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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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December 04 2012

Should We Ice Injuries?

By Mark Sisson
105 Comments

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-1? (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.

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105 thoughts on “Should We Ice Injuries?”

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  1. 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.

    1. 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.

  2. When I started Crossfit,ice didn’t help a lot but upping my Omega 3’s helped a ton.

    1. 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.

    2. interesting point. maybe teams should O3 together rather than ice bath, or whatever_____ insert tradition ____here, they think is helping their team do well

  3. 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?

    1. 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.

    2. 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.

  4. 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!

    1. 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.

      1. If he managed to sprain both at once, I am more interested in the story about HOW.

        1. 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.

    2. 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.

  5. 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.

  6. 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

  7. 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!

    1. 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.

    1. 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.

  8. 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!

    1. 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.

    2. I spray tight joints or my back with magnesium solution and make a point to have epsom salts in the bath.

  9. 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.

    1. 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.

  10. 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.

  11. 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 🙂

  12. 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.

    1. 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 :))

  13. 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.

    1. It’s very refreshing to get a “it’s complex and kinda ambiguous” answer on the ‘Net.

  14. 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.

  15. 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.

    1. 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.

      1. 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.

  16. 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.

  17. 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.

  18. 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!!!

  19. 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.

  20. 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.

  21. 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.

    1. 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!

  22. 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.

  23. 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.

  24. 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.

  25. 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..?

  26. 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

  27. 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.

    1. 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!

  28. Definitely prefer compression over icing. Icing has never really helped with my previous injuries, but all other aspects of RICE (including moving once I’m able to) definitely do make a difference!

    I went from a sprained ankle to starting P90X in 2 weeks without icing last summer!

  29. What about heat packs?

    I tend to get a sore neck fairly often (I know, I should upgrade to a better pillow, but what? I use memory foam for now).

    I’ve found heat packs really help reducing the pain and increasing range of motion quicker. Any science behind this?

  30. As a 62 year old woman who has been unfit most of her life and who has just taken up some vigorous exercise I have an interest in reducing post-exercise pain. I tried heat but found it made the pain much, much worse. Ice and cold baths reduced the pain considerably. But by far the most useful has been to wear compression garments during the excercise and for 90 minutes post exercise and to keep moving slowly and deliberately off and on over that time. The garments also stopped me putting on 200-500 grams in weight post exercise which was probably the waste lymph being stuck where it shouldn’t have been. Its thumbs up for the compression garments from me. I’d also compress post injury now rather than focus on the ice.

  31. Great article, great discussion.

    We continue to work hard to manage our athlete’s and patient’s swelling without ice. These protocols are particularly important to many of my tactical solider athletes working in hot, dry, austere environments without an icing option.

    Humans are such extraordinary healing machines that I’m sure we will continue to heal ice/no ice.

    Some bright friends have pointed out that an evolutionary argument isn’t a very good one. I do continue to question whether every human being’s inflammatory response to injury is a mistake that we should try to mitigate through icing.

    We are filming a follow up soon.

    Thanks for the comments everyone.

    Kstar

  32. in treating gout over the years I have not had success in reducing pain or inflammation until recently a physiotherapist introduced me to compression,cold-hot water therapy and light cycling to get the blood moving.Icing and elevation did not help at all.If the attack is severe the only relief is anti-inflammatories.At another time I will write you a success story because primitive blueprint program has relieved my gout completely for one year without use of any medications during the year.

    1. Terry, I am also a gout sufferer and will be very interested in your program.

      Frank

      1. Hi frank
        By chance I met a wellness practitioner who also a gout sufferer,recommended to stay away from nightshade vegtables.I eliminated them in January of 2012.Before this I followed the normal gout recommendations from doctors and websites but had no success.I have suffered more than usual in the last 3 years up till 2012.I used colchicine and indomethacin for relief but only when needed.In 2011 I seemed to have to rely on using them more often and always had pains in right foot even while not incurring a full attack.
        Back to January 2012.While doing some research on nightshade vegtables I stumbled on dr,mercolas website which led me to reduce my grains to rice and corn up until August of 2012.I could not believe the results myself.I have not required any meds except 2 days in July.For the rest of the time I have incurred no pain whatsoever.Wow I was excited!I decided to take it a step farther,which led me to paleo which in turn guided to Marksdailyapple .In August I adopted the primal blueprint program and have lost 20 lbs .
        My feet feel even bit better and no pain or meds since August.I am even eating some red meat again and had a couple of glasses of red wine!
        Hope this helps you and other gout sufferers.I have lived with it for 20 years.I am 52 but feel like20 again.

  33. I’m a midwife’s assistant…there is much conjecture about the use of ice versus warmth for the perineum after childbirth. Care to weigh in?

  34. I have found with my 30+ years of teaching first aid and over 20 years delivering it (firefighter/EMT) that ice alone does wonders for lessening pain and bringing down swelling. When we bring patients into the hospital with a strain, sprain or break the doctor will always say, “Keep iceing that until the swelling is gone so I can put a cast/splint device on it properly”. I do recommend RICE to all of my students when they are treating a minor injury themselves. I have also seen ice bring down the pain greatly with patients that can’t tolerate pain medications. I work in a busy suburb of Chicago and have also administered first aid often during my 6 years in USMC so I must have used ice (cold packs mostly) over 1000 times, seldom using compression until after doctors treatment. Is that a big enough test group? I’ve used ice and later compression on myself about 25 times over the last 35 years for various swelling injuries, and found it to work well and I heal quickly.

  35. A very good analysis. I have been in athletics to varying degrees since high school and college, mainly gymnastics then and tennis and weightlifting now, and it seems to me that the lymph “pumping” is related to the movement of the surrounding areas. So compression is part of it, but so is, as you propose, the gentle movement.

    I stopped icing injuries long ago. It seems to me that nature did not intend us to ice our injuries. The idea that all inflammation is bad is, as you suggest, simply misguided. The pain after an injury prompts us to restrict movement. That is most likely an adaptive issue as well. But you still need to keep moving. NS pressures for continued movement (finding food and self-defense, etc) would apply to all sorts of creatures before people.

  36. 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.

  37. 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!

  38. Hans Kraus. Read his stuff – move, move, move after injury. Great results.

  39. 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.

  40. 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!

  41. 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.

  42. 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.

    1. 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.

  43. 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.

  44. 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… MedicalHealthArticles.info
    thaks

  45. Tiger balm and compression if you’re a masochist .

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

  46. 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.

    1. 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.

  47. 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.

  48. 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.

  49. 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. 🙂

  50. 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…

  51. 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? 🙂

  52. 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…

  53. 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.

  54. Now, what about icing burns? I would think that, at least at first, it would draw the heat out and help to prevent blistering.

  55. 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.

  56. 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

  57. 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..

  58. 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…

  59. 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.

  60. 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.)

  61. 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!

  62. 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.

  63. 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.

  64. 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.

  65. 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.

  66. 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?

  67. 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.

  68. 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.

  69. 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.

  70. 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.