Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
4 Dec

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.

They conclude that “based on the available evidence, cryotherapy seems to be effective in decreasing pain,” but evidence is scant for any further conclusions. Another review using many of the same studies had similar findings, noting that the vast majority of the available studies purporting to examine the effect of cryotherapy on soft tissue injury employ surgery patients with open injuries. The authors stress the need for more research using patients with closed soft tissue injuries – sprains, strains – rather than surgery patients.

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.

You want comments? We got comments:

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  1. It seems to me that, whatever the body does, it must not do in the interest of harming itself. So very often, people treat “symptoms”, that are really part of the healing process (fevers being a good example) I find myself “treating” my injuries less and less. I have yet to be disappointed by my body’s ability to recover.

    Darrell wrote on December 4th, 2012
  2. I love reading the comments and hearing what everybody has been doing. I to never understood icing as I always assumed that it restricted blood flow and that doing that would slow healing. The injury needs all the good stuff that the blood can bring it and the temporary pain relief from the ice was not worth the slower healing. I get a lot of ridicule for my thinking but I stuck to it. I also try and not take any pain meds as I don’t like the way they make me feel and I always thought that pain was your bodies messaging system – “Don’t do that.” Luckily I have never been seriously injured – Just a sprained ankle and some knee pain growing up. Thanks again for the info!

    Shelby wrote on December 4th, 2012
  3. Hans Kraus. Read his stuff – move, move, move after injury. Great results.

    Edmund wrote on December 4th, 2012
  4. To add to my previous comment. I guess no one is considering ligamnet tears, joint dislocations or small bone breaks (ankles, wrists, etc.) These types of injuries are often not obvious. Primative man would have no way of treating them, so the lymphatic fluids that collect in that area and cause swelling would, over weeks and months, solidify and become hard as bone. I’ve seen people in 3rd world countries with these deformities. In primative times those old injuries would limit the functioning of the limb to the point that the individual might not survive if he had to hunt and gather for himself. In our time ice and compression would remove the lymphatic fluid so the injury can be (X-rayed) corrected quickly and efficiently by a doctor. So if you can’t move the joint or limb after an injury and it does not start getting better after a few days please use RICE and see your doctor.

    Donald wrote on December 4th, 2012
  5. Hi All,

    I’m an emergency nurse practitioner (and personal trainer) and have a fairly balanced view of ice. Personally I hate using it – too cold for me, the cold hurts more than the pain! I give patients a choice – if it helps, use it! If not, then don’t! I advocate compression/supportive bandage, the balance of rest and use, the absolute need for limb elevation and rest (with gentle ankle/joint movements). Partial weight bearing with crutches for a few days then weightbearing (still with elevation as much as possible and not going for long walks either!). Good article and yes….not that much research out there for soft tissue injuries really!

    Michelle wrote on December 4th, 2012
  6. I had a pretty nasty shoulder injury do to impact. I kind of nursed it for a while and it would not heal. When my doctor advised that I started exercising more it get better rapidly. I agree with you about keeping some mobility with injured areas.

    Glen wrote on December 4th, 2012
  7. A little bit different, but the same in the disruption of the natural process because “that is what we do.”

    This summer my son had swimmer’s ear. With a perforated ear drum we found out at the doctor. He presented with his ear hurting, and a fever. I gave him pain reliever, but it wasn’t bringing down the fever right away. It was summer, he was cold, offices are always air conditioned, so I let him take a blanket into the doctor’s office.

    First the nurse yelled at me that he couldn’t have the blanket on, because he had a fever. Then the doctor started when she came in. So I asked her what the purpose of a fever was. She then smiled at me, because she knew that I knew that the purpose of a fever is to raise the temperature of the body to kill the germs. She advised extra liquids, and as many blankets as he wanted. And keep an eye to be sure it didn’t get really high.

    The nurse came back in after and yelled at me again for allowing him the blanket. I told her I had already talked to the doctor and she had said it was fine. She huffed out of the room, shaking her head.

