10 Reasons – Icing Injuries is Wrong

iceIf you know me, you are aware of my anti-ice stance. The ice debate continues to heat up. As peer-reviewed data continues to pour in, the evidence for the use of ice to treat musculoskeletal injury still lacks. I’ve written about ice many times, but many of my anti-ice articles are science-y and focused around one topic. I wanted to do something different this time. I wanted to keep it short, sweet and comprehensive. So, I bring you 10 reasons why we shouldn’t ice injuries.

  1. Inflammation is the first physiological process to the repair and remodeling of tissue. You cannot have tissue repair or remodeling without inflammation. Ice constricts blood flow and impedes the inflammatory cells from reaching injured tissue. The blood vessels do not open again for many hours after ice is applied.
  2. Inflammatory cells are designed to release a hormone known as Insulin-like Growth Factor (IGF-1). 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. The application of ice inhibits the release of IGF-1.
  3. We are contradictory. We have adopted many therapies from Europe and Traditional Chinese Medicine like prolotherapy, acupuncture, and PRP injections. These are all pro-inflammatory, meaning they stimulate or increase the inflammatory response. Studies have found these therapies to be beneficial. Ice does the opposite of these forms of treatment.
  4. Swelling—a byproduct of the inflammatory process—must be removed from the injured area. Swelling does not accumulate at an injured part because there is excessive swelling, rather it accumulates because lymphatic drainage is slowed. The lymphatic system does this through muscle contraction and compression. Ice has been shown to reverse lymphatic flow.
  5. Gabe Mirkin, MD—the physician who coined the term RICE—has since said he was wrong. “Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.” – Gabe Mirkin, MD, March 2014
  6. In a position statement (the review of many scientific papers) made by the National Athletic Trainers’ Association on the management of ankle sprains (2013) found that ice therapies had a C level of evidence, meaning little or poor evidence exists. In an interview, the author of that article said: “I wish I could say that what we found is what is really being done in a clinical setting…. Maybe our European colleagues know something we don’t…there is very little icing over there.”
  7.  Ice does not facilitate proper collagen alignment. Diagnostic imaging of chronic tendon injuries like Achilles tendinopathy, jumper’s knee, runner’s knee, and plantar fasciitis show poor collagen arrangement of connective tissue. Study after study shows that exercise (especially eccentric loading) helps align collagen.
  8. Ice impedes cellular signaling and inhibits the proper development of new cells. The processes of mechanobiology and cellular signaling take progenitor cells—infant cells who do not know what they are going to be—and makes them into rebuilding cells like myocytes, osteocytes, tenocytes, chondrocytes, etc.
  9. Ice slows nerve firing and interferes with the strength, speed, and coordination of muscle. A search of the medical literature found 35 studies on the effects of cooling and most reported that immediately after cooling, there was a decrease in strength, speed, power and agility-based running.
  10. Ice does control pain, but that pain relief lasts only 20-30 minutes and as evidenced above, has detrimental side effects to healing. There are many other things we can do to control pain that do not impede healing.

I had a discussion with a physician regarding ice and he said something to me that stuck, “There clearly exists a dogmatic polarization on the use of ice in our medical communities! Old habits die hard. Many colleagues still insist on using ice…despite the current scientific evidence available that shows it does not work.”  Health care providers are supposed to be evidence-based. The evidence is clear that ice is not the best method when treating injuries. Follow the evidence.

If you want to read more about icing, NSAIDs, cellular signaling, or mechanobiology, click here and it will pull up a list of articles.

Bibliography:

