From a young age we’re taught that if something hurts you should put ice on it. If you sprain your ankle at practice, wrapping a bag of ice tightly around the injured area is the first step in treatment. We do this because we’ve been told that icing helps reduce harmful inflammation and swelling, and even kick starts the recovery process after intense workouts.
In the rehabilitation world, physical therapists, athletic trainers, and chiropractors use ice every day in clinics and training rooms. In my early career as a physical therapist, each of my patients would get a cold pack wrapped tightly around their injury after their rehab session. As time has passed and research has progressed, I’ve stopped this practice altogether.
A Brief History of RICE
In 1978, Harvard physician, Dr. Gabe Mirkin, coined the term RICE (Rest. Ice. Compression. Elevation.) as the recommended treatment for sports injuries in his landmark ‘The Sports Medicine Book.’ Since then, the medical community has religiously used this protocol for the treatment of all acute injuries.
There is no denying that using ice provides temporary pain relief. The scientific research now indicates that pain reduction is the number one benefit of ice. However, just because your pain has decreased, doesn’t mean you’re helping the injury. In fact, you might be doing more harm than good!
If, literally, everyone is using ice, how are we so wrong about it?
Dr. Gabe Mirkin (the man who invented the RICE protocol) withdrew his original statement in 2013 in the forward to the second edition of “Iced! The Illusionary Treatment Option” by Gary Reinl. He wrote, “Subsequent research shows that ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury.”
Unfortunately, his withdrawal hasn’t spread as much as the RICE protocol did. There are still many professionals who swear by RICE, as well as the general public.
Inflammation & Swelling
We’ve always been told that inflammation and swelling are bad things that we need to stop as soon as possible. These are not bad things, however. Inflammation and swelling are normal responses to injury.
Ask any medical professional what the three phases of healing are and they’ll tell you the same thing: inflammation, repair, and remodel.
Inflammation is the first stage of the healing process, no matter the location or severity of the injury in the body. When injury occurs, inflammatory cells, called white blood cells, rush to the site of the injury to kickstart the healing process. Tiny cells called neutrophils are deployed to destroy bacteria. Macrophages come to remove the damaged tissue cells caused by the initial trauma. At the same time, these cells also release an anabolic hormone called Insulin-like growth Factor (IGF-1) into the surrounding area that sparks the next phase of the healing process, muscle repair and regeneration.
Placing ice on an injury essentially places a roadblock in front of the white blood cells trying to get to the injured area. This stops the natural inflammation process from occurring. While you think you’re helping the healing process, you’re actually delaying it from ever starting by preventing your body from doing what it needs to do.
But what about swelling? Isn’t ice great for that?
If you ask any healthcare provider why they use ice for swelling, they’ll likely tell you it’s because excessive swelling can lead to increased pain, decreased range of motion, and lengthen recovery time. This is true. If swelling is allowed to stay in a joint, it can have negative effects. Swelling itself isn’t a good or bad thing. It’s simply the end response of the inflammatory cycle. It’s what we do about it that makes all the difference.
Physiology 101
Following injury, the surrounding blood vessels dilate as part of the inflammatory response and the small capillaries surrounding the damaged tissue open to allow white blood cells to arrive. This rush of white blood cells out of the capillaries also pulls additional fluid into the surrounding tissue. Swelling occurs for a reason. It contains the waste byproduct of the initial damaged tissue. It has to be evacuated through an intricate network of vessels in your body called the lymphatic system.
Your body has a few different pathways to move fluid from place to place. Your circulatory system pumps blood cells and fluid to and from your heart all day long. This continuous transport system works day and night, when you’re resting and when you’re moving around.
The lymphatic system also runs throughout your entire body. The lymphatic system is completely “passive.” This means you have to make it work. When you contract your muscles, the lymphatic vessels deep inside your body are squeezed and the fluid within is forced to move.
Swelling is merely the buildup of waste around the injured area that, in time, needs to be evacuated through the lymphatic system. It is a natural response to injury that only becomes a problem when it is allowed to accumulate.
Ice does not facilitate clearance of swelling through the passive lymphatic system. While resting and icing may feel good in the short term, you’re actually trapping debris around the injury and stunting the natural healing process from occurring!
The Science
A 2011 study looked into the effects of ice after a muscle injury (one group received ice for 20 minutes following the injury, the other did not). The injuries were then closely followed for the next 28 days. The results were not what you would think.
