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.

64 thoughts on “10 Reasons – Icing Injuries is Wrong

    1. Joshua Stone Post author

      thanks, that blog would be a loaded question, because depending on the injury type, severity, location and current stage of healing therapy would differ drastically.

      Reply
  1. David

    I believe cold therapy has been a major factor in the successful outcomes in several spinal cord injuries in the NFL. It does offer control pain and calm the mechanoreceptor activity.

    Reply
  2. Sacred Healing TreeSteven Blackstone

    Then what are the alternatives to treating immeduiate trauma? As a Chinese Medicine practitioner of some 30 years specializing in sports medicine, I highly recommend that every athlete have a Chinese herbal paste on hand called “san huang san”. or Herbal Ice. This preparation is available at http://www.modernherbshop.com/ and can be used in the same way as ice would for injuries. I have found that ice slows the healing of injuries to the degree that long term residual effects can be seen years later and often ice treatment leads to re-injury.

    Reply
  3. Micah Kust

    Do you have a list of resources for these facts, trying to challenge the idea of ice in my physical therapy orthopaedic classes but need a comprehensive list of things to show. This is a good start though and have found some of the articles in question but a list would be awesome.
    Thanks

    Reply
    1. Joshua Stone Post author

      I did not add the reference list to this post, but if you follow the link at the bottom of the post it will pop up a bunch of similar posts regarding icing. All of these have the references you seek.

      Reply
  4. Jared

    What about ice baths/cryotherapy chambers outside of injuries? These are simply used to recover from workouts. Are there still benefits to these?

    Reply
    1. Joshua Stone Post author

      There is evidence that supports the use of ice for athletes who need a quick turnaround. For example, if the Butler Bulldogs (I noticed your email’s domain ;)) are playing in March Madness and have a sweet 16 game on Thursday and an elite 8 game on Saturday, then yes, an ice bath will help, but there is a twist.

      An ice bath will help, but not because you are “recovering” better or faster. Our bodies natural healing process – inflammatory process – causes pain and discomfort. Hence soreness after a heavy lifting workout. But this is needed to recover and repair tissue. Inflammation also turns off and inhibits muscle function (again, part of the healing process). So an ice bath after a game activity will slow inflammation and make us feel better and have improved performance on back to back days. It does not make us “recover” though.

      Ice baths after a game or an event stop the necessary processes to heal and repair tissue. So, in the rare events of back to back competitions and the athlete needs to be fresh I would suggest it. However, if you did this repeatedly you create an environment where we do not allow tissue to repair tissue. So I would not make it a habit and would only advise it if rest between between events is not an option.

      Reply
  5. Jake Spivey

    It seems that that there are may cases that could benefit and those which would not benefit from ice. I tend to avoid ice after treatment in my PT practice but there are times it is required. Just as the body is trying to heal with sending the appropriate cells to the injured region there are times acute injure and post operatively that there is excessive swelling, If that type of swelling is not managed appropriately then it will have a detrimental affect on muscle control so much it will shut it down as a protective mechanism. I do not think all is black and white, right or wrong in the medical community but manage case by case.
    Also if this is the case about ice where does compression stand as well as draining a joint of excessive fluid?

    Reply
    1. Phill W.

      There are no consistent findings in the literature to my knowledge that supports the use of cryo or thermal therapies to reduce effusion. If you apply cold of hot to an area, you affect the veins and the arteries and they respond in a manner where the net effect is zero. Apply cold and both vessels vasoconstrict and the blood is trapped. Apply heat and the vessels dilate but there is no pressure gradient. Gravity and mechanical compression seem to be the only real answer unless you know how to use the protein concentration in the blood (oncotic pressure) to pull edema/effusion into the lymph system.

      Reply
  6. Jim Nespor PT/ATC

    Josh, Can’t find the references. Could you please post 2 or 3 of the references that have a Pedro score of 8 or higher please? Thanks, Jim Nespor PT/ATC

    Reply
    1. Joshua Stone Post author

      Jim, see below as I have shared a few. I did not perform an exhaustive lit review, but did provide what you asked for. I hope it helps.

      My question to you; why a PEDro score 8 or higher? Categorically, 6-8 are “good” studies and 9-10 are “excellent”. Excellent studies are hard to come by, but 6-8 are far more numerous. If you want 8, then categorically, 6 and 7 should work as well, correct? I did not include 6/7 though, because that is not what you asked for. If I want to formulate level 1a conclusions we need more than one >6/10 RCT. So, would three 8/10 scores give us a brand new level of evidence category of 1aa+? My apologies, if this comes off snarky, but clinicians / researchers ask for evidence to support my stance, but have yet to provide me evidence for mass over use of ice we use clinically.

