Hands up if you try to do the right thing and ice an injury?
Even if you don't, it's widely known you probably should. After all, decades of Sports Medicine have consistently told us this.
Icing an injury has been so popular for so long that it's essentially something we do without really thinking too deeply about. Mainly because it really doesn't feel like we need to.
But as the great Bob Dylan once said "The times, they are a-changing."
Thanks to some really good thinkers the post-injury management landscape is changing. So much so, that it may be time to reconsider using ice to treat your sprain or strain.
Interestingly, this traditional post-injury ritual may, in fact, be taking us in a completely different direction to where we need to be if chasing optimal recovery time and results.
As a Physiotherapist, I stopped using ice to treat injury over 5 years ago now, and I couldn't be more impressed. I've seen such a dramatic reduction in recovery time across the board.
But don't take my word for this, let's discuss why you should consider giving ice the cold shoulder as well.
The History of Icing an Injury
Before we can challenge decades of traditional ice-related thinking, we need to appreciate why we do it - and have done it for so long.
As most will know, we often ice an injury based on the RICE method - the most recognizable protocol in Western Medicine. R.I.C.E stands for rest, ice, compression and elevation and is used post-injury in the hope of promoting faster healing and return to sport.
The RICE acronym was originally created by Dr Gabe Mirkin - a Doctor of Sports Medicine from the University of Harvard over 40 years ago. It appeared in his best-selling Sportsmedicine book way back in 1978.
And it has stuck ever since.
Going back a little further, Gary Reinl, author of Iced: The Illusionary Treatment Option and self-proclaimed "anti-ice man", suggests our love affair with ice evolved from one specific incident over a decade earlier.
In 1962, 12-year-old Everett Knowles was boarding a freight train in Somerville, Massachusetts. He was involved in an accident that completely tore his right arm from his body. What followed was the first successful reattachment of a severed body part.
During this process the severed arm was put on ice for preservation, and a tourniquet was placed on the area and elevated to restrict further blood loss. The boy was also told to remain calm and rest - the very foundations of today's RICE protocol.
It's suggested these details were then presented to the public for future reference and have slowly morphed from a severed limb action plan to what it has become today - an attempt to speed up the healing process.
Now it's used by everyone from recreational athletes to professional sportsmen and women. It's also part of most post-surgical protocols and the foundation of every first aid course.
There's now an ice pack in almost every first aid kit and many home freezers.
Why We Ice an Injury
Keeping the above in mind, the following are usually the four reasons we ice an injury:
- reduce swelling
- reduce inflammation
- pain relief
- we know we should
And we do this under the guise of the RICE protocol:
- Rest from activity
- Ice applied for 15-20 minutes
- Compression on at all times
- Elevation of the injured area above the heart
- Pain relief and anti-inflammatory medication often accompany the RICE protocol
Ice is known to be a very useful pain reliever and effective at restricting blood flow through vasoconstriction of blood vessels.
And on the surface all of this makes sense. Once injured, we want to prevent as much swelling, inflammation and pain as possible in order to kick-start our journey back to full health as soon as possible.
But here's the thing.
The above ideas don't match our physiology. In fact, when you take a step back we run into two major issues:
- What we're trying to achieve with ice almost directly contradicts what the body is trying to do post-injury.
- Not only may ice fail to speed up the healing process, but it may actually be slowing it down.
And if you consider we often ice because it's either something we've always done or something we feel we should do it may be time to re-think the need for it entirely.
The Body's Natural Healing Response
To highlight why ice may no longer have a role in acute injury management, let's look at what actually happens to the body during the healing process.
Interestingly, the pain, swelling, and inflammation we try so hard to prevent or reduce with ice are integral to the body’s natural healing response. So much so, that without something like inflammation, there is no healing at all.
The Stages Of Healing an Injury
The healing response is a cascade of events that instantly occur post-injury. It's the body's way of solving a problem and there are two general stages:
The first phase is the inflammatory response initiated by our immune system.
From a vascular perspective, we see blood clots and vessel constriction to stem the flow of bleeding from damaged tissue. Simultaneously we see dilation of the healthier, surrounding vessels to allow the body's "clean up crew" to do its work. These cells facilitate the repair and/or removal of damaged tissue.
One of the by-products of this initial inflammatory reaction is swelling. Despite what many think, swelling is neither good nor bad. It's just the build-up of waste yet to be evacuated from the area. It also helps to splint and immobilize the injured area and temporarily reduce surrounding muscle activity.