During the first few hours following injury it is common to see macrophages flood the area. The researchers found several within the damaged muscle fibers of the “no icing” group. However, those who had been given ice showed almost no signs of macrophages.
At three days post-injury, the “no-icing” group already showed signs of regenerating muscle cells. Yet, in the icing group, these cells were nowhere to be found. At four days out, regenerated muscle cells were found in both groups but those in the “no-icing” group were significantly larger than those in the icing group.
At 28 days post-injury, the regenerating muscle of the “no-icing” group was 65% larger than the icing group. In addition, the researchers found significantly more scarring in the icing group compared to the untreated muscles. The authors of the study concluded, “Judging from these findings, it might be better to avoid icing, although it has been widely used in sports medicine.” Despite “conventional wisdom” that tells us ice is a good idea, research shows that ice actually delays muscle repair after injury and gives us direct evidence that ice can ultimately lead to increased fibrosis or scarring.
When you stop moving for an extended period, your body responds by shutting down the essential processes that regulate your muscle mass. For example, previous studies have estimated we can lose 0.5% of muscle per day and up to 5% in a weeks time. This shrinkage in muscle size (disuse atrophy) is one of the major complications following severe injuries and those that require surgery. (See our article “Blood Flow Restriction Training: A Physical Rehabilitation Game Changer.”)
In 2005, researchers conducted a meta-analysis (meaning a study of all available studies) on the use of cryotherapy directly after ACL reconstruction surgery. They concluded that the only benefit was in lowering pain. Icing did not improve how much the person could move their knee or lead to any decrease in swelling.
Swelling is, no doubt, a significant concern after any surgery (especially those in the lower body, such as an ACL reconstruction). When swelling builds in and around the injured area and remains, it can lead to a cascade of problems (decreased mobility, blunted strength, increase in pain, etc.). But remember, icing does not help facilitate the pumping action of the passive lymphatic system, which is the only way to remove swelling.
How do we facilitate this evacuation?
We move.
Exercises performed in a relatively pain-free manner not only accelerate swelling removal through muscle contraction, but also optimize the healing process without causing additional damage. It may seem counterintuitive that we want to move an injury, but that’s actually the best thing to do. Loading damaged tissue with proper exercises as soon as possible following injury actually accelerates healing of muscle and bone. The last thing you want to do is wait around and see how you feel tomorrow or the following day.
Performing pain-free exercise, or muscle activation, following injury has countless benefits. To start, muscle contraction enhances fluid movement, which is essential in the inflammation process, by improving macrophage function and allowing these essential white blood cells to remove damaged cells. It also boosts muscle repair and regeneration and limits scar tissue formation through activation of stem cells (called satellite cells).
Directly after injury, the goal with movement is to facilitate healing without causing additional damage. Exercise too intensely and place too much load on your body and you’re only going to make things worse. This is why it’s not a good idea to perform heavy back squats one day after spraining your ankle, or attempting to run 4 weeks after ACL reconstruction surgery.
Loading the body in a pain-free manner allows us to find the crossroads between efficient and safe recovery. One of the safest muscle contractions for acute injuries and post-surgical cases is isometrics. An isometric describes the action of muscle contraction without joint movement. Try this now. First, straighten your knee out. Then squeeze your quad muscle as hard as you can for 10 seconds. You just completed an isometric contraction for this muscle group.
In the early rehabilitation stage (1-4 weeks) following ACL reconstruction surgery, the smallest amount of muscle contraction can help remove swelling through the passive lymphatic system. This also prevents disuse atrophy by increasing muscle protein synthesis (helping you preserve muscle mass while you recover), and decreasing pain. This is why simple exercises like ankle pumps can be so helpful for athletes directly after sustaining an ankle sprain.
As pain decreases, load should be increased to facilitate optimal healing. For someone with knee pain, this may mean progressing bodyweight squats from partial depth to full depth, and eventually adding a weighted barbell.
At my clinic, we use Blood Flow Restricted Exercise to safely load patients. We have seen dramatic results with healing and prevention of disuse atrophy.
Ice is a good option if you’re looking for pain relief, but if you want to heal as quickly and efficiently as possible, skip the ice and try movement instead!
– Michael Siegenthaler, PT, DPT
References
Mirkin G, Hoffman M. The Sports Medicine Book. 1978. Little Brown & Co
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