      I was just searching over the weekend for a RCT that provides evidence that cryotherapy and cryotherapy alone facilitates tissue healing or improved functional measures. There are a bunch of correlative studies, a lot of studies that make over generalized conclusions, but RCTs with good to excellent PEDro scoring? Nothing. If someone would come to me with 5 RCTs of PEDro 6 or 10 that provided statistically significant data that said rest, ice, and/or rest+ice as a interventions provide better functional outcomes than exercise or movement, then I would say OK, we have the evidence to use ice as much as we do. If you come across any of those with a PEDro of 8 or higher, please do share.

      To your question:

      PEDro Scored:
      8/10 – Bleakley CM, O’Connor SR, Tully MA, Rocke LG, Macauley DC, Bradbury I, Keegan S, McDonough SM. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 2010 May 10;340
      8/10 – Glasgow PD, Ferris R, Bleakley CM. Cold water immersion in the management of delayed-onset muscle soreness: is dose important? A randomised controlled trial. Physical Therapy in Sport 2014 Nov;15(4):228-233.
      8/10 – Knobloch K, Kraemer R, Jagodzinkski M, Zeichen J, Meller R, Vogt P. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic Achilles tendinopathy. J Orthop Sports Phys Ther. 2007;37:269–276.

      You did not ask for SLR’s / Position Statements, and they are not applicable to PEDro scoring, but these are critically appraised and at the top of the evidence research pyramid. So I presume these would meet your criteria as well.


      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.
      Sussmilch-Leitch SP, Collins NJ, Bialocerkowski AE, Warden SJ, Crossley KM.Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Journal of Foot and Ankle Research 2012 Jul 2;5(15):Epub.
      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. AJSM 2004 Jan-Feb;32(1):251-261
      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.

      Reply
  7. Travis Hansen

    Hey Josh,
    Fantastic piece! Quick question. Does swelling just affect local blood flow and nutrient delivery, or why specifically does it slow the recovery process.

    Reply
  8. Nicola Taddio

    The answer could be hidden in this interesting paper:
    The inflammatory response: friend or enemy for muscle injury?
    Toumi H, Best TM.
    Br J Sports Med. 2003 Aug;37(4):284-6. Review….

    Reply
  9. Micah

    We were discussing post knee surgery today and the use of icing. Prof indicated that ice is definitely indicated in the first few weeks and can be used to gate pain primarily but also to minimize some effusion. Is there any problem with using ice in this situation?
    Also, prof stated that the literature is still supportive of icing, which by your comments I think you would disagree with. Seems like the research isn’t dismissing icing, but it isn’t really supporting it either. Also said that ice doesn’t get deep enough to affect the inflammatory process that is happening, is there truth to this.
    I believe ice can be used to gate pain but as an ATC and future PT I am wondering where the line is between gating pain and affecting the repair process.

    Reply
    1. Joshua Stone Post author

      Ice does have pain relieving effects and using the gate theory it does work. However, ice also inhibits much needed healing. Besides ice only reduces pain for 20-30 minutes after the application is taken off. Do you really want to stop our bodies natural healing processes for 20 minutes of pain relief? We have many other tools at our disposal that reduce pain and do not stop healing. A TENS unit for example has been shown to reduce pain (also using gate control theory) as much as ice, but the pain relief lasts longer with TENS vs ice. On top of that a TENS unit will not interrupt natural healing.
      The evidence supportive of ice is a bit twisted. Make sure the research article is specifically looking at ice vs. another mode of treatment (TENS, E-STIM, US, Exercise, Massage, etc.) Also I would not ice for 2 weeks after surgery. We are interrupting local blood supply and denying our bodies ability to start the repair process. All that said, your teacher gives you the grade – I suggest you listen to him despite my disagreement.

      Reply
      1. Hoog Karina

        Micah, did you get a list? I am also interested for the same reason. Having some background scientific resource for discussion. TXS.

        Reply
        1. Micah K

          There are links to other posts that Josh has written in previous years that have very good resources listed with them.

          Reply
    2. Phill W.

      If you want to control pain, why to utilize electrical stimulation in combination with acetaminophen (or other prescribed narcotics) post surgery when pain is high.