Pain is another feature of the inflammatory process. Local nerve endings become sensitized thanks to the brain's perception of threat and the compression of the injured tissue by swelling.
Pain is there to help us understand what we can and can't do with the area.
For these reasons, it's typical for an inflamed area to feel hot, look red and swollen and be tender.
The first phase traditionally takes a week depending on the injury and how well we manage it initially.
2. Tissue Repair and Remodeling
The next stage involves regeneration and remodeling of the injured tissue.
We see scarring, wound closure and new blood vessel growth as things progress.
As the days/weeks go on newly repaired tissue remodels itself to respect lines of tension and loading. This helps optimize the function of the once-injured area.
So as you can hopefully appreciate, the body has a very particular response to an acute injury. One that happens each and every time damage occurs.
Things That Can Affect the Healing Process
Although an automatic response there are things that negatively affect the healing process:
- more trauma
- poor sleep
- chronic stress
- other diseases like Diabetes etc
- anti-inflammatory drugs
So with all this in mind, it raises a very important question.
If we are very clear on the reasons why we ice an injury, yet those reasons contradict what needs to happen for the injury to heal, why is ice so popular?
Let's break down this disconnect.
Why It's Wrong to Ice an Injury
In everyone's defence, using ice to affect swelling, inflammation, and pain does make sense on some level - particularly if we see them as bad. But a small shift in perspective clearly shows us that we genuinely need swelling, inflammation, and pain for basic healing.
Dr. Ledbetter, a leader in the field of understanding the inflammatory process suggests there can be inflammation without healing, but never healing without inflammation.
In other words, we have to enter the tunnel at the inflamed, swollen stage in order to successfully exit at the healing stage. Otherwise, there's no healing.
Furthermore, attempting to influence these factors with an ice pack suggests we think the body has it wrong and/or we know better.
And when you look at what ice does and compare it to what needs to happen, it may, in fact, slow down tissue healing not speed it up.
Ice Delays the Healing Process
Our physiology speaks for itself here.
Here's what happens to the healing process when you ice an injury:
We know ice restricts blood flow. But this blood flow carries cells that support the inflammatory process needed for healing. We also need to appropriately evacuate any waste as well.
The harsh reality is that as soon as we remove the ice and the tissue re-heats, the inflammatory process continues anyway. So why the need to unnecessarily delay what should (and will) happen?
Much like putting a tube of toothpaste in the freezer, ice makes congestion harder to remove.
Furthermore, Gary Reinl suggests ice can make surrounding cells more 'leaky' leading to greater congestion and swelling - not less.
So not only may ice delay the inflammatory process but it may also decrease the body's ability to effectively remove waste and congestion.
Icing for pain relief is a noble cause because it works. Ice does decrease your ability to feel pain.
But at what cost?
Pain clearly defines what we can and can’t do. Icing for temporary pain relief makes it difficult to know what is OK to do and how much is too much.
Having said that, there is a place for pain relief. If pain prevents you from sleeping, affects you mentally or impacts your life in other areas, by all means, consider it. You don't have to be a hero. Just use ice for the right reasons and be aware of the associated consequences.
It's worth noting that pain will reduce once we remove the swelling, so it makes sense to invest your attention there as well.
Ice may actually increase cell death post-injury. Our cells need blood flow to survive and it's well known how ischemia (reduced blood flow) can create accidental cell death.
We know ice reduces blood flow, so it's much harder for those cells to receive that literal lifeblood if we're delivering less life-giving blood.
So as you can hopefully appreciate we are potentially getting in our own way here by using ice to treat an injury.
As pain, swelling and inflammation are necessary responses to an acute injury, why then do we apply ice in order to stop/prevent the above from occurring?
At this point, it is vitally important to be clear.
We do not want to disrupt these normal processes – they will happen either way. Instead, we want to assist our body in its ability to move through these processes quickly.
When It's Appropriate to Ice an Injury
Interestingly, there are still times when using ice makes sense.
But it all depends on your immediate goals.
Take Boxing for example.
It makes sense to apply ice for something like a nasty cut above your eye.
Why? Because in this specific instance, you do want to try and delay the inflammatory response. It's in your best, short-term interests to see from that eye for the rest of the fight.
The difference here is that the immediate goals outweigh any long-term consequences. Once the fight is over, the role of ice would diminish. If the Boxer was trying to recover as quickly as possible for their next fight, ice should be avoided.