    I understand not wanting to be in pain, and personally, I HATE being cold, there is nothing more uncomfortable. So when my kids have a fever, if they are not in pain, I feel there is no real reason for the iboprophin unless the fever gets really high, and yes, they can bundle up all they want. Let the body heal itself, if it does not cause undo pain.

    CrazyCatLady wrote on December 4th, 2012
    • Often, when I get a low-grade fever, I wrap up in sweat pants and a hoodie, turn out the lights, get into bed, and focus on relaxing fully while breathing deep and regular. Within ten minutes, I’m asleep. When I wake up an hour or two later, I always feel much better. Help the body do it’s work. It’s not rocket science. Medical people whose focus is on “relieving symptoms” are missing the forest for the trees.

      SLC wrote on December 6th, 2012
  8. I love this post! I’ve always been curious but have had trouble finding any decent research. I have never really iced my wounds.. for two reasons. For one it’s never made sense to me to slow down my bodies natural response, and also, I just don’t like the feeling. I have a high pain tolerance though so that could be another reason I’ve never found it necessary.

    anomaly wrote on December 4th, 2012
  9. Now this is very informative and meaningful post. I also always ice whenever I got injuries in basketball cause that’s what I been practicing since child. And later on I got some tips on how to handle this kind of things, thanks to the one who posted this.

    Just to share some helpful health tips that I am surely will help you, just go this site…

    kenny wrote on December 5th, 2012
  10. Tiger balm and compression if you’re a masochist .

    They also talked about NSAIDs being really bad for the healing process.

    zen wrote on December 5th, 2012
  11. I’m a physical therapist and I see injuries from sprained ankles to knee replacements. Everything I’ve read so far is pretty on point, but there is something missing.

    Modalities with a combo of ice, compression, and elevation works great with distal extremities like an ankle. If I’m working a game and an athlete sprains his/her ankle, I do a hivolt EMS in a ice bucket for 15-20min. immediately and see good results.

    The thing I see missing is one of the biggest reasons why you should ice after an injury: to prevent atrophy to the supporting musculature. Inflammation and edema cause an increase hydrostatic pressure that press on muscles and its nerve innervation “shutting off”. This causes atrophy and a decrease in function. If not taken into consideration, this can cause muscle imbalances and improper joint alignment. That’s why when we see a patient post-op with knee replacement, ACL reconstructions, or even a sprained ankle, we prescribe “quad sets” or “ankle pumps”. Yes these help with blood circulation and cleaning out the area of white blood cells, but also to maintain the muscles that are there.

    Debates with the use of therapeutic modalities always come up, whether its the effectiveness of hot/cold pacs, electromuscle stimulation, and ultrasound. Ice is a natural analgesic and always recommend it if indicated, research proves this, as Mark has provided.

    Josh PT wrote on December 5th, 2012
    • How does the no-ice approach work for head injuries? We were always told to ice immediately and stay awake for two hours — preferably with someone else present to make sure we did!

      If you’re treating yourself, especially for training-related pains and strains, I think it’s a matter of personal preference whether or not you ice.

      I’m okay with run-of-the-mill pain and soreness from training, but I know from experience(s) that for sudden, acute pain I have to ice immediately.

      Several years ago I tore my ACL during MA training, and, despite the loud popping sound, thought I had merely strained my knee. I was in denial for the rest of the evening, neither icing, nor taking an anti-inflammatory.

      The next morning I woke up nauseous and with a tight, swollen, unbelievably painful knee. I couldn’t bend it, but there was no way I was going to admit I was hurting, so I said nothing, hobbled down the hallway, passed out, and fell down a flight of stairs.

      As a result of that incident and a more recent one (strangely enough also involving the same flight of stairs) I have come to realise that my body reacts to sudden, severe pain by shutting down, and, as my husband says, “re-booting”.

      So the moral of the story is that maybe the right thing to do is whatever is right for you. I should have iced and medicated.

      Helga wrote on December 5th, 2012
  12. Ice, ice baby. Heat is for pain relief. hence why footballers use it when they want to play a game the next day with an injury- the heat masks the pain. Good for chronic injuries.

