Why Ice and Anti-inflammatory Medication is NOT the Answer

Icing a sprained ankle In July I posted a blog discussing The Overuse of Cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!

The Stigma of Inflammation:

Editor in Chief of The Physician and Sports Medicine Journal (Dr. Nick DiNubile) once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders; inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair, and remodel. You cannot have tissue repair or remodeling without inflammation.  In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1). Researchers headed by Lan Zhou, MD, PhD, at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated “overwhelmingly, NSAIDs inhibit or delay fracture healing” (2). And you want to stop this critical process of healing by applying ice, because inflammation is “bad”?

The Anecdotal Rationale for Ice:

Somewhere along the line the concept that ice facilitates healing became conventional wisdom. Sorry, that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.”  Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps work so well at removing swelling.

Inflammation is a necessary component in the first phase of phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of “Iced! The Illusionary Treatment option gave me a good analogy. Take two tubes of toothpaste, one is under ice for 20 minutes, the other is warmed to 99 degrees. In which tube will the toothpaste flow fastest?  It does not take an advanced physics degree to know that answer.

What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A study published in 1986 (yes, 1986, is old, but this is a foundational study) found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). Ice can increase swelling and retard debris removal!

The Acronym RICE is Bogus:

The acronym RICE is bogus in my opinion. First, Rest is not the answer. Rest does not stimulate tissue repair. In fact rest causes tissue to waste and can cause abnormal gene transcription of collagen tissue. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscle.

The other reason RICE is bogus is obvious; Ice. Ice does nothing to facilitate collagen formation. Ice will not influence progenitor cell development. Ice does not regenerate tissue. Ice does not facilitate healing – it inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.

Closing thoughts:

Bottom line, ice and NSAIDs are over utilized. I am not saying never, but I am saying ice is not a magical cure all that fixes everything and is required for healing. It is not the gold standard that it has come to be. My goal with this blog is to get individuals to stop and think before immediately turning to ice and NSAIDs. Is it really the best option? Is it necessary for this injury at this stage? I understand it is not the only form of treatment clinicians use, but ice certainly is the most heavily used. Go ahead, I will wait while you look at your treatment logs.

My goal is to get this trend reversed one clinician and one patient at a time. Have you seen the video discussion between Kelly Starrett, DPT and Gary Reinl? If not I recommend you watch it. It’s fascinating. I am glad to have expert minds like Kelly and Gary in this fight with me.

I ask health care professionals to do one thing, just try it. Pick one client with chronic musculoskeletal pain, skip the ice, skip the NSAIDs and try to use light exercise as a repair stimulus. Then, try skipping the ice on a client with an acute mild injury. The outcomes might surprise you. Great Thought Provoking Reads

  • NATA 2013 Meeting. **If you have access – read these**
    • Selkow, NM, Pritchard, K.  CRYOTHERAPY FOR THE 21ST  CENTURY: UPDATED RECOMMENDATIONS, TECHNIQUES, AND OUTCOMES. NATA 2013 Annual Meeting.
    • Dolan. New Concepts in the Management of Acute Musculoskeletal Injury. NATA 2013 Annual Meeting.
    • Johnson, M, Denegar, C. Mechanobiology, Cell Differentiation and Tendinopathy – From Bench to Bedside. NATA 2013 Annual Meeting.
  • Articles and Peer-Reviewed Literature
    • William JR, Srikantaiah S, Mani R. Cryotherapy for acute non-specific neck pain (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 8.
    • Block, JE. Cold and Compression in the Management of Musculoskeletal Injuries and Orthopedic Operative Procedures: A Narrative Review. Open Access Journal of Sports Medicine 2010:1 105–113
    • Hubbard, TJ, Aronson, SL, Denegar, CR. Does Cryotherapy Hasten Return to Participation? A Systematic Literature Review. J Athl Train. 2004 Jan-Mar; 39(1): 88–94.
    • Bleakley, CM and Davidson, GW. Cryotherapy and inflammation: evidence beyond the cardinal signs. Physical Therapy Reviews. Volume 15, Number 6, December 2010 , pp. 430-435(6).
    • Bleakley CM, Glasgow P, Webb MJ. Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting? Br J Sports Med. 2012 Mar;46(4):296-8.
    • Hart JM, Kuenze CM, Pietrosimone BG, Ingersoll CD. Quadriceps function in anterior cruciate ligament-deficient knees exercising with transcutaneous electrical nerve stimulation and cryotherapy: a randomized controlled study. Clin Rehabil. 2012 Nov;26(11):974-81.
    • Hubbard, TJ, Denegar, CR. Does Cryotherapy Improve Outcomes with Soft Tissue Injury? J Athl Train. 2004 Jan-Mar; 39(1): 88–94.
    • Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.
    • Takagi, R, et al. Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys. February 1, 2011 vol. 110 no. 2 382-388

