Icing Injuries: Are We Evidence-Based?

Are you an evidence-based practitioner? Think about it; are you really?

An athletic trainer working a Division 1 women’s volleyball tournament with elite Top-25 teams sent me a text: “You should do a study on the average number of ice bags used by volleyball teams after a match… Entire teams are getting ice on both knees and the hitting shoulder. No post-match mobility work, just pounds of ice. Crazy! Some athletic trainers and strength and conditioning coaches are too ignorant and too lazy to provide proper warm-up and cool-down protocols to address mobility.” This is not shocking to me. I worked with Division I volleyball for several years and I observed this too. This is where I learned ice is overused.  This isn’t just a volleyball thing; this is an all-sport issue.

The athletic trainer quoted above is a rare breed. He takes time to look at each athlete’s functional deficits and addresses them individually. He employs specific warm-up and cool-down protocols to address mechanics and mobility and prevent injury. His team is healthy (knock on wood). His athletes are not doused in ice after practice and shoved off.

Why aren’t more trainers using these practices? Personally, I just shake my head and wonder. I really have no clue. Despite the evidence, the scene described at the beginning of this post is common. The only thing I can do is continue to share the evidence. First, I am going to recap a few things I’ve said before. Pay attention, because you might find similarities to new data I introduce below.

  • Mechanotransduction and cellular signaling:
    • Abrahams, et al., 2013: Tendinopathy is a result of gene polymorphism, not inflammation.
    • Load stimulates mRNA to be sent to the endoplasmic for gene transcription and proteogenesis.
    • The new proteins repair damaged tissue and become the new collagen, the new bone, and the new muscle.
    • Durieux, et al., (2009): Focal adhesion kinase (FAK) is regulated through load. FAK governs repair of striated muscle.
    • Flück, et al., (2008): tenascin-C, a protein responsible for tissue remodeling is expressed only in damaged tissue and regulated by mechanical load.
    • Load is why we get bigger when we lift heavy weights. Load is why bone stimulators heal fractures. Load is why we heal tendons and ligaments.
  • Why ice inhibits inflammation:
    • Nick DiNubile: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?”
    • Inflammation is the first physiological process in the repair and remodeling of tissue. Without it, nothing after can happen.
    • Macrophages release the hormone Insulin-Like Growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts heal.
    • Ice prevents the body from releasing IGF-1.
    • It is IMPOSSIBLE to have tissue repair or remodeling without inflammation.
  • The godfather of RICE, Dr. Gabe Mirkin
    • The man, who coined the term RICE, says he was wrong.
    • Rest does not stimulate tissue repair. Rest causes tissue to waste and can cause abnormal gene transcription of collagen tissue.
    • Ice delays healing.
    • Anything that reduces your immune response will also delay muscle healing, such as cortisone-type drugs, pain-relieving medicines like NSAIDS, immune-suppressants and applying cold packs or ice.

Now, keep those points in mind as I introduce you to a new article. This article is at the top of our evidence food chain when it comes to evidence-based practice. This is a review of all current and quality evidence about the management of patellar tendinopathy. I repeat, a review of all current and quality evidence about the management of patellar tendinopathy. Here is link to the full text article.

Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy. 2014.  60: 122–129.

I am skipping through all of the other great stuff this article has-prevalence, etiology, risk factors, and assessment—to get to the key points noted in the management section.

  • Reducing an athlete’s symptoms requires load management.
  • Isometric contractions have been shown to be analgesic and pain reducing.
  • Long-term outcomes of peritendinous corticosteroid injection, oral steroidal medication, or iontophoresis are worse than those obtained with exercise.
  • Exercise, pulsed ultrasound and transverse friction massages have been compared, and exercise had the best effects in the short and long term.
  • Extracorporeal shockwave therapy, corticosteroid injections, platelet-rich plasma and other injections are interventions frequently used in the clinical setting, yet have limited evidence supporting their use in patellar tendinopathy.
  • Eccentric exercises have generally been shown to have good short-term and long-term effects.
  • When comparing corticosteroid injection to the proximal patellar tendon to a decline squat eccentric exercise protocol and a heavy slow resistance protocol only the strength groups showed improvement at 6 months.
  • It is important to factor in stage of tendinopathy and treat it as part of a well-rounded rehabilitation program involving kinetic chain exercises, education in proper landing technique and management of load and return to sports.
  • Currently, the most important factors in managing athletes with patellar tendinopathy is to educate them about how to modify loading.
  • There is little evidence to support use of corticosteroids, biophysical modalities or anti-inflammatory techniques to treat patellar tendinopathy.

So, I ask again, are you an evidence-based practitioner? Are you examining the latest evidence and doing what is best for your patients and athletes? If you find yourself turning athletes into flexi-wrapped ice monsters, it’s time to drop the excuses and reassess your practice.


5 thoughts on “Icing Injuries: Are We Evidence-Based?

  1. Pingback: Stone Athletics – Icing Evidence Based? | Smith Martial Sciences

  2. Giorgos Fougias

    I really loved your final paragraph!its all the money!very good article and the strongly review from Cook!its so true all the subject!you destroy “the easy ways”!

  3. laurakellylac

    In my experience in fact the opposite of ice works – warm bath even hot tub immediately following injury. No doubt it enhances the immune response rather than limiting it. I have no research for this but this is what I do for myself – skiing injuries, dance injuries etc – and I have never had any long term damage. Awesome article.

    1. Joshua Stone Post author

      Thank you Laura!

      I have not found research to support this either. In my experience this did not pan out well for me. However, we must do what works best for our patients in our practice.

  4. Pingback: Icing Injuries – Great article from Joshua Stone, Athletic Medicine | Case Notes

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