Updated: Mar 24, 2020
No seriously, STOP!! What's the most common thing we do when we sprain an ankle or strain a muscle...…..we ice!
Now before you throw your hands up in disbelief and scream at the top of your lungs how ridiculous that statement is, hear me out. Ice is not what you think it is. It is NOT helping the healing process from injury and in fact, an overwhelming amount of research shows it does the opposite! Other than temporarily numbing the sensation of pain, ice delays healing and recovery. But before you take my word for it, let's take a deep dive into the history of icing and why its use became "conventional wisdom"
From a young age, we're taught that if something hurts, you put ice on it. If you sprain your ankle at footy practice, wrapping a bag of ice tightly around the injured area is the first step to feeling better! We do this because we've been told icing helps reduce harmful inflammation and swelling and even kick starts the recovery process after intense workouts.
It's not uncommon today to see the best athletes in the world post-game interviews with bags of ice wrapped around their knees or shoulders. With a simple Google search, you can easily find photos of Michael Jordan with ice on both knees. Of course, we all started to use ice! As the saying goes, we all wanted to "be like Mike."
As a high-level rugby player, I commonly used ice on my sore body after intense training sessions and games where my body has been put through the rinser. I was told this was a "normal" part of being a top athlete. We would even jump into ice baths after games to help kick start the recovery process....or at least that's what I thought I was doing!
In the rehab world, physios, chiros, and osteos use ice every day in the clinics and training rooms across sports. In my early career as a Soft Tissue Therapist, it wasn't uncommon that every one of my patients would get a cold pack wrapped tightly around their injury after their session - to help "reduce" swelling!
However, the profession that has been using ice the longest is the medical field. Published articles dating back to the early 1940s explain that doctors would commonly use ice to help decrease infection rates, block pain and reduce the rate of dying on the operating table during amputation surgeries. This is because ice slows down cellular metabolism, allowing surgeons to keep as much muscle tissue alive as possible. While ice was originally intended to preserve severed limbs and decrease complications in the operating room, it would eventually sneak its way into being used for ALL injuries! For decades this has been the go-to method to quickly fix our injuries. The popular term that was invented is called RICE. RICE is a mnemonic acronym for four elements of treatment for soft tissue injuries: Rest, Ice, Compression & Elevation. The mnemonic was introduced by Gabe Mirkin in 1978. He has since recanted his support for the regimen. In 2014 he wrote, "Coaches have used my 'RICE' guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping. In a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. Although cooling delayed swelling, it did not hasten recovery from this muscle damage."
Now if you were to ask a medical doctor today why they recommend ice for the common ankle sprain or backache, they'll likely say it helps alleviate pain, reduce inflammation, and restricts swelling. In fact, this is why some surgeons insist their patients use ice for months on end after surgery.
If literally everyone is using ice, how are we so wrong about it?
There is no denying that ice provides temporary pain relief. Slap an ice pack on an area of your body that is in pain and instantly you're going to start feeling better. In fact, if you look at the scientific research out there on the use of ice, a reduction in pain is the number one benefit! The ice helps to numb the injured area and decrease any kind of pain. But here's the deal - just because the pain is decreased does not mean you're fixing the injury. In fact, you're actually doing more harm than good. But, the main reason we use ice is to reduce or stop swelling. Our body's natural process of healing is to swell up, so in most circumstances, swelling is actually a good thing. We've always been told that inflammation and swelling are bad things that we need to stop as soon as possible. I'm here to tell you today that these are not bad things! The ice is stopping blood flow to the injured area, but it needs blood to help heal faster. Think of frostbite in your fingers, they are sooo damn cold, and blood is restricted to the area and so will eventually die! Once you get any kind of soft tissue injury the body is now in protection mode and the swelling is playing its part to shut down muscles and limit movement.
Ask any medical professional what the three phases of healing are and they'll all tell you the same thing: inflammation, repair and remodel. Don't believe me? Check any medical textbook and you'll find the same answer. Inflammation is the first stage of the healing process no matter the location or severity of the injury in the body. If this is a normal response to injury, why do we want to prevent it?
Plain and simple, healing requires inflammation. It is an essential biological response following an injury. While chronic levels of inflammation can clearly play a role in certain diseases (such as autoimmune disorders like rheumatoid arthritis or lupus), it is extremely beneficial to muscle regeneration directly after an acute muscle injury. In fact, a lack of inflammation blunts the healing process and contributes to poor muscle regeneration! This "blunting" of the healing process occurs when you use ice! But what about swelling? Isn't ice great for that?
If you ask any medical doctor 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. However, 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.
To make matters even worse, the way in which we use ice also has the potential for decreasing muscle strength and size! Remember the common protocol of RICE (Rest, Ice, Compression, Elevation)? When most people have an injury, they wrap a bag of ice tightly around the painful joint or muscle and stop moving. We do this because we've always been told moving the injury will cause further damage. However, immobilising your injury is actually doing more harm than good.
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 week period.
The reason swelling accumulates around an injured area of your body is because we stop moving! It's not because there is "excessive swelling" but rather because we aren't doing anything to facilitate lymphatic drainage to pull it away. Instead of trying to block swelling from accumulating in the first place by icing, we need to be proactive and work on improving the evacuation of the fluid and waste that does accumulate! No matter if you sustained a small injury like a sprained ankle or just got out of knee surgery to repair a torn meniscus, you need to turn your attention to evacuating swelling, not preventing it.
So, how do we facilitate this evacuation??