**Update**:  I’ve had an enormous amount of feedback for this post. I greatly appreciate all of it – good and bad. I am adding this note in regards to an overwhelming amount of questions / comments about acute injury.  My response is yes, in many cases I would skip the ice for acute injuries as well!! What is the benefit to delaying the healing process? Some will say, “to prevent hypoxic death” or “to reduce pain”. There are other ways we can stop hypoxic tissue death that do not stop healing.  I agree ice has pain modulating effects. But to this I ask, at what cost are we reducing the pain? Is a temporary (30 minutes) pain reduction more important than healing? References

  1. Buckwalter, JA, and  Grodzinsky, AJ.  Loading of Healing  one, Fibrous Tissue, and Muscle: Implications for Orthopedic Practice. Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999.
  2. Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
  3. Haiyan Lu, Danping Huang, Noah Saederup, Israel F. Charo, Richard M. Ransohoff and Lan Zhou. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal. Vol. 25 no. 1 January 2011. 358-369.
  4. Guyton, AC and Hall, JE.  Textbook of Medical Physiology 10th Ed., W. B. Saunders Company. 2000.
  5. Meeusen, R. The use of Cryotherapy in Sports Injuries. Sports Medicine.  Vol. 3. pp. 398-414, 1986.

 

351 thoughts on “Why Ice and Anti-inflammatory Medication is NOT the Answer

  1. Joel Blackburn

    Ok. Another Devils advocate argument. I guess if you live in Alaska vs. Florida or Andes vs. Portland, your screwed when you get a injury? See the relativity of it all and the continuum aspect I mentioned earlier. For sake of argument, I will pretend that icing is utterly worthless which i don’t believe can be proved yet. The opposing argument would be is it really that harmful if at all?
    I’m an ER physician. I’m sure I’ve seen as much or more trauma than any of you on this blog. I Have yet to see ice make a problem worse. In fact, in many more cases now more than ever it is life saving and limb saving in the cases of limb amputation, drowning and cardiac arrest. So, as the detective in ace ventura said, and I paraphrase, I have to worry about that little thing called evidence. Not speculation. Show me a validated concrete study and I’m on board. Until then it’s business as usual. Otherwise, it’s like trying to convince my niece that vaccines don’t cause autism.

    Reply
    1. Joshua Stone Post author

      Joel,

      You are trying to compare ER-worthy trauma to the a lesser degree musculoskeletal injury like we see in athletes or the lay person. Never, in any of my posts, did I recommend not using ice for serious traumatic injuries. I have found no evidence to mention such a thing. In fact in later articles, I have noted that evidence does support the use of ice S/P ACL reconstruction for 48-72 hours. Again, I am not referring to traumatic issues.
      I respect you as an ER physician. I agree you have seen much more trauma than I. However, that does not mean you can disregard my experience. I am very confident that I have evaluated, treated and rehabilitated from start to finish many more sprains, strains, tendinopathies, and itis injuries than you have.
      Moving on: you speak of evidence, which is where my problem with ice lies. You want evidence saying that ice does not work. The real question here should be, show me the evidence that ice does work. In my articles, I have provided control trials and lit reviews. You must not have seen them. I evaluate the data I read and call attention to articles that have fair to good PEDro scores. The evidence is equivocal, but more often than not, ice does not improve healing times, it does not remove swelling, and does not facilitate tissue repair. Again, these are your everyday musculoskeletal injuries. The research I’ve done does not speak of saving a limb from amputation or hours of surgery. I’ll leave that data combing to the ER docs. Keep it in perspective.