Similarly, if you dislocate something it may make sense to try and limit as much pain, inflammation and swelling so it's easier to relocate later on.
This is also why ice made perfect sense back in 1962 to preserve Everett Knowles' severed arm. There was clearly a more pressing need. Again, ice should no longer have been used once the arm was re-attached and healing became the bigger priority. But here we are anyway.
Why We Should Stop Using RICE
As with ice, here are some things that need clarification with the RICE method.
We know the only way swelling can be removed from an injured area is via the Lymphatic System. We also know this system is completely passive. It needs muscle activation and movement to pump congestion away. Rest and disuse clearly don't achieve this. Furthermore, the body needs movement and load to help realign and re-organize repairing tissue and to stop muscle atrophy. Again, rest doesn't help this at all.
As we've already mentioned, ice may, in fact, delay almost everything to do with the healing response. It may contribute to greater swelling and increase local tissue death despite being an effective pain reliever.
The idea of compression for swelling also needs discussion. Not only does local compression limit the movement of fluid coming into the area but it will also limit the movement of fluid going out as well. It's impossible to selectively compress the 'in' vessels and not the 'out' ones. Compression bandages, compression socks, and stockings may not be the most effective way to overcome swelling.
Again, we know that swelling is the accumulation of waste at the end of the inflammatory cycle and it needs a clear path out. Compressing these vessels doesn't facilitate this. The negating effects of compression become even more profound when we add rest to the equation. We double down on ways to limit the removal of swelling.
Remember the accumulation of swelling doesn't mean the body has produced too much. Instead, it means there's a failure to appropriately evacuate the swelling that's there - so it pools.
Elevation makes sense, but it also doesn't. We elevate to help the removal of swelling, but it also makes it hard for blood to flow where it's needed.
Have you ever stood with your arm up in the air for a few minutes? It doesn't take long for blood flow to be affected. Remember, we need to let the body do what it's already trying to do. It knows how much blood needs to get to the injured tissue for efficient healing - we don't.
We can optimize swelling removal with other techniques that don't come with side effects.
While not an official member of the RICE protocol, we often associate anti-inflammatory and pain-relieving drugs with acute injury management. But as you can now hopefully appreciate, they shouldn't be. We need pain and inflammation for optimal healing. Medication may provide temporary relief from pain and discomfort but will ultimately drag out your recovery at the other end.
As with ice, there are situations where subduing pain and inflammation can help. But they should never be used in place of other measures (we'll get to these in a minute) without being aware of the added consequences to recovery time.
Dr. Gabe Mirkin Changed His Mind
Perhaps the most compelling reason to stop following the RICE protocol comes from Dr. Gabe Mirkin himself. Dr. Mirkin, who as you may recall coined the RICE acronym in the first place, has publicly changed his mind.
In an article published on his website back in 2015, Dr. Mirkin outlined his change of heart based on new insights and a broader perspective.
As of today he no longer recommends the use of ice for injury, and neither should you.
How to Best Facilitate Healing and Recovery Without Ice (and RICE)
As a Physiotherapist, it’s important to reinforce that I no longer recommend the use of ice for injury based on the above information. I’m not a martyr to the cause. But I am no longer a spokesperson on its behalf.
This shift in thinking makes perfect sense to me, but more importantly, my patients are recovering faster than ever before. Which is clearly the goal here after all.
All it took was becoming aware of and removing an unnecessary handbrake I didn't know existed.
By avoiding ice, we can now see injuries that typically take a month, and settle in as little as a few weeks. All just by assisting the body to do what it's always been trying to do - and not getting in its way.
With this in mind, we can finally get a sense of how long injuries should take to heal.
Having said that we still need an alternative to ice. After all, this isn't a conversation about ice vs nothing.
Thankfully there are many effective options to choose from. So much so this conversation is almost moot anyway. Even if ice did as advertised, we probably don’t need to use it anymore.
1. Responsible Pain-Free Movement
The body relies heavily on muscle activation to remove swelling and congestion. It's the reason why ice, rest and compression fail as adequate options.
Clearly, too much movement has to potential to be just as disadvantageous as too little, but do what you can as soon as you can. The buzzword here is 'relative rest'. Do what you feel you can do responsibly.
This is also why we want to avoid pain relief if possible. We want to be right up against your comfortable threshold for movement without encroaching on pain.
The challenge is to find that balance based on your injury.
Here are some ideas:
- A crutch, walking stick, or moon boot will allow you to find your comfort level of loading without going overboard.