      Reply
  10. Ty

    Your review is short sited, biased, and lacking real logic. It smells of a high school persuasive paper, only using the facts that support your opinion. A closer look at the literature (including a cochrane review) reveals several pros for tissue cooling, which are conveniently missing from your opinions. Perhaps you should list, or better yet grade, your evidence so people can see this is simply an uninformed compilation of one side of the story. There are pros and cons to every intervention. Having studied in this area for years, the pros far outweigh the cons when it comes to joint cooling.

    Reply
    1. Joshua Stone Post author

      Thank you for the comment, Ty. I do not think it is short-sighted or biased. What bias do I have? I get no kickback from saying what I say. My website does not generate revenue. I am not selling product or supporting any product. Its based on my clinical experience that led me to review the evidence. The evidence is what steered me here and it took a long time for that transition to occur.

      I agree there is good / bad data, but I have articles that have good to excellent (6+/10) PEDro score and many are critically appraised systematic lit reviews or position statements. How can one deny a position statement or a systematic lit review where the authors have combed over hundreds of high-quality RCTs and came up with C-level evidence to support the use of ice? I didn’t make that data up or twist it, the authors reported that data.

      I do not disagree with you though, research is equivocal and there are and always will be pros and cons to every intervention. I am not denying that. That’s how research works and why we ask questions. Anyone can find data to support a view. I do, however, strongly disagree that the pros to ice far outweigh the cons of ice. Even if your statement was true, it does not justify the gross over use of ice as a modality. Ice is not the end all cure all that we make it to be.

      Those who challenge my stance or disagree always question my evidence. What about the pro-ice evidence? Where are the 6+ PEDro RCTs that say cryotherapy and cryotherapy alone improves outcomes? Where are the SLRs / MAs and Position statements that support ice over other tools, manual therapies and exercise? And if you can find me ONE study that says ice facilitates gene transcription and converts progenitor cell to an osteo/myo/fibro/teno-cyte you will have me sold. Ice does not stimulate the processes of mechanobiology and cellular signaling. It does not alter gene upregulation and does not tell the body how to repair tissue. Ultimately, that is what we need – we need tissue to heal, repair, and remodel.

      All that said, we are clinicians. We are to be experts and we are to do the very best we can to help our clients. You have your methods, and I have mine. I am ok with disagreeing, but I do ask that we have an open mind to alternatives.

      Reply
      1. Joe

        Josh,

        To imply that you have no bias because you are not getting a “kickback” is irresponsible and inaccurate. Your bias stems from the fact that you are not reporting all of the facts and being very opinionated and persuasive with your thoughts. You have an invested interest in this topic because you firmly believe that “ice is evil”, based on a previous post of yours. Many of the topics as to why ice, in your opinion, is not valid can be stated with a level of accuracy. However, some of the very same articles you use to help defend your position can also be used to help show the whole picture as well as show that your position is not clearly defined with your supported references. For instance, your first article used is a protocol and has yet to be performed. How do you draw conclusions from this protocol? Your next three articles talk about a very specific population and may not reflect the generalization of the whole population. The position statement from the NATA does state that cryotherapy is rated with a C but also states that NSAIDs and function exercise are rated with an A. However, you also state that NSAIDs can also harm the tissue healing cycle during the inflammatory stage, yet this is viewed as the best approach. With that being said, if you are to read the entire article, you will note that most rehabilitation techniques for the management of acute ankle injuries are rated with a B and C, thus indicating that this may be the best available level of evidence. Lastly, this article does not refute the use of cryotherapy but states that the data is still inconclusive or weak.

        With my area of expertise being with functional movement, I agree that early activation of tissue may be beneficial in the healing process and return to activity. Clearly a majority of your latter articles used help defend your position. However, your position to me, from reading your posting, is that ice is bad and exercise is good. However, none of your articles provided compare exercise vs cryotherapy on tissue healing process. Your articles provide insight on how each relate to functional outcomes as well as pain management, which show benefits from all accounts to some degree. However, where are your articles that refute the use of cryotherapy on the inflammatory process of the tissue healing cycle?

        Another position to ponder is that if you look at most research on modalities of any form, such as cryotherapy, electrotherapy, US, etc, the critical appraisal scores are relatively low. What you provided as high scores are related to exercise perscription and do not compare exercise perscription with the use of cryotherapy. My opinion is that you won’t find these articles because it would be stupid to compare two separate forms of treatment.