      Reply
      1. Dave

        I have to admit I was enjoying your article and was hoping it was going to present some good solid evidence that icing acute injuries intermittently (as we’ve been instructing patients for years) was bad.

        I got as far as your implication that the body’s natural response to something can’t be bad and realized that this article was either emotionally driven and lacked logic, or you think that over-generalizing is somehow a good thing.

        I’ll assume you didn’t mean to imply that anaphylaxis is a good thing. I’ll also assume that you didn’t realize that many of the bodies reactions, including swelling and increased pain, played an important role in the past, before humans knew anything about medicine because they provided a natural deterrent to further activity which might put an already-injured limb in more danger.

        I have yet to see a published study that shows that icing an injury delays healing. I have seen a study that shows that if you genetically alter mice so they can’t swell in response to an injury it delays healing, but there’s no way to know what other healing effects besides swelling those genetic alterations might have inhibited. If you know of a study showing ice AS WE CURRENTLY USE IT (i.e. not the “long term” use you mentioned) is bad for healing, I’d love to read it and if it has definitive evidence I’ll be happy to admit you know better than I.

        Until that time, since ice is PROVEN to reduce swelling and pain, the benefits far outweigh any proven disadvantages. If you want to tell your patients they have a choice between the treatments, knock yourself out. But to refuse to give pain relief because you think it may delay healing is irresponsible (and you haven’t even stated HOW much it delays healing…one day? two days?).

        As for the comment you made in response to the ER doc, you obviously haven’t worked in an ER if you think that the only thing we see are “ER-worthy” injuries. The doc was clearly referring to ALL injuries requiring ice when he said he had never seen ice make one worse. He did use extreme examples to make that point, but you erred by acting as though those examples were the only injuries he’s seen in the ER. Do a few ER rotations. 90% of the patients aren’t “ER-worthy”.

        Reply
        1. Joshua Stone Post author

          Thanks for the comment, Dave.
          If you are looking for “some good solid evidence that icing acute injuries intermittently (as we’ve been instructing patients for years) was bad.” or “… a published study that shows that icing an injury delays healing.” you obviously have not read any of the articles referenced. This article was posted a while back. Since then, additional studies have come out.

          Here is my problem with icing and the supporters of: They want me to prove that icing delays healing. How about this, prove to me that it works! My problem with ice is our overuse and mindset that it is a cure-all and should be used for every situation. It’s not and the research does not support this. Again, take the time to read the cited articles. Then read the other articles I’ve posted on here that include more data.

          Also, this statement “…ice is PROVEN to reduce swelling..” is false. Ice does not reduce swelling. In fact, ice increases lymphatic permeability and perfusion. Ice inhibits the inflammatory process, but does nothing to swelling. These are two very different things. Once is needed to heal and the other is a byproduct that must be removed.

          I agree, I am not an ER doc, nor do I pretend to be. That said, how often does an ER doc see a patient? Has this ER doc seen a patient on day 1 of injury and then worked with this patient every day for months until that patient is back to a full functioning status? I am not an ER doc and fully admit I would not survive one day in an ER clinic. Those folks are much smarter than I. But, do not pretend to have worked with a musculoskeletal injury from day 1- return of full activity and say “…had never seen ice make one worse.” .

          Reply
        2. Chad

          Joshua does have legitimate articles to back his statements. But for someone with a background in medicine a simple side by side comparison should suffice. Look at the 4 phases of healing ( hemostasis, inflammation, repair, remodel). Then look at the hematological effects of icing. Compare the first two phases of healing (which are heavily researched and proven), to the effects of icing on local blood flow and inflammation (also heavily researched and proven). They are undeniable opposites. So if the body is doing things required to heal, and icing is doing the opposite then healing times are certainly delayed I cording to logic. Not emotion.

          Emotion however states that we can prove that this is true, when in reality you just won’t stop icing and consider an alternative long enough to see if it really works or not. Also the lymphatic system is a one way system that is run by muscle contraction and large vessel pulsation a in the trunk ( heavily researched and proven with conclusive evidence). Icing does neither of those things. It actually does the opposite which decreases muscle contraction and vessel pulsations(also proven with research). So how can a cold bag of ice reduce urrent swelling? It can’t. Ice simply does not fit into any physiological principle of healing that we have. It does not fit with the model of the healing process with increased blood flow and inflammation, it does not fit the model we have for how lymphatic drainage occurs, and it does not facilitate new blood flow and tendon loading that our model of movement suggest.

