Written by Zenia Wood on the Physio Network
Ice is an extremely hot (or rather, cool) topic in sports medicine and acute injury rehab, and for good reason. The way we treat injuries is continually changing based on the most up to date research. Due to this, it’s no wonder there is confusion around whether ice is good, bad or indifferent for injuries. When someone rolls their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. Ice appears to be an ingrained part of the acute injury management process, but does this align with the latest research?
The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin (1). His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate healing. This initial protocol became deeply rooted in our culture and for 20 years we were ‘RICE-ing’ injuries before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE (2).
The reason for the changes?
Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery (3). But what about ice?
There is certainly a consensus throughout the literature that ice acts as a great analgesic (pain numbing agent) by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged from topical ice application. What we are much less certain of now then we were in 1978, is it’s healing properties. Anecdotally (and likely due to the analgesic effect) most people report ice makes injuries “feel better”, at least in the short-term. But what impact does immediately icing an injury have in the mid to long-term? In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his “’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping” (3). What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process (3).
Ice was finally revoked in 2019 from the injury management process with the latest and most comprehensive acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise) (4).
With all of this new-found evidence on the negatives of icing injuries, it begs the question:
‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’
I will however caveat this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function (5).
This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.
In these circumstances ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it (6). In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be of benefit in the early stages (or at all) during injury management.
So for now, based on the current research, I’d keep ice in the freezer for the most part. As we currently understand it, ice is less important than we once thought. The exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, ice may be beneficial in the early stages only. What then should be our primary focus?
Encouraging people to return to movement safely again, as soon as it is practical.
Nailsea Physio Thanks Zenia Wood and the Physio Network for providing this blog post.