing to get a “it’s complex and kinda ambiguous” answer on the ‘Net.
I injured my knee on the first day of summer. Doc thought I tore something, but I just seriously aggravated the cartilage. I tried icing and taking Advil, but it was still very swollen. It wasn’t until I started wearing a compression knee brace that I could manage my pain. Wore the compression brace for 2-3 weeks. It helped tremendously with supporting the injured area, while still allowing me to walk. Whenever I took the compression off and tried to walk, my knee would hurt and swell. After 3 weeks, I used the compression only for re-establishing exercise (short walks) without any setbacks.
Tom Bisio and Frank Butler talk about ice in their book, “A Tooth From The Tiger’s Mouth.” I highly recommend any active person read this book, which succinctly describes and explains how Chinese Medicine can be used for injuries like sprains, burns, lacerations, and even broken bones! Chinese Medicine warns against using ice because it slows the healing of injuries and may even cause worse problems later in life because of incomplete healing. According to their book, many techniques and medicinal liniments, plasters, salves, etc. were developed on the ancient battlefields. This battlefield medicine had to be fast and effective so generals could salvage as many soldiers as possible for the next fight. I found this to be so interesting and the book is full of practical suggestions for injury recovery, as well as recipes to make these herbal liniments that naturally move blood and body fluids, reduce inflammation, and support the healing process rather than suppress it. Best health.
I’ve used traditional Chinese Medicine before for a condition “incurable” in Western Medicine (Amenorrhea brought on by poor diet and using the pill). The right practioner knows what their doing.
The remarkable thing is that the practioners quite often test “new to them” treatments on themselves. I’d love to see Western Docs do that more often.
Well remember the ancient proverb? “Pain is weak energy leaving the body.” I live by that rule everytime I’m exercising or just experiencing pain.
Icing anything does not come natural to me – it’s just not something it’s usually done where I come from. I never understood icing a sore throat with popsicles, too – it’s sipping hot herbal tea with honey that works. Icing a high fever? No, the most effective remedy is a rub with cider vinegar made with rose petals.
I did get a very bad foot sprain a few years ago, and, after I wasn’t able to walk for a month, I went for accupuncture. The second acupuncture appointment did the trick, I went there limping and came back walking normally. Nothing short of a miracle, imho.
I wouldn’t recommend ice – I would, however, recommend cold wet cloths – only as cold as you (or the injured one) can tolerate. The idea is that the coldness initially induces blood vessel contraction (and protects damaged blood vessels). It also helps to relieve pain.
You would use cotton strips, immersed in cold water, then placed just over the injured area. Wrap with dry wool strips. The cotton will become dry, so it is important to keep rewetting it.
The old time natural hygenists in the UK would use this hydrotherapy technique *exclusively* for just about any kind of injury – bruises, cuts, mild burns, sprains, strains, etc.
I’ve been having some SI joint pain since becoming pregnant with baby # 2 (well, since about month 5 or so). Basically, the ligaments on the right side of this joint are over-stretched and inflamed (likely due to the relaxin hormone kicking in already). What has helped me the most is strengthening the muscles around that area (to give the ligaments a break), but I honestly feel that ice helps too! It seems to calm things down a bit for me… I don’t get shooting pains when I ice in the evening and it seems to contract these too-stretched-out ligaments in a way that my body needs. Anyway, I guess it depends on the issue but I plan to keep icing!!!
I did a post on this in July:
“Is R.I.C.E Paleo?”
http://yelling-stop.blogspot.com/2012/07/is-rice-paleo.html
I think you’re better off listening to music…
A massage therapist once told me to ice for maybe the first day following an injury, then alternate heat and ice from there on in (like heat for a half hour, then ice for a half hour, sort of thing). She claimed this had sort of a “pump” effect. I have no scientific evidence to back this up, but I have found this to work pretty darn well and wanted to mention it in case anyone else cares to give it a shot.
I hurt my shoulder playing volleyball yesterday. Personally I dont ice unless I am in A LOT of pain. I feel that there is no difference in the healing process and also : its Winter and its cold enough outside
I’m interested though in what Matty said, and I am going to try upping the omega-3s.
I tried to treat a really painful and intractable case of tennis elbow (caused by tennis) by icing it after I played each time, but it didn’t budge for months. My elbow only grew weaker and more inflamed. Still icing daily, I visited an orthopedist, who recommended a lay off along with physical therapy. The PT employed therapeutic ultrasound, which provided no relief after several $$$ sessions, so I stopped going. I finally visited a bodywork person who does A.R.T., a soft-tissue massage technique. When I combined the A.R.T. treatments with a nightly HEAT session (via a heating pad) and a specific daily eccentric exercise (not a quirky movement(!) but one that lengthens the muscles as they contract), I healed very quickly. The heat felt wonderful. I think heat brings blood and energy to an injured area whereas ice shuts everything down. I don’t even have a twinge of pain in my elbow now even when I play many days in a row, which is unusual with tendinitis.
