We have had the opportunity to work with many athletes from multiple sports. With the multitude of treatment options available to athletes and their healthcare teams, the one constant that you see in every training room is a bag of ice. Ice bags strapped to shoulders, wrists, backs, necks, knees and ankles. Ice for athletes is so commonplace that most of us have never stopped and asked: Is there any science that proves that our athletes benefit from icing all of their soft tissue injuries? Or worse, is there evidence that shows that the use of ice for soft tissue injuries will actually delay the healing process?

What Is Ice Good For?

First off, what is ice supposed to be used for? Most of us would answer that ice helps decrease the pain and inflammation of an acute injury. Recent research studies state that ice has been shown to reduce tissue temperature, blood flow, pain and metabolism. A recent blog article entitled Cold vs Heat Therapy. What Should You Use for Your Injuries goes into detail as to the mechanisms involved in icing injured tissue. However, does ice application improve treatment outcomes (i.e. does it reduce impairment after injury and does it help athletes return to sport participation faster)?

There is lack of evidence to support the use of cold therapy (cryotherapy) for healing. This is an amazing statement considering that most athletes reach for an ice bag as their first choice of therapy with almost any new injury. So let me say it again, there is really no strong evidence that supports the use of ice for healing soft tissue injuries. Furthermore, a recent movement in the manual therapy community has proposed that icing might even be counterproductive to proper natural healing following acute injuries.

What About RICE?

Decades ago Dr. Gabe Mirkin coined the term RICE (Rest Ice Compression Elevation). Most recently, clinical trials on the efficacy of RICE for inflammation control after acute injury or surgery have supported the use of compression but have found very little support for the value of icing other than for a temporary numbing and pain suppression effect.

Evidence shows that cryotherapy slows metabolic processes and nerve conduction velocity. During healing we breakdown injured tissue and rebuild new tissue. Cold inhibits this function, so in a sense we could be slowing the healing pathways.

Even the creator of the RICE acronym, Dr. Mirkin, has issued a statement that suggests that the way we treat acute injuries needs to be rethought: “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.

What is Healing and How Does Inflammation Help?

There are 3 phases of healing following an acute injury:

1. Inflammation – see detailed explanation below
2. Proliferation – rapid reproduction of new cells
3. Remodeling – formation of new cells into new tissue

Inflammation is a normal response following acute soft tissue injuries. Acute inflammation results in increased permeability of the blood vessels, allowing more blood to arrive, and causes fluid build-up around injured tissue. This accumulation of fluid (edema) at the injury site should be considered a positive reaction as it increases sensitivity to pain and restricts movement (to prevent us from further injuring the tissue). Contained in this fluid build-up are healing white blood cells that begin the proliferation phase of healing at the injured site that will soon lead to remodeling of the injured tissue. The lymphatic system naturally and slowly removes all the waste products and excess fluid buildup caused by the inflammatory process. It turns out that we could be negatively affecting tissue remodeling and healing through our desire to get rid of inflammation with icing.

But If Not Ice What Should We Use?

The two options that seem to demonstrate the most promise related to promoting the healing process are compression and movement/exercise. So let’s change the RICE acronym:

• replace the Rest with Movement (as much as can be tolerated based on the injury involved)
• drop the Ice
• use Compression in the form of bands, sleeves, compression clothing etc.
• Elevation still makes sense if possible

Evidence has shown that tissue loading through movement/exercise or other mechanical means stimulates formation of type I collagen fibers (remember the remodeling phase of healing). Also, while the circulatory system relies on the heart for continuous transport of blood through its vessels, the lymphatic system does not have a “heart” and therefore primarily relies on muscular contraction/movement for lymphatic drainage. Lymphatic drainage may be assisted by elevation and compression.

Here is What We Suggest

Ice can cause a temporary decrease in pain after acute injury, but is it worth the potential hindrance to proliferation and remodeling of the healing cascade? Until more research is performed on this topic to clarify the issues, we are left with a best guess as to what action to take for acute soft tissue injuries. Only use ice if your pain level is severe enough to prevent sufficient rest/sleep. If you use ice, adhere to the guidelines already outlined in a previous article. BTF recommends that you focus on movement/exercise within your pain tolerance levels for most soft tissue injuries. Luckily, BTF has a multitude of exercise videos available in the Videos section of our backtofunction.com website to get you started. For specific instructions on the best exercises for your condition, please consult with one of our elite doctors, as they will help you Feel & Perform Better!

References:

• Stone Athletic Medicine. stoneathleticmedicine.com
• Bahram Jam PT, Paradigm Shifts: Use of Ice & NSAIDS Post Acute Soft Tissue Injuries. Aptei.com
• Hubbard, T.J. et al. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Journal of Athletic Training. 2004.
• Guilhem et al. Effects of Air-Pulsed Cryotherapy on Neuromuscular Recovery Subsequent to Exercise-Induced Muscle Damage. The American Journal of Sports Medicine. 2013.