  1. William JR, Srikantaiah S, Mani R. Cryotherapy for acute non-specific neck pain (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 8.
  2. Forsyth, A. L., Zourikian, N., Valentino, L. A. and Rivard, G. E. (2012), The effect of cooling on coagulation and haemostasis: Should “Ice” be part of treatment of acute haemarthrosis in haemophilia?. Haemophilia, 18: 843–850. doi: 10.1111/j.1365-2516.2012.02918.x
  3. Rajamanickam, M., Michael, R., Sampath, V., John, J. A., Viswabandya, A. and Srivastava, A. (2013), Should ice be used in the treatment of acute haemarthrosis in haemophilia?. Haemophilia, 19: e267–e268. doi: 10.1111/hae.12163
  4. Forsyth, A. L., Zourikian, N., Rivard, G.-E. and Valentino, L. A. (2013), An ‘ice age’ concept? The use of ice in the treatment of acute haemarthrosis in haemophilia. Haemophilia, 19: e393–e396. doi: 10.1111/hae.12265
  5. Dolan. New Concepts in the Management of Acute Musculoskeletal Injury. NATA 2013 Annual Meeting.
  6. Selkow, NM, Pritchard, K.  CRYOTHERAPY FOR THE 21ST  CENTURY: UPDATED RECOMMENDATIONS, TECHNIQUES, AND OUTCOMES. NATA 2013 Annual Meeting.
  7. Johnson, M, Denegar, C. Mechanobiology, Cell Differentiation and Tendinopathy – From Bench to Bedside. NATA 2013 Annual Meeting.
  8. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and preventing of ankle sprains in athletes. J Athl Train. 2013;48:528-545
  9. http://www.medscape.com/viewarticle/823217_1 – accessed April 9, 2014.
  10. 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
  11. 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.
  12. 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).
  13. 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.
  14. 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.
  15. Hubbard, TJ, Denegar, CR. Does Cryotherapy Improve Outcomes with Soft Tissue Injury? J Athl Train. 2004 Jan-Mar; 39(1): 88–94.
  16. 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.
  17. 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
  18. 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.
  19. Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
  20. 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.
  21. Guyton, AC and Hall, JE.  Textbook of Medical Physiology 10th Ed., W. B. Saunders Company. 2000.
  22. Meeusen, R. The use of Cryotherapy in Sports Injuries. Sports Medicine.  Vol. 3. pp. 398-414, 1986.
  23. Abrahams Y, Laguette MJ, Prince S, and Collins M. Polymorphisms within the COL5A1 3′-UTR That Alters mRNA Structure and the MIR608 Gene are Associated with Achilles Tendinopathy.Ann Hum Genet. (Epub – ahead of print) Jan 2013.
  24. Khan, K M, and Scott, A. Mechanotherapy: How Physical Therapists’ Prescription of Exercise Promotes Tissue Repair.  Br J Sports Med. 2009;43:247–251.
  25. Joseph, MF, Lillie, KR, Bergeron, DJ, and Denegar, CR. Measuring Achilles tendon mechanical properties: A reliable, noninvasive method. J Strength Cond Res. 26(8): 2017–2020, 2012.
  26. Fragala, M. S., Kraemer, W. J., Mastro, A. M., Denegar, C. R., Volek,  J. S., Hakkinen, K.,  Anderson, J.M.,  Lee, E. C., and Maresh, C. M. Leukocyte β2-Adrenergic Receptor Expression in Response to Resistance Exercise. Med. Sci. Sports Exerc. Vol. 43, No. 8, pp. 1422–1432, 2011.
  27. Fluck M, Mund SI, Schittny JC, Klossner S, Durieux AC, et al. (2008) Mechano-regulated tenascin-C orchestrates muscle repair. Proc Natl Acad Sci U S A 105: 13662–13667.
  28. Scott, A., Khan, K.M.,  Duronio, V, Hart, D.A. Mechanotransduction in Human Bone In Vitro Cellular Physiology that Underpins Bone Changes with Exercise. Sports Med. 2008; 38 (2): 139-160.
  29. Joseph, MF, Taft, K, Moskwa, M, and Denegar, CR. Deep Friction Massage to Treat Tendinopathy: A Systematic Review of a Classic Treatment in the Face of a New Paradigm of Understanding.Journal of Sport Rehabilitation. 2012, 21, 343-353.
  30. Durieux AC, D’Antona, G, Desplaches, D,  Freyssenet, D, Klossner, S, Bottinelli, R, and Fluck, M. Focal adhesion kinase is a load-dependent governor of the slow contractile and oxidative muscle phenotype. Jof Physiol.  2009;587:14. 3703–3717.
  31. P Kannus and L Jozsa. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991 Dec 01;73(10):1507 1507-1525.
  32. Couppe´, M. Kongsgaard, P. Aagaard, P. Hansen, J. Bojsen-Moller, M. Kjaer, and S. P. Magnusson. Habitual loading results in tendon hypertrophy and increased stiffness of the human patellar tendon. J Appl Physiol. 105: 805–810, 2008.
  33. Adamantios Arampatzis, Kiros Karamanidis, and Kirsten Albracht. Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude. J of Exper. Biology. 2007. 2743-2753.
  34. Clark, MA, and Lucett, SC. NASM’s Essentials of Corrective Exercise Training. 2010. Philadepha.
  35. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby; 2002.
  36. Saithna A, Gogna R, Baraza N, Modi C, Spencer S. Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review. Open Orthop J. 2012;6:553-7
  37. Sussmilch-Leitch et al. Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Journal of Foot and Ankle Research. 2012, 5:15.
  38. Murtaugh and Ihm.  Eccentric Training for the Treatment of Tendinopathies. American College of Sports Medicine –Training, Prevention and Rehabilitation. Volume 12 & Number 3 & May/June 2013.