As a physical therapist I learned that the lymphatic system is not used to doing so much work as is suddenly required of it when injury occurs. So icing pulls the reigns on blood inflow, allowing lymphatics to “catch up”. But i have always wondered why the body would not have evolved better. Did cavemen find ice in summer for injuries? Probably not. I think it is the typically poor western diet that causes OVERinflammation. I have always found it helps with my injuries, but started Paleo diet a few weeks ago, so next injury will test it. Very interesting stuff!
After ankle sprains, my basketball coach would have me do “shock therapy” where I would put my foot into ice water for 5 minutes, then immediately into hot water for 5 minutes. He said it was to help pull/push blood from the area, thus speeding my recovery. After reading this article, maybe he was ahead of his time.
Sounds like Contrast Bath Therapy. I’ve also heard of using ice packs and heating pads for a dry form using the same concept.
Sometimes my right hand and arm feel swollen. I get relief when I am swimming in a cold pool. It’s not ice but has the effect of shrinking some of the tissues, which seems to help.
Great article Mark! I am also a licensed PT, and I typically advise my patients to ice for 3-7 days following traumatic injury/sprain/strain. Possibly a week or two more following surgery due to the larger amount of trauma. I would agree that it has a larger benefit for pain relief than it does for swelling. The swelling has to recede on its own or be mechanically helped through compression or massage. After that initial acute phase it is important to start moving again as the joint will remain stiff. Gentle progressive movement will help strengthen and normalize the injured tissue.
Aside from tending my own, most of my experience with injuries is from working with horses in various disciplines. with racehorses and other superior athletes, we tend to use ice boots and alternate it with hot or warm therapy depending on the issue. These are mostly tendon sprains, not back soreness type of issues that are usually caused by a direct external influence. cold hosing or other cold wet therapy (standing in a cold creek) seems to work well also and the patients do seems to get some immediate relief. We tend NOT to wrap injuries that we treat with heat therapy as it traps the heat and sometimes worsens the issue. There are several natural herbal remedies such as Arnica which seem to provide some relief for minor issues and we now use it as a maintenance application after a hard workout even without injury. Some over the counter medications can provide temporary relief such as Mineral Ice, but you never use these with an open wound and never wrap a limb after rubbing it with these or you may actually blister. We also find that a warm or cool bath followed by a good body splash works really well at keeping stiffness at bay after a good workout and then moving around for awhile as opposed to crashing on the couch (or in the stall). Absorbine works really well, although readers can probably find something prettier smelling in their grocery store. Before youall laugh at my comparisons, research shows that the wrong kind of carbohydrates causes all kinds of metabolic issues with horses so its not just a human syndrome. Cushing’s disease, anyone..?
I really like this post. solid scientific evidence in the field i like to keep an eye on!
I’ve learnt for the soft tissue injuries to apply the RICER policy,
the traditional ‘Rice’ with the added “R” being Rehab. most people remember the RICE basics, so i find it’s important to fully explain the rehab; the importance of movement as soon as possible, even if it is just stretching the joint/muscle, so as not to lose functionality whilst it heals.
It also throws into the mix the question of athletes/everybody these days using pharmaceutical anti-inflammatories to “recover” quickly from these injuries.
again, good post!
matt
Use DMSO instead
I’m a Physical Therapist and ice is not intended to be used for more than 24-48 hours post injury/surgery and it is definitely to be used in conjunction with compression and elevation. Beginning light range of motion should start within 24 hours depending on the type of injury and degree of injury. In my professsional opinion, ice in conjucntion with other modalities is beneficial and I have seen good results when ice is used as an adjunct modality to a complete rehabilitation program.
Wendy –
As a fellow P.T., I completely agree with your well-stated comment. Mark – the question at hand was if icing disrupts the inflammatory process. As you noted, the research is poor in showing that thermal modalities (ice, heat, ultrasound) actually reach target tissues. If the application of ice fails to reach the target tissues, one could reason that it likely has little impact on the inflammatory process. To reiterate my fellow P.T.s, ice is great for pain management, but compression, elevation, and gentle mobilization are key following an injury. After surgery, many patients utilize a CryoCuff (or similar brand) which combines ice & compression. Great discussion!