- If you can't weight bear, you can still wiggle your toes and tense muscles. It doesn't matter what you do as long as you do it often and it doesn't hurt.
We need to find a way to engage your passive Lymphatic system, otherwise swelling will pool, muscles will atrophy and healing will be delayed.
This one's a given but needs clarification.
Some feel massage isn't appropriate for an injured area. It absolutely is but I find the right type of massage is key. A gentle, more superficial massage is fantastic to help flush out congestion in the area. Particularly involving the surrounding tissue.
Anything deep or involving the damaged tissue specifically needs to be avoided initially.
Massage also has the secondary benefit of reducing pain. As mentioned before less congestion means less compression of injured tissue. Similarly, an appropriate massage will also make your body feel less threatened and more relaxed - a key feature in the amount of pain you experience.
From what I see clinically, massage and getting the injured area moving in a respectful manner make all the difference to optimizing healing. Beyond these basic ideas, there are a few more things that deserve your attention.
3. Voodoo Floss
Voodoo Floss is an amazing recovery tool popularized by American Physical Therapist Kelly Starrett. It uses strong elastic compression and respectful pain-free movement to facilitate faster recovery.
The idea here is to wrap up the injured area so it's comfortably tight. Then it's just a matter of actively bending, moving and 'flossing' the injured tissue while compressed for just a minute or two.
The Voodoo Floss bands are fantastic for freeing up glued-down tissue, assisting the removal of swelling and re-perfusing damaged tissue all within your limits of pain and mobility.
It's genuinely one of the most valuable techniques I've ever seen or used. It's important to note I have no affiliation with the brand itself, I'm just a fan of what short intervals of compressed flossing can do.
Having said that it's important to distinguish Voodoo Floss from less-than-ideal general compression. The Voodoo Floss bands have a specific and extremely short-term application. Its intense compression, strong elasticity, and movement-dependent use effectively supercharge waste removal. We also need to respect its relative intensity so that we don't aggravate the damaged tissue. You may do additional damage if you go too aggressive (too tight, too much movement, done for too long) but common sense should help you avoid these issues.
If you don't have a Voodoo Floss band, a theraband or old inner tube from a bike tire will also help. But do it and get a sense of how good it is. Just know it’s appropriately titled.
4. The MARC Pro
Another game-changing piece of rehab equipment is a muscle stimulation machine - the most notable of which is the MARC Pro.
Machines like the MARC pro use the strategic placement of electrodes to gently stimulate low-grade, non-fatiguing muscle contraction. Again, the passive Lymphatic system needs muscle activation to facilitate swelling removal. A muscle stimulator can gently tense and relax these muscles for hours.
5. Deep Breathing
If you've been a Your Wellness Nerd follower for a while now, you'll have heard me reference the Wim Hof Breathing Method quite a bit. I've been playing around with his breathing technique for a number of years now while exploring what else it can do for my patients and I.
Interestingly, deep breathing may help us reduce pain and promote faster healing via nervous system down-regulation, hyper-oxygenation, and basic focus.
The idea is simple. Take 30-40 deep breaths (as per Wim's breathing protocol) and supercharge your body with oxygen. After taking your final breath in, breathe fully out and stay there until you feel ready to breathe in again. This can be anywhere from 30 seconds to 3 minutes and above depending on the person.
When in this exhaled state place your hand over the injured area and focus on it. Think of sending all that new oxygen to the damaged tissue to help the repair. After literally a few seconds you may start to feel the area pulse. Rinse and repeat as many times as you can. The more you can direct your body's resources to the damaged area, the faster things may proceed.
Similarly, conscious deep breathing has the added bonus of being able to down-regulate our nervous which becomes instantly heightened when pain is involved.
I certainly acknowledge this can seem a little weird but give it a go for yourself. I'm rapt with the results I'm seeing.
Frequently Asked Questions
RICE stands for rest, ice, compression, and elevation and is currently the most widely recognized and performed acute injury management protocol in the world. This is despite the man who invented the phrase - Dr. Gabe Mirkin, recently coming out and stating he no longer believes this to be useful
We've long thought that ice 'helps' inflammation, mainly because we see it as 'bad'. But our physiology tells us something different. Inflammation is not only normal but vital for healing to occur. We are better off letting the body do what it's trying to do rather than interfere with superficial ice application.
In a word, no. We've long thought that ice does speed up healing by limiting swelling and inflammation. However, these processes are actually needed for healing to occur. Using ice to treat injury is similar to pressing pause on the healing process, thus actually making it take longer than it should.