        I do feel that ice or RICE or PRICE or POLICE or RICES can help in the management of an injury as I feel that early activation and functional movement assessment can help diminish compensatory movement and help minimize risk of injury. However, to fully refute that ice is bad and can have no benefit is absurd. Used inappropriately and for prolonged duration can lead to delayed recovery and possible secondary tissue injury and damage. However, used appropriately and based on the individual patient, ice can help aid in the management of the injury.

        To be an evidence-based practitioner is to be an educated individual that uses the evidence, experience, and patient values to make a rational and clinically based decision to improve patient outcomes. By only providing a narrow view of a very large topic is not using all the evidence to help apply and improve outcomes. However, I do not refute your experience that this approach for you is beneficial.

        I believe your agenda here is pure and to persuade individuals to gain perspective to make their own choice and potentially provide further evidence to help this topic, however, I believe you need to provide more details. Otherwise, I feel this topic to be very slanted and persuasive to have readers follow your lead in the treatment of patients/clients.

        My last note is that you state that you agree to disagree but hope that we all have an open mind to at least acknowledge that early movement is beneficial. I do not think any rational or evidence based healthcare practitioner will disagree with that concept. However, I feel the confusion comes from the lack of evidence to compare cryotherapy effects vs exercise effects on the tissue healing process. From my opinion, I feel these are two totally separate topics that need to be addressed separately. I would encourage you to also have an open mind to re-evaluate your posting and try to help us understand the benefit vs consequences of using cryotherapy on tissue healing cycle. Therefore, a PICO question may be stated, “For patients with acute ankle sprains (0-48hrs), does the use of cryotherapy vs no cryotherapy aid in the progression from inflammatory stage to repair stage of the tissue healing process? I feel this would better help defend your position and may better serve to providing a more evidence based approach to clinical decision making.

        Reply
        1. Joshua Stone Post author

          My lord, Joe! I just typed up a two page response to your comment and accidentally hit refresh. So, my apologies, but you now get the abridged version.

          You make a very good point and thank you for the comment. I really do appreciate comments, no matter if they agree or disagree, so long as they are professional and well thought. After reading your statements I can agree, my view is slanted and biased. I am only presenting one side of the facts. However, this is what I feel needs to be done to get clinicians to open their minds. My job (as I define it) is to get us to think and ask are we doing the right thing? Personally, I don’t think we are.

          Through my years as a clinician, I – like my peers – used iced religiously. Then one day I tried skipping the ice. Over time those who skipped the ice had better outcomes. I read the research and found the data to be – as you mentioned – equivocal at best. So, if the data is equivocal, why do we have such a big dependency on ice? Why are athletes wrapped in ice after practice? Why after games and events do the home and visiting teams have coolers full of pre-made ice bags? Why do treatment logs show ice being used 2-3x more than any other therapeutic intervention? Is ice THAT good? Is the data that supports ice that overwhelming that it deserves that much use? No, it does not.

          We – the profession in general – have developed an over dependency on ice and the data absolutely does not support this. What I am trying to do is get people to think twice. We have a toolbox filled with many tools. Let us use the best tool for the situation. Ice is not always the best tool. Wish I had time to write more.

          Reply
          1. Joe

            Josh,

            I agree with you from my experience ice is being used more due to laziness and lack of time from both the patient and clinician.

            People do not like change but in a profession that is ever changing we have to commit ourselves to being open minded and use our resources to make the best available decision for the care and management of the patient. This is difficult to many but I feel the more evidence we can present and the more shared experiences will help people feel more comfortable about the changes taking place.

            Thanks

    1. Joshua Stone Post author

      Hi,

      I provided a couple of references on the comment above. Also at the end of the article there is a link to ask of my other icing articles. Follow that link and you will find a bunch of references. This article is s pull from those.

      Reply
  11. Mark Shires, ATC (@Mark_Shires)

    Josh-

    Always a good read! I think as mechanotherapy continues to gain traction we need to defferentiate between “jump starting the inflammatory process” and starting to affect/tweak the healing process. Or just get rid of inflammatory in our vocabulary and talk about the fluid itself – edema, odema, ecchymosis, etc.

    Mark

    Reply
  12. Gad

    Does that mean athletes have been doing it wrong all this while? For example NBA players ice after every game or practice. Curious to hear your comment on this. What about hot / cold treatments after strenuous activity?

    Reply
      1. Paul

        Great article. I very much agree with your position, though I do feel as though NBA players who regularly play back to back ice to alleviate discomfort, much like ice baths are used to blunt the inflammatory response… Would you agree?