Remember when you fell down as a child and your dad yelled, "Walk it off!" It's quite possible that your dad was right all along about keeping it moving after getting injured. Too quick do we instruct athletes to shut it down completely after an injury. We do need to keep in mind, that moving too much and too aggressively may make things worse. The classic rolled ankle is a great example here as the best thing to do once this occurs is actually try and walk on the ankle ASAP if possible. Small pain and discomfort are fine, but if you are in a lot of pain, then obviously do not walk on it. This is more of a sign of some serious damage. Now if you are able to walk, this will allow the muscles around the ankle to contract and deliver more blood to the area, to promote faster healing. One thing to try and avoid is limping, as excessive limping can start to cause other issues further upstream in the knee and hips.
We still need to eventually get rid of the selling but in a more natural way. Injured tissue loves heat and movement as it helps to promote more blood flow to the injured site to aid in healing. Exercises performed in a relatively pain-free manner not only accelerate swelling removal through muscle contraction but also optimises the healing process without causing additional damage.
Now 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 the 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 following injury has countless benefits. To start, muscle contractions enhance the inflammation process by improving macrophage function (the clean-up crew) and allowing these essential white blood cells to removed damaged cells. It also boosts muscle repair and regeneration and limits scar tissue formation through the activation of stem cells.
So, we’ve touched on how ice can hinder the natural healing process after small and large injuries, but what about using ice after an intense workout?
Elite athletes around the world are always searching for the best techniques to accelerate recovery and gain an edge on their competition. In this continuous search, many swear by jumping in a cold ice bath or wrapping some ice packs across their legs after heavy training. Many athletes who claim that ice baths are the only recovery technique that allowed them to get through a high-volume squat cycle. But what does the science say?
When you have a hard workout, the muscles of your body sustain tiny amounts of micro-damage. This “trauma” sparks inflammation similar to what happens after an acute injury (like a sprained ankle). The rush of inflammatory cells to the site of “damage” help kick start recovery by first eliminating damaged cells. They then recruit stem cells from surrounding tissues to help repair and regenerate new muscle cells.
If you comb through the available science on the use of ice after intense workouts, the main finding is that ice baths decrease your perception of muscle soreness by changing how your body senses pain. As far as the effect of ice baths after training on recovery of performance on your next session, research is split. Some studies show a 5 to 10-minute plunge can assist with performance during the next training session, some say it has no effect, and a few studies even say it can be detrimental.
Periodic use of an ice bath may assist some athletes when they need to quickly recover from their performance between same-day training sessions and competitions. However, in the long term, regular use should be cautioned as the continued use of ice can be harmful to the natural adaptation process for developing muscle strength and hypertrophy.
Let me explain why:
Muscle soreness and muscle fatigue are not the same things. While you may feel less soreness after icing, you’re not necessarily recovering any faster physiologically. Remember there is a reason for soreness. It is a normal reaction to intense training just like the inflammation cycle is to injury. However, the more accustomed an athlete is to a particular style and intensity of training, the quicker they naturally recover between sessions and the less soreness they feel.
This is why you feel so sore you can barely stand up from a chair the first day following a high-volume squat session. However, two weeks into the same training cycle you don’t feel nearly as sore following similar workouts. Your body learns to adapt to the training stimulus (this is called the repeated bout effect). This is why a majority of research on elite athletes has shown ice baths to not help at all with recovery and performance.
In fact, multiple research articles have shown that ice will actually interfere with the normal adaptive response to exercise that helps us recover and gain strength. Here is a direct quote from one such research article published in the Journal of Strength and Conditioning Research, “These data suggest that topical cooling, a commonly used clinical intervention, seems to not improve but rather delay recovery from eccentric exercise-induced muscle damage."
Unless you’re looking for that instantaneous bounce-back the day of a competition, you should be very cautious of the long-term effects of ice on recovery. When you really take time to look at the science, using ice after a workout has the potential in the long term to stunt the process for muscle growth and strength gains.
Instead of reaching for that ice pack or jumping in a tub filled with ice, I recommend using an active recovery approach. This can involve going for a short 10-minute walk, performing a light workout of bodyweight squats, or even going for a swim or a bike ride (basically getting off the couch and doing any non-fatiguing exercise that gets you moving and your blood pumping).
If you’re extremely sore the day after an intense workout, I recommended performing a few minutes of soft tissue mobilisation. Research has shown a few minutes of rolling on a foam roller or mobility ball can significantly reduce delayed onset muscle soreness (called DOMS).
If by now you still aren’t convinced that the benefits of ice have been completely overblown and flat out wrong in many cases, I offer you one last piece of evidence.
Every year a group of authors who are experts in the treatment of acute injuries gather and comb over the current scientific literature and establish position statements for the National Athletic Trainers’ Association (NATA). In 2013, they released one such statement on the recommended treatment for ankle sprains (an injury commonly addressed with the RICE protocol).
After evaluating all of the available scientific literature on possible treatments for ankle sprains, they assigned ratings from best “A” to worst “C.” Do you know which rating icing got? A big fat “C.” They even wrote that “strong clinical evidence for advocating cryotherapy is limited.”
Do you know the treatments that were assigned a rating of “A”? Functional rehabilitation! With this position statement, the profession that sees a majority of acute injuries among athletes acknowledged that icing is not as good as we all thought and rather the best form of treatment is moving and loading the injured area through rehabilitation exercise.
At the end of the day, our approach to treating injuries and soreness after training is quite simple. We want to get the good stuff in (white blood cells) and the bad stuff out (swelling that includes cellular debris from the damaged tissue). I hope by now you can see that this process is not optimized by using ice. You will never see a dog ice its leg after hurting itself, but somehow within a short period of time, they will be walking normally again!!