The current recommendation for how long to ice an injury is 15-20 minutes every 2-3 hours, for the first 2-3 days. But as you can now hopefully appreciate, we seriously need to consider whether ice has any role to play in acute injury management at all.
In a few words - not really. While certainly not ideal and most likely counterproductive, ice should not be demonized. If used respectfully it won't hurt you and it won't stop your injury from recovering anyway. It'll just delay things unnecessarily. There are many valuable uses for ice but these no longer relate to speeding up the healing process. It's not bad, it's just not ideal.
In specific moments when icing an injury is appropriate (see above), it's best to wrap your ice pack in a damp cloth or towel. This allows for better cold transference. Breaking up the ice will also help it conform to the injured area.
There are many benefits to an ice bath - none of which relate to faster healing from injury. An ice bath has a fantastic ability to engage the Parasympathetic nervous system. This is advantageous for better sleep, decreased stress and overall recovery. A recent research article suggests something as simple as a cold shower can lead to fewer sick days from work. But an ice bath has the same negative effects on our tissue as an ice pack. So we should avoid it where possible when recovering from injury.
An ice bath will still dampen vascular and muscular adaptations despite being commonly associated with post-workout recovery. Like an ice pack, it has the ability to decrease blood flow and impact inflammation - leaving it a sub-optimal technique to use.
With this in mind, it's best to engage with an ice bath as far away from the training stimulus as possible. Perhaps the next morning instead. This way you've been able to sleep and optimize recovery whilst still down-regulating the nervous system.
The body knows what it's doing. Technically there is no such thing as "too much" swelling, just the amount your body deems appropriate given the circumstances. Remember, swelling is the accumulation of waste at the end of the inflammatory cycle. If there's more swelling than expected, perhaps it's better to ask why the swelling is not being removed as effectively as it should be. Usually, the answer comes back to the ice of ice, and a lack of adequate movement.
Until recently, this was the topic of good debate. Now, with our advanced understanding of the effects of ice on injured tissue, it's at least a little clearer. With ice off the table, it's important to discuss what role, if any, for heat.
As it stands there aren't too many reasons to use heat either. Clearly heat will increase blood flow to the injured area, but in a similar vein to ice, we don't want to dictate terms to the body. By heating an injury we run the risk of driving too much fluid to the area. This is problematic if we don't also increase the rate at which we remove that fluid. Otherwise, we'll see increased swelling and delayed progression of healing.
A heat pack is fantastic to help loosen stiff, tight and generally dysfunctional areas. But it's not recommended for use on damaged tissue. Interestingly heat may be useful for chronic swelling, but as always, movement trumps all in the ice vs heat debate.
DOMs or delayed onset of muscle soreness is a label for next day discomfort after exercise. Local ice is not recommended based on its ability to delay the healing process further. Massage, gentle movement and muscle re-activation are far more beneficial to optimize recovery.
Elevation is important to assist in the optimization of waste removal from the injured area. As mentioned above, the body relies on the passive Lymphatic system to remove the swelling. Using gravity can help facilitate this process.
Compression socks and stockings are potentially disadvantageous despite how common they are. We know compression stops the flow of fluid to an area, but we forget it also restricts the outward flow as well.
The only way fluid can be removed is by the Lymphatic system - a passive system reliant on muscle activation to work. As a result, we need movement to best clear swelling, not immobility and general surface compression.
Despite decades of use, it's time to reconsider your stance on icing an injury.
This topic is certainly controversial in my field. Not because it isn't true, but because it challenges decades of rusted-on thinking in an industry of rusted-on thinkers.
We know what ice does to the body yet this directly contradicts what the body is trying to do when healing. It may, in fact, be doing the opposite.
There are times when ice can be used effectively, but these are special circumstances where optimizing and preserving immediate short-term function takes priority. They are not the norm.
For what it's worth I used to be an advocate for icing an injury just like everyone else. But now I'm not and I couldn't be happier with the results.
It's important to reinforce that this isn't a conversation about ice vs nothing. It's not anti-pain relief either. Ultimately, it's about recognizing the need to challenge our thinking when faced with a new perspective. Thankfully there are far more effective replacement options.
We've never really had the need to question this too much because people do get better at the end of the day. But as you can hopefully see by now, it isn't because of ice, it may actually be despite it.
So let's leave the ice for a well-earned margarita and enjoy those faster recovery times!
What's your opinion on using ice to treat an injury? Let me know in the comments below!