          Lastly, previous research that “supported” icing was mostly inconclusive. It drew assumptions for healing based on the knowledge that it does slow down inflammation and reduce pain. But don’t be naive– we know just because inflammation maybe be decreased and pain is gone does not mean the problem is not still there. Furthermore, all studies reviewing the effects of ice on reduced swelling have been confounded by human movement unless all subjects were placed in confinement and not allowed to move a muscle. Human movement activates lymphatic drainage. So if test subjects were moving and icing the study can never definitively say the ice reduced the swelling.

          Reply
          1. Joshua Stone Post author

            I get this a lot Alex. Just because we say no to ice doesn’t mean heat is the answer. This is the inherent issue with ice. We depend on and rely on ice so much that when taken away, we feel there must be an alternative.

      2. Helen Wild

        Thank you Joshua for having finally given some evidence to a theory that made total sense to me. I am not an expert but out of common sense applying ice seemed counter productive…. The same as we should not stop a common fever, why should we stop swelling, our bodies natural response to injury?

        Reply
        1. Robertw

          There is one minor problem with the article and the suggested program. Ice is used to address pain. At some point the nerves , which can suffer injury while repeatedly stimulated -as is the case with inflammation- have to be calmed down a bit. Thats what the ice is for . It quells PAIN , which unless the injured person has some real psychological problems does -in most cases have to be mitigated too support the healing process because such a process is almost always affected by a persons emotional state, and PAIN does not support a positive mental attitude. Prolonged and incessant pain wears down the will, and destroys morale, both of which must be running on all cylinders if a person is actually going to heal.

          Reply
          1. Dr Chad Nowlin

            The point is not whether control pain or not. We no it does that and the mechanism by which it reduces pain is well researched and understood. The point is that you are temporarily decreasing pain at the expense of healing time. No redesign to pain gait with ice and slow down healing time when there are a dozen other modalities to reduce pain. Also you will have to bring on some pretty legit research to support low moral reducing healing times so that should not even factor into this discussion.

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  9. Pingback: The Great Ice vs. Heat Confusion Debacle | What's Up Doc?

  10. Jennifer

    As someone currently dealing with an ongoing shoulder injury that I would love to heal sooner rather than later this article makes sense but is also frustrating. I hear and understand what you’re saying NOT to do but in return you don’t offer up suggestions on what DOES work and help healing. So I feel all this does is lead me to a confusing standstill.

    Reply
    1. Dr. Chad Nowlin

      Jennifer this is a great comment!

      Active recovery is the best thing you can do for an injury when considering alternatives to icing. When muscles contract the pump swelling out and bring in fresh blood flow. As this is repeated the area of injury is decongested. When you perform movements the should only be what you can do without causing pain. To activate the fullness of the lymphatic system you could do ball squeezes with your hand on the involved side, bend and straighten the elbow, and perform small shoulder movements if possible without causing pain. Some great low level shoulder movements you could try are what is called Shoulder Isometrics (you can look these up online for examples).

      Another great tool to have is what is called the Marc Pro. While this does cause money it is the absolute best substitute to icing since it pumps your muscles for you without causing pain or fatigue. It is what I use in the clinic and it works really well.

      I hope this information helps you out a bit!

      Reply
  11. jason

    lol. the ongoing ice vs heat and active vs passive modalities debate…
    how about this? they both work… sometimes concurrently, other times in a sensible order…
    pt: my low back hurts when I bend over to touch my toes.
    therapist: great. we need to strengthen your back.
    let’s put heat on it and you can bend over and touch your toes 25 times
    pt: but it hurts to bend and touch my toes even once???

    asking pts to perform arom while in acute pain is assinine. stabilize pain, passive modalities (yes including ice), then move to arom/strengthening, and promote healing/blood flow with heat and other forms of movement…

    this notion you’ve discovered something groundbreaking is laughable.

    game ready devices in my office prove day in and day out that cryo with compression speeds healing time in acute injuries.

    somebody forgot about the calor, rubor, dolor, section in their PT text….

