Injured? Please Back Away from the Ice

Ice or “cryotherapy” has become a hot topic in the sports medicine world over the last couple years. Clinicians have debated on gold standards of not only when or how to apply ice modalities but recently, even if we should be using it all all!?


The fact that MLB pitchers are starting to ditch the ice packs around their shoulder post outing, should at least cue you take a deeper look. The same discussion is happening within my clinic, between practitioners and patients, who are asking me, “When and how long should I ice?” or even, “Is ice good or bad for me?” I’m sorry to say the answer to that last question is not a simple one.


Depending on a few factors, ice modalities can be beneficial or detrimental to our goals.


As a Physical Therapist we have gotten used to seeing ice applied to an injury, more specifically after tissue damage (i.e. sprained ligament or torn muscle). In this specific situation I can definitively say, ice is NOT YOUR BEST OPTION. I would even go on to say it is bad for you and recommend avoiding it at all costs!


In the absence of tissue damage, using ice for other purposes actually can be hugely beneficial, but what I want to stress here is the importance of NOT icing down that freshly injured knee!


Until recently, my philosophy on ice has been fairly benign. I have found that most medical professionals tend to have neither strong positive or negative feelings and leave it up to their patients or athletes. However we still see an overwhelming number of folks still not adapting to the evidence and continuing to take a pro-ice approach!


Many sports medicine professionals are stuck in the mind frame of: ice and ibuprofen fixes everything. My former view was it may have slightly helped with swelling, it seemed to help with pain, and there were really no negative effects other than it melting and soaking whatever you were wearing.


So why not use it, right? Wrong! It turns out ice is not this little benign treatment that only has positive side effects, in fact it even has the potential to PROLONG recovery.


We need to look at the healing process to explain why ice has negative side effects. It all starts with some form of tissue damage. his could be rolling your ankle while playing soccer, Trevor Bauer’s shoulder hurting after throwing over 100 pitches, or twisting your knee while crushing a WOD. That tissue damage sets in motion a cascade of events signaling your body to move towards repairing the damage.


The first stage of healing: inflammation. Inflammation is a good thing and is IMPERATIVE for proper healing to occur. This is usually where ice modalities are introduced. The conventional thought is we need ice to decrease the inflammation to aid in healing. By applying ice it is going to decrease blood flow to the area and thus reduce inflammation, which is a good thing, right?


This is my first argument against ice: Why should we slow down the inflammation process, which naturally occurs and if removed from the equation would stop healing all together? The dogmatic thought on this is “there is too much swelling and that’s what we are fixing!” If we are going to make that argument, how do we know how much is too much or how much is too little? Sorry to say there is no answer to that question.


Our bodies are the most complex and efficient machines on the planet, so why would it have a system in place, that routinely has an overreaction (i.e. swelling)? I am here to tell you, when your ankle “balloons up” after spraining it, THAT IS NORMAL, and not something that has to stop. Keep in mind this “evil” inflammation is bringing in all the healing factors to establish a good foundation for recovery. By attempting to decrease the inflammation you are actually decreasing the pipeline of supplies for healing. In practice, the ice is only going to make that ankle stiff and have the potential to cause far worse problems down the road.


Let’s move past the inflammation argument. The biggest issue I have with the use of ice after injury is it causes TISSUE CONGESTION. Let's take a couple of steps back and look at healing in an even broader sense. We can simplify healing into two steps. Put very bluntly our bodies need to bring good stuff in and get the bad stuff out. There are two systems that help perform these two tasks; our circulatory system brings everything in and our lymphatic system removes the waste. If there is any dysfunction with either of these two systems the whole process is dead upon arrival. THIS IS WHERE ICE COMES BACK TO BITE US. If it is applied it will reduce the blood flow, which causes tissue congestion! Everything in our body is designed to be in motion. I don’t care if it’s moving your arm overhead or your heart pumping the blood. If that movement doesn’t occur things go haywire.


By decreasing inflow you are going to have a direct correlation with decreased outflow. This development of tissue congestion is not only going to slow tissue healing but now because the inflammatory markers are sitting in the tissue, adjacent areas are going to start to be damaged. This means longer healing time and longer periods of you sitting on the bench. The only way for our body to remove that waste is our lymphatic system, which unlike our circulatory system is completely passive. This passive system relies on MUSCLE CONTRACTION AND MOVEMENT to help push the waste along. This means movement is the key to recovery, not ice and immobilization. In fact, as long as you can actively move without causing further tissue damage, that is the best thing you can do. It works like milking a cow: you need outside forces to help push the fluid along the path. So next time, think again before wrapping and applying ice after you roll that ankle! Please, you are only inhibiting these two systems from doing their job.


This is a very simplistic view of the healing process and there are many more steps to promote optimal recovery. This is just some advice to start that healing process on the right path, preventing you from wandering through the woods of recovery. If you don’t want to take my word for it, Dr. Gabe Mirkin, the MD to coin the phrase RICE (Rest Ice Compression Elevation) backtracked on the use of ice a couple years ago stating “Subsequent research shows that ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery.”


He even agrees that movement is the key. You can be the first of your friends to join the same movement of professional athletes ditching the use of ice post injury.


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