    Ice is for controlling inflammation (as are the other 3 elements of RICE that restrict blood flow to the area). Good for new, closed injuries. Inflammation is the body trying to kill an axe with a mosquito. Kind of like the massive autoimmune response people had to the SARS virus. The immune reponse was so severe it killed people, even though the virus itself wasn’t that harmless. Inflammation repairs the injury quickly with scar tissue displacing the original tissue before it can regrow (which frustratingly takes some time).

    Scar tissue is feeble and creates a weak spot, so reinjuring the tissue is more likely. Using thermoregulatory vasoconstriction to reduce blood flow to the area reduces the onslaught of leukocytes to the injury, limiting the inflammatory process and hence scar tissue formation.

    While icing an injury will take longer for the pain to go away and the down time from exercise is frustrating. The quality of repair will be much better in the long term.

    Once inflammation has gone though (about 72 hours after, roughly), RICE should be stopped. Otherwise the tissue becomes weak and stiff. Then bringing back some mobility can begin.

    hollyanne wrote on December 5th, 2012
  13. This article reminded me of an article I read on T-Nation.

    The first portion of the articles talks about the “METH approach” which stands for movement, elevation, traction, and heat. This approach seems to confirm most of the Mark’s findings.

    Jake wrote on December 5th, 2012
  14. Thanks hollyanne, that is exactly what I advise in my first aid classes and to my patients on the ambulance. You said it much better then I could, of course.

    Donald wrote on December 5th, 2012
  15. The best treatment you never heard of is DMSO. I have used it many times during basketball tournaments. Here is a link on what I am talking about.

    JT wrote on December 5th, 2012
  16. Ice baths and really cold showers also send out a cortisol spurt which can just stress you out further if you already overdid it with work outs. But like you said Mark, they definitely do have a positive effect on Mr. Happy. :-)

    Victor Dorfman wrote on December 5th, 2012
  17. As a PT I would generally agree that ice is good for an initial acute injury for the first 24-48 hours for pain management. Pain-free movement, distraction, compression, and elevation for swelling management.

    I’ve always thought the idea of ice for swelling control is silly since once a tissue is cooled more blood will just be shunted back to the area to warm it back up. It is counter intuitive.

    In the end neuromuscular factors are likely the main concern regarding injury recovery. Upon injury a reflexive arc is created to protect deep, vital structures (think arteries/veins/nerves/organs), and is thus the probable culprit why an injured body part sharply spasms in pain when jolted or moved a certain way.

    I hypothesize this is also the reason why injuries often become chronic and “nagging” months after the initial injury, or why the swelling just never seems to go away completely…

    Justin wrote on December 5th, 2012
  18. Mark,

    In the past, you posted a link to a piece that advocated NOT using ice and making activity the main component in inflammation reduction and injury rehabilitation. I haven’t been able to find it, but i would like to send it and this to my daughter–a student in an athletic training program.

    Any chance one of the worker bees could find it? :)

    Kent H wrote on December 6th, 2012
  19. TCM says ice is for dead people.

    kevin wrote on December 8th, 2012
  20. I guess I have 2 stories to tell that are my own personal experiences.

    I played Ultimate Disc at close to the national level for several years in my youth (up until I was about 33).

    Until I finally invested in ankle braces (which I always use now), I must have sprained my ankles about 20 times both sides.

    I used this technique especially at 2-day weekend tournaments. If I sprained on Saturday, I put the ankle under HOT water for about 45 minutes, then layed down. In the morning, the joint would typically be locked, so I would hop back over to the tub and put it under hot water again for about 30-45 minutes and slowly unlock the joint. Then about 30 minutes of slow walking to get the range of motion back.

    Then I would put it into compression and cleat up for the Sunday games.

    Seemed to work – NO ice. And furthermore NO advil/ibuprofin either.

    The second story is about a break of a bone in my hand 2 years ago.

    Doc said that given my age it would take upwards of 12-14 weeks to fully heal (if I were a teenager – healed in 4-6 weeks). They recommended icing it and taking pain killers and inflammation reduction medicine.