59 thoughts on “10 Reasons – Icing Injuries is Wrong

  1. Karel Curras Special K

    I believe the application and use of ice differs in the type of tissue that it affects. In my view, everything is multifactorial. Anatomy follows physiology and heat and ice always depends on how it affects the individual not the masses despite of scientific evidence similar to weight loss programs.

    Reply
  2. Pingback: [Guest Blog] Josh Stone: 10 Reasons – Icing Injuries is Wrong | NCCPT BLOG

  3. Ved

    Thank you for the article, I enjoyed reading it and it was informative. I just wanted to get everyone’s thoughts on something that I’ve found to be a bit of a double standard.

    I’ve met a few people who are studying the science of becoming strength & conditioning coaches. And every time we talk about anything medical or muscle related they take this pretentious stance that ‘If it’s not published in an official medical journal, it’s BS’. As if EVERY single thing on the Internet is either false, or meant to promote a person or organisation. Personally, I’ve picked up a lot of useful information online and disagree but these people are so persistent with this opinion of the Internet. What are your thoughts? Thanks, Ved

    Reply
  4. Pingback: Aplicación de Hielo en Lesiones – Estas seguro que es eficiente? | mejorandoconfisioterapia

  5. Pingback: 10 Reasons – Icing Injuries is Wrong | Stone Athletic Medicine | BBDoc

  6. Pingback: 10 Reasons – Icing Injuries is Wrong | Everyday Health

  7. Pingback: Is R.I.C.E. the right treatment approach to Tennis Elbow? | Tennis Elbow Classroom

  8. Todd

    Ok, I see the wisdom of following the evidence, no more icing.

    Now, what do we do that will facilitate healing? Just compression? Just elevation?

    Reply
    1. Joshua Stone Post author

      If you follow the link at the bottom of the article it takes you to other articles that discuss healing. Search Mechanotransduction. That explains how movement and load facilitates healing.

      Reply
  9. Dean Vosler

    A little background might explain my view on icing. First I am 64 yrs old. I started my academic journey studying physical education. During the rhe athletic training intro course we were told that some coaches in colleges in California were icing pitchers elbows. Their thought was it reduced any inflammation, but our discussion resulted in the conclusion that this would not really accomplish anything as the body’s response was a temporary reduction of the circulation followed by vasodilation. This was easily demonstrated in placing a hand in ice water with immediate vasoconstriction occuring and approximately 5 minutes later vasodilation evidenced by a very red hand. Later I would learn about various blood flow adaptations while studying physiology as a graduate student in biology. We also discussed the effects of icing on the clotting of blood after injuries. It was concluded that the mechanisms of clotting were dependent on enzymes that didn’t function at cold temperatures. I would later learn a more detailed description of the cascade effect of blood clotting and the eventual forming of collagen, scar tissue, in the healing process, again in enzyme biochemistry, pharmacology and pathophysiology courses. I also worked as a lifeguard during my summers and was required to be certified in advanced first aid. So I was very aware of emergency first aid procedures. There was no use of ice for treatment of injuries. Several years later I started a career as a police officer and the new first aid for injuries was the term RICE. Well I was a little surprise to see the use of ice for anything other than preserving blood. With the numerous injuries I suffered I never used ice only compression and elastic wraps with much less time on light duty. I believe you are correct and there are many medical practices driven by non-scientific beliefs and profit motives. Ever wonder how much has been made on chemical cold packs. Humans are homeothermic and have developed physiological schemes to deal with injury healing, they do not include hypothermia. Human enzymes, proteins, do not function well at lower or higher than body temperatures. Because an entrenched practice is taught in medical schools and every auxiallry medical field doesn’t validate it. Don’t use ice for anything to do with healing. I would also recommend stopping the use of glucocorticoids, but that is another discussion, another common practice with dire results.

    Reply

Leave a Reply

Your email address will not be published. Required fields are marked *