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. Interesting article. I rolled me ankle earlier today so I’m going to try the compression with no ice treatment and see how it goes!

    Chai Lee wrote on February 20th, 2014
  2. my experience with ice and compression:
    i have had shoulder injuries bilaterally as well as wrist and thumb injuries; both are fairly on and off (i have no choice in having to use these body parts in my situation) and both are diagnosed tendinitis at ortho docs. ice and bandages–particularly Rocktape-work really well for me. i only ice 10-15 minutes and do it only at night before i sleep for a few days. this works SO WELL and it enables my tissues to heal. sometimes pain feelings in the extreme are counter-productive for health. physical therapy makes things worse until i am well-healed. i gave up on that. stretching and gentle movements also work well after a few days or weeks and allow a gradual build-up of exercise.
    i have never taken pain meds; being an animal doctor, i know the harm NSAIDS can do to joints, vessels and cartilage; and, i don’t like either the primary or the secondary effects of opioids.
    so far, so good for ice and compression with rest, for me.
    i believe in ice also, because if you ever try and put an inflamed body part in cold water, you FEEL how good it feels. i do believe in the signals our body gives us about what is good or bad for us.
    over-doing anything is not productive though.

    johanna wrote on March 19th, 2014
  3. Sorry I am late to the party! I am a PT. I love that we are questioning ice. Need more research! (For example: studies look at serum igf-1 levels after cryo… That is different than levels at site of injury interstitially. The serum levels could result from MORE igf flowing out blood into injured tissue which we want.). Need studies of actual injuries that follow over time, and that compare apples to apples.
    I do more neuro rehab, so don’t see these types of injuries clinically except in myself, but I do have something to add- I work in rural developing countries regularly. I can vouch that just letting the body do it’s thing with a closed tissue injury is not good just because it’s natural…places with no ice and poor survival with prolonged rest or immobility, no drugs, etc. I have seen lifelong deformity/disability from things like bad sprains left to their own devices with no rest, ice, etc.

    Koren wrote on March 27th, 2014
  4. Baseball pitchers ice their arms, basketball players when injured will soak in a tub off ice. These people have the most qualified trainers and physical therapists that recommend ice and the athlete’s performance and paycheck depend on it.

    victor wrote on April 23rd, 2014
  5. Thanks so much Mark. This makes so much sense it’s weird it isn’t “common”. I have a bad case of plantar fascitis and my foot gets really inflamed. I have been on and off Aleve, tried ice etc but it hasn’t healed and now I know it’s because they only address the symptoms and even may slow healing. Now when my foot gets really swollen I just compress with one of Kelly Starret’s voodoo bands. I look forward to moving right one day and competing again in Grappling Tournaments.

    Derek wrote on September 26th, 2014
  6. Hey guys. I wanted to bring up two important facts that weren’t talked about in the article, and they are how reducing pain from ice could be deterimental and how icing delays swelling, not reduces it.

    In cases with a soft tissue injury, icing can reduce pain. The pain is an important stimulus to prevent movement at the site of injury. Thus, reducing pain from icing at the site of injury could actually worsen the injury and increase the time required to heal. While movement is vital for healing, controlled movement without causing pain is more effective than movement without pain from icing. Also, making those muscle numb around the site of injury makes them less effective at activating the lymphatic system.

    Secondly, from my research ive seen icing just delaying swelling (and possibly increasing it if used too much), not reducing it. So, why use something that isn’t that effective and can possibly be worst?

    Brian Stirling wrote on February 18th, 2015
  7. This is really interesting. I have been an athlete for a long time and I have thought about this for quite some time. I have found that the best thing for me is to ice for 20 min then off for 20 then on for 10 then wrap my injury. After that I just continue to wrap my injury (no ice) for a week or two. Then instead of heavy lifting and running, I try to walk a lot and if I’m feeling good go for a light jog. I also don’t take Advil unless I’m feeling really bad. I think pain is like a warning to you and your body and Advil just tricks your body into thinking that the injury is isn’t as bad as it is.

    John wrote on May 5th, 2015
  8. I’ve always wondered about this issue. I googled it and found this article. Right now I am healing a muscle strain in my calves from lifting too much weight on the seated calf-raise machine. Specifically it affected my solarus muscle beneath the calf. I’ve had major swelling to the point where it is difficult to walk. I iced once, a day after the injury, but have allowed my body to do it’s own thing and the swelling is going down on its own and the muscles are healing. While the swelling was still severe, I thought about doing some cardio on a stationary bike, but i went on for about a minute and noticed that the blood flow to the legs was creating more swelling. But one day later, after the swelling had subsided somewhat, i did 30 mins on the precor machine. This seemed to help a lot. I think the lymph started really moving around and the vigorous circulation through the affected area seemed to help. The exercise itself seemed to hasten the recovery process. In this case the precor/eliptical machine put gentle stress on the affected area, but kept it moving. separately, I noticed that doing cardio on the elliptical machine also helped my plantar fascitis, which i had been struggling with for about a year. It’s the same thing…. it seems that the consistent vigorous circulation through the affected area probably opens up all the vessels, heats things up and circulates the lymph and blood in a way that helps the healing process. All of this is good as long as you are not pounding or doing aggressive motion to the affected area. These are my personal observations.

    As for icing…. instinctively I don’t like it. It’s such a shock to the body when the tissue is warm. I usually don’t do it because of the initial discomfort.

    Michelle wrote on May 22nd, 2015
  9. I just found this since I am having tendon problems (elbow). Chinese medicine offers some solutions. I will not name the herbs but will suggest you ask a Chinese herbal practitioner.

    Dan wrote on July 12th, 2015
  10. Hi there,

    Four weeks ago I fell down stairs. My knee instantly swelled up and I felt a tearing sensation. Went to A and E immediately. They wanted me to do a straight leg raise which I couldn’t do. Had an xray and was told I had fractured my pstella. Sent home with a cast on my leg. Two weeks later had an ultrasound and was told nothing was torn or ruptured but did have a hairline fracture in knee. Following week, now three weeks from fall was told now I dont have a fracture at all and dont need to wear splint any longer. Was told to ice, rest and need to get muscles working again and an appointment with physio.

    So my knee is still swollen, painful, hurts to bend, bad strain maybe ?

    One week out of splint I have been using ice pack three times a day and having a daily bath with epsom salts. Knee still swollen but is slowly going down. Not sure what is working but feel something is slowly. Didn’t need to be in a splint for three weeks as there wasn’t a broken bone, so would I have been on the way to recovery by now.

    Tina wrote on May 3rd, 2016

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