    I did neither. I used heat (hot water soaks), drank some beer (vasodilation), and let the hand swell up like a balloon. Did very little elevation (the ‘cask’ provided a bit of compression). Actually did the reverse and lowered the hand to aid swelling.

    Hand was fully healed in 5 & 1/2 weeks!

    Just like a teenager (of course, I think eating primal helped too)!

    Just saying…

    Iluvatar wrote on December 9th, 2012
  21. 30 years ago I read a copy of “muscle builder” magazine and the article I read suggested the ice/motion method to promote healing of soft tissue and minor joint injuries such as bruising. Ice the (knee) until it is chilled, then remove ice and slowly move the joint to promote “pumping” the blood with it’s healing properties through the affected area until it “warms up” a bit. Then repeat this treatment a few times for best results. I had been suffering from painful knees from hockey for years, and this method was far superior to the ice only for an hour treatment I had been doing previously.

    Pete wrote on December 9th, 2012
  22. Now, what about icing burns? I would think that, at least at first, it would draw the heat out and help to prevent blistering.

    Poppins wrote on December 10th, 2012
  23. I’m a PT as well. I’ve thought for many years that icing is only effective for some people for pain relief and agree that it makes no sense to use anything that would slow down the inflammatory cascade which is, as Mark explained, how we heal. I suggest that people use ice if it has worked for them in the past, otherwise try heat which is often more comforting.

    I’ve been told that Chinese Medicine doesn’t advocate ice for acute injuries either.

    Sharon wrote on December 10th, 2012
  24. One word: Haemophilia.

    Lee wrote on December 11th, 2012
  25. After reading further into your book, Mark, you do cite evidence that sugar & grains cause inflammation in the body. My hypothesis is that perhaps one on the Paleo diet might not need to ice. ? I have been lucky not to have an injury since starting the “diet” a month ago. Anyone have a case study?? (no ice after injury eating Western diet, no ice after SIMILAR – that’s the hard part – eating Paleo.)
    I have also found Omega-3 supplementation to work very well. I do recommend that to my patients as well as icing (if visible inflammation), elevation. I had gotten out of habit of recommending compression. Will suggest it again.
    Thanks for the cool post!

    Katie wrote on December 26th, 2012
  26. Hi, Apple Cider Vineger works as an astringent and draws fluid away from an injury. A dressing can be soaked in it and wrapped around the injury for 20 mins at a time or diluted Apple cider vinegar for children. Can be used effectively for bruising also and minor cuts if they are covered in Vaseline beforehand. Works extremely well and physio’s and sports therapists are using this instead of ice. A.C.V is great if taken in water or neat for gout and fungal problems. Hope this helps..

    Beverley Robinson wrote on June 17th, 2013
  27. Hi, thanks for sharing this information that is evidence informed. I had a sprain on my ankles (both feet!) after a jump. The swollen parts have completely gone down. Today makes it exactly two week after the injury. I had a x-ray examination that shows not broken bone or fracture. Now I’m trying to exercise my ankles but my legs can not withstand my weight. However, I observed that each time I use ice on the sprained ankles.. it goes nump, I feel on pain, and I could stand up with any aid! But few minutes after the icing the pain returns. It is a bit confusing. What do I do? How the healing process to take it course or keep applying ice? Pls reply. Thanks again for the information…

    Ime Samuel-Etukudoh wrote on August 18th, 2013
  28. Thank you so much for your contribution on the subject of icing. I have assumed for a long time that icing is at best dubious for treatment of soft tissue injury but did not do the research you did to find proof.
    I am a PT and only use ice for pain relief and decrease in pain medication. I might want to look more into compression treatment though for post surgery knee patients from now on.

    pieter wrote on November 30th, 2013
  29. In 1981, at age 24, I had foot surgery. Immediately, a cryo machine was used to keep my foot at a cold temp. I never had any pain, even after I went home. Never had PT or rehab. Healed fine. (Of course, my whole body was off balance after that and I had resulting problems. Maybe I was off balance before that.)

    Janet wrote on December 26th, 2013

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