        Reply
  13. Paul

    I am a PT and regularly would use ice with my clients. However, after incurring a severe ankle sprain myself, the day before my best friend’s wedding (in a location where ice was not available), I decided to push through the discomfort and progressively weight-bare. An injury I would have diagnosed to have sidelined me from competitive sport for 4-6 weeks, and with an active rehabilitation, using the RICE principle MINUS THE ICE (RCE?), I was able to (uncomfortably) jog for short periods 2 days later. Back to rugby 16 days post injury.
    It made me realise how an active rehabilitation, and promoting blood flow (limiting apoptosis through IGF-1 as you eluded to), lead to a better prognosis, with more cellular repair as opposed to cell death. Resultantly, less inward migration of collages fibres, and less non-functional scar tissue layer down. I now employ this method (especially for athletes) within my clinics, and have had outstanding results, with a much faster recovery, with better functionality.

    Reply
  14. Mike Jones

    That is quite an interesting article, hadn’t heard of anything wrong with icing before in the many years of sports I played or in my years majoring in Kinesiology. I have a second ACL surgery coming up so I did wonder about using ice for my bone, but I did notice the other comment someone wrote about post knee surgery, Gate Control Theory, and the TENS unit. Thanks for the research and information.

    Reply
  15. Timothy J. Demchak PhD, ATC

    Very interesting list of reasons not to treat with ice. You seem to have mixed acute treatment and treating for other reasons like pain post practice. I agree with most of your reasoning. One alternative treatment that has supporting research is Low Level Light therapy now termed Photobiomodulation.

    Reply
  16. John

    I find it interesting that your article does not list Ken Knight’s “Cryotherapy in Sports Injury Management” in the bibliography. He essentially wrote the book on cryotherapy, as there really isn’t another one out there. He specifically talks about the bodies inflammatory response and the fact that once it is activated it tends to overshoot it’s needs causing secondary hypoxic injury. This is the reason for using ice for acute injuries. To harness the response and get it back on track and reduce secondary injury. He also advocates early mobilization and using ice massage to reduce pain and muscle guarding in order to facilitate early mobilization. So the book which laid the foundation for cryotherapy and was written over 20 years ago, essentially supports what you are saying, but explains how to use it properly within the inflammatory cycle and how to utilize it to get early mobilization. Why write an article saying ice is useless for injuries? Why not refer to this book for some of your information? There’s a better way to go about it. Shock and awe just creates more confusion and people trying to defend a dogma. Use all the information to open people’s minds and show them what they have available to them and how they might adjust their current use.

    Reply
  17. Eric

    I am currently a student, but what I have been taught and understand is that inflammation is an important and required process for tissue repair, but cryotherapy is used in order to prevent EXCESSIVE or CHRONIC inflammation which can become detrimental to the natural healing process. Also, I have never understood that icing completely occluded blood flow to a given area, but rather decreases the blood flow and prevents excessive blood and fluid accumulation. Therefore, when used in conjunction with active rehabilitation and movement, cryotherapy can aid in optimal tissue healing. Let me know if you feel my line if thinking is flawed.

    Reply
  18. Roberta J Robison

    I am curious as to your opinion on the benefits (or lack thereof) of the homeopathic remedy arnica montana as a pain and swelling reducer. It is my understanding that it is regularly used by smoke jumpers if they sprain an ankle, for instance. Our family uses it all the time with quite astonishing results. In your opinion, would its swelling reduction compromise healing in the same way icing would?
    Further, what specifically do you recommend for pain – NSAIDS?
    thank you for a very insightful article and webpage!

    Reply
  19. Darren M

    Idiotic w zero randomized controlled trials to support any “evidence” you have on use of NSAIDs and ice. All opinion – no facts w any level of statistical significance. I hope to God you aren’t a doctor or trying to sell some kind of homeopathic therapy for injury.

    Reply
    1. Paul

      NSAIDs have irrefutably been shown to decrease platelet aggregation (Schafer, 1995; Konkle, 2005; Jarvinanin, 2011…) take your pic. There is a plethora of evidence. Hence the reason that elite sporting teams are now limiting the use of NSAIDs to post 48-72 hours of an acute injury.
      Furthermore, Van Dam Bekernan (2012) completed a systematic review of all literature regarding the reduction of excessive inflammation by the use of 1. Ice 2. Compression 3. Ice and compression. It showed that compression was significantly more beneficial than ice, and that ice and compression combined showed no significant difference to compression alone… With the exception that the use of ice slowed lymphatic drainage and therefore promoted a slower return to normal effusion. Hmmmm… No evidence?
      Your band wagon is getting away…

      Reply

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