Changing brings difference, difference brings progress and if progress was easy to achieve it would not be so hard to accomplish.
This is always going to be a difficult topic to discuss when dealing with an acute injury. The knee jerk reaction is to apply the ice to the sprained ankle or twisted knee as it’s something commonly used in general practice for over 40 years. This is not me condoning the use of the ice if you’ve had good experiences with it in the past, just providing another way of approaching the recovery of an injury with current literature and using clinic reasoning.
Most of us have been familiar with R.I.C.E. (Rest, Ice, Compression, Elevation) for the initial treatment of acute injuries, which was first published in sports medicine book by Dr Gabe Mirkin in 1978. The acronym was easily remembered and became engrained in all environments with little to no challenge of its overall effectiveness. In the last 7-8 years, there has been more evidence published to question inclusion of ice as an essential tool for an acute injury. In fact, Dr Mirkin has reviewed the current research and done a complete turn on his own recommendation of using ice.
Why use Ice?
The whole idea of icing was to restrict blood flow to the damaged structure, to minimise swelling and bleeding. This was to be applied at regular intervals for the first 2-3 days. It was believed that the swelling restricts range of motion and delays the overall length of recovery. Also, it works as a natural numbing agent to help with pain relief
What’s happening when we get injured?
A multitude of things begin to happen in the body when faced with an injury. You may be aware of the three stages of an injury; acute inflammation, proliferation and remodelling. In that inflammatory stage the blood vessels dilate and increase permeability allowing an increased supply of white blood cells (Microphages and leukocytes) to the damaged site. These blood cells will help break down the damaged tissue and to promote healing will produce growth hormones. There is also increased swelling and the joint becomes more restricted and increases sensitivity to pain which both protects the joint from further damage. Our other less known system in the body, the lymphatic system (the “sewerage” system) slowly helps drain the area of fluid and other by-products.
What is the current evidence showing?
If blood flow is restricted through ice, this limits the release of white blood cells to the area. Lu (1) found that with a steady supply of growth hormone soft tissue can heal at a normal rate compared to tissue with limited/no supply of the hormone. Also, when ice is applied it has a longer lasting effect on vasoconstriction even after the ice has been removed (2), meaning the supply of these white blood cells is depleted for a prolonged time.
Also, the lymphatic system that I mentioned which helps draw away swelling and the “junk”, this is assisted by the pumping action of muscle contractions. Bleakley (3) demonstrated that the strength of a contraction is depleted when iced is applied and this would impact on the pumping action to lymph nodes that help draw swelling away from the injured site. Also, icing the injured site causes changes to the permeability of the lymphatic system causing fluid to leak back into the injured site cause more swelling (4 – I know it’s old but it was a foundational study).
Another study in 2011 (5) broke down the stages of healing even further, the soft tissue was sampled physiologically and under a microscope, comparing damaged tissue that had been iced and non-iced.
|Time after injury||No Icing Group||Icing Group|
|12 hours||Macrophages were found within the necrotic muscle fibers (Macrophage migration to an injured site to phagocytose the necrotic muscle fibers is essential for “clean-up”)||Less macrophages were found within the necrotic muscle fibers|
|Day 3||Regenerating muscle cells present||Reduced regenerating muscle cells|
|Day 4||Normal sized muscle cells produced||Smaller sized regenerating muscle cells|
|Day 14||Normal maturation of the regenerating muscle fibers||Maturation of the regenerating was visibly reduced|
|Day 28||Cross-sectional area of the regenerating muscle was 65% greater than the icing group Collagen fibers were seen only among the bundles of muscle fibers as it is seen in healthy muscles||Regenerating muscle fibers was significantly less in the icing group (P < 0.01) Abnormal collagen formation where collagen fibers surrounded each muscle fiber|
If no ice then what are we left with?
So now we know ice doesn’t need be put on this pedestal of being an essential tool in recovery post injury. It still has its place for pain modulation, but only for short periods otherwise it will cause prolonged vasoconstriction. Also along the lines of avoiding limiting the inflammatory process, we need to refrain from anti-inflammatories and stick to a mild pain killer (ie Panadol) if struggling with discomfort. If this does not control your pain levels, seek your GP for advice on stronger medication
Following an injury, we fear the worst which is understandable, therefore it’s important to have it assessed by a health care professional to determine the degree of the injury and be receive the best advice, treatment and referrals if needed (i.e. X-ray). To kick start the repair process, begin moving the joint or damaged tissue within a comfortable range as soon as possible at regular intervals through the day. When resting consider having the area elevated above the heart and wear some compression. This will all assist with the lymphatic drainage, putting your body in the best environment and allowing it do the work.
Other options worth considering if you have a high pain tolerance and a keen mobiliser. I’ve seen some good results with regular intervals of using voodoo floss recovering from injury. Although there is no literature to support voodoo bands. But in terms of releasing myofascial tissue which is the main structure the band is impacting on, this can improve lymphatic drainage (6).
There is no harm in using ice, as we’ve been using it for a few decades now, but looking at the latest research and its impact on recovery times, you might want to consider your options before chucking on the bag of peas.
- H. Lu et al, (2010) Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal
- Khoshnevis et al, (2015) Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
- Bleakley et al, (2012) Should Athletes Return to Sport After Applying Ice? Sports Med
- Meeusen, R. (1986) The use of Cryotherapy in Sports Injuries. Sports Medicine.
- Takagi, R, et al, (2011) Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys
- Bruno C, (2016) Lympho-Fascia Release and Viscerolymphatic Approach To Fascia,