    Reply
    1. Chad Nowlin

      You have missed the point of the icing debate entirely. The debate is not whether it decreases pain or not. And when it comes to reducing pain there are 52 other passive modalities the decrease pain but do not slow the internal healing process.

      Reply
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  13. Amy

    You said in your update, quote; “What is the benefit to delaying the healing process? Some will say, “to prevent hypoxic death” or “to reduce pain”. There are other ways we can stop hypoxic tissue death that do not stop healing.”

    Can you elaborate on these ways of stopping hypoxia tissue death that will not stop the healing process?

    Reply
    1. Dr. Chad Nowlin

      Secondary hypoxic tissue death is not caused by inflammation, it is caused by swelling. Since that is the case using ice or anti-inflammatory to stop secondary hypoxic death is asinine. If swelling is managed early and appropriately there is less secondary cellular death. This is achieved by active recovery which speeds lymphatic drainage, or a device like H-Wave Low frequency or Marc Pro to flush the fluid out of the joint and tissue space. Swelling essentially drowns the tissue preventing oxygen uptake much like a person drowning underwater. If you remove the fluid, you remove the barrier to oxygen uptake and decrease secondary cellular death. We know the best way to remove fluid is to activate the lymphatic systems which operates primarily on muscle contraction. Even the smallest movements activate the lymphatic system so pain free movement should be used for active recovery. No matter how small the movement the benefit far exceeds sitting still with a bag of ice.

      Reply
  14. Blossom

    What do you use to stop additional bruising – bleeding under the skin? Icy cold Water helps to stop bleeding from scratches or cuts for people with some bleeding disorders. i know that it has helped one patient on several occasions.

    Reply
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  16. Stephen Butler

    This is so refreshing. For those of you claiming Josh is not supported by the research just look at his references. The journal of Applied Physiology article does indicate that with muscle injury in the animal model ice does impede the healing process. I understand the resistance to change. I am amazed that NSAIDs are still used regularly and even advertised to be used immediately after an injury. There is a plethora of research indicating NSAIDs have a deleterious effect on tendon and bone healing if taken in the first week after injury. The combination of 1. lack of evidence ice helps, 2. ice has a slowing impact on inflammation, 3. NSAIDs inhibit healing by inhibiting inflammation. Perhaps we should avoid ice immediately after injury until evidence supports its use.

    Reply
  17. Researcher

    The author of this article provided numerous studies to support anti-icing. I thought it interesting when he commented that few who posted here appeared to have read those studies. I decided to do just that. I found the studies cited as supporting anti-icing either did just the opposite or were not related to sports injuries. I strongly encourage anyone reading this article to read the abstracts of the studies listed above as references. Those abstracts are available online for many of the studies. I have provided links to the ones I reviewed so the reader can come to his or her own conclusions.

    First, Bleakley et al. (2011) does not suggest icing is ineffective. Read the abstract here [http://bjsm.bmj.com/content/early/2011/06/15/bjsm.2011.086116]. It simply says the effectiveness of icing is diminished if the cooling source and injury site are too far apart. In other words, less cooling equals less benefit. In effect, the study is stating that there IS a benefit to icing. Another icing study by the same researcher, Bleakley et al. (2004), has an abstract where the researcher plainly states “there was no evidence of an optimal mode or duration of treatment.” Those interested can find the abstract here [http://www.ncbi.nlm.nih.gov/pubmed/14754753].

    The least supportive study cited in the article above, as it relates to anti-icing, was the research performed by William et al. (2013) [http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010711/full]. The study itself was credible; however, it was a study performed for non-specific neck pain. The authors clearly stated that they were investigating the use of icing for “neck pain with no specific underlying pathology (e.g. fracture, dislocation, neoplasm, disc disease, degeneration) or systemic disease.” Similar to the other research referenced, the study does not support anti-icing because the researchers did not investigate the injuries discussed in the article above.

    In summary, several of the studies this article provided that supposedly support the harmful effects of icing are actually irrelevant to the point. Others support icing as an effective treatment at best or non-harmful at worst.

    Reply
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