Icing Helps, Can’t Prove Otherwise
In September 2007, during a football game against the Denver Broncos, Kevin Everett of the Buffalo Bills, suffered a severe spinal cord injury that immediately left him paralyzed from the shoulders down. Immediately after the injury, the team’s orthopedic doctor, began treatment based on a familiar premise, apply ice to reduce swelling. As they were transferring Everett to the hospital, Dr. Cappuccino induced modest or moderate hypothermia or cold therapy by injecting the body with cold saline. The effect was similar to applying an ice pack on a soft tissue injury. It prevented the hemorrhaging and swelling that typically occurs from such an injury. This innovative approach at the time has been credited with helping Kevin Everett to walk again. A fracture of the cervical spine, as severe as the one that Everett sustained, historically, leads to permanent quadriplegia.
The scientific and medical community concurs, especially with personal and anecdotal stories such as Everett’s, that there is no doubt that icing an injured area helps reduce inflammation and pain. But after more than 30 years of using RICE to help manage soft tissue injuries, the effectiveness of RICE has come into question. We are well acquainted with the acronym RICE. If you don’t recognize it, it stands for Rest, Ice, Compression, and Elevation. This acronym has been around since 1978 when Gabe Mirkin introduced the term to treat soft tissue injuries. The usual icing protocol is to ice the injured area up to 48-72 hours after the injury – using rounds of 15-20 minutes of icing 2 to 3 times per day.
The debate centers around whether the best approach to recovery caused by trauma to an injured area is really icing or foregoing that icing process entirely for mobilization. This debate gained a lot more traction when in 2021, Dr. Mirkin retracted his statement in favor or not icing. Why has RICE become the most hated acronym after more than three decades of using ice? The question is about recovery.
In Dr. Mirkin’s retraction statement, he indicates his stance change was a result of medical literature that indicates icing hinders the recovery process and prolongs healing by not allowing inflammation to takes its natural course. What is the role of inflammation in the recovery process?
THE INFLAMMATION PROCESS
Immediately after a sprained ankle or other soft tissue trauma, that area becomes red, warm, and painful, and it begins to swell. The swelling process, also known as edema, is the result of acute inflammation, a response triggered by damage to living tissues.
When inflammation begins, this process is used to remove the damaged tissue to allow the body to begin to heal. There is dilation or widening of blood vessels to increase blood flow into the tissue, creating redness in the traumatized area. This is followed by an increase in blood vessel permeability, allowing fluid, proteins, and white blood cells to migrate from the circulation to the site of tissue damage. Swelling is the result of the all this movement to the injured site.
THE EFFECT OF ICING
Applying ice to an injury is done mostly to control pain and swelling acutely. The typical icing protocol calls for icing 10-20minutes two to three times per day up to 2 days after the injury. This helps constrict the blood vessels and slows down the white blood cells and organelles to help ease the pain that comes with inflammation.
Those against using ice cite this effect of icing on the inflammatory process. They argue that ice prolongs recovery because it hinders inflammation and therefore stops the recovery process.
Depending on the type of injury, however, swelling can become so severe that it restricts movement of the affected part of the body impeding its ability to heal and recover by restricting normal mobility. When swelling becomes painful and severe, “properly” icing the affected area is actually best. If inflammation isn’t managed, and is allowed to continue, this persistent low-level swelling, can actually cause prolonged tissue damage and unusually slow healing.
Ice can also cause tissue damage due to prolonged exposure to ice. In these extreme cases, frostbite forms, causing tissue, muscle and nerve damage. Tissue damage or tissue necrosis is caused when the skin is exposed to temperatures below 31 degrees F for about 30 minutes. At low cold temperatures, the skin freezes and ice crystals in the tissues form causing the damage. To prevent tissue damage, medical professionals always instruct individuals to have a protective layer between the ice pack and the body’s skin. Ice bags or ice packs should be wrapped with a towel before applying directly on the skin. As indicated earlier, icing should only be done in bouts of 15-20minutes and no longer than 2-3 days after injury.
RECOVERY TIMES FOR SPRAINS
Given the vasoconstriction effects to reduce inflammation, this automatically means that icing does slow down recovery, right? Not really! With all this talk about ‘slowing recovery,’ there’s evidence that an injury takes longer to heal when applying ice as indicated, right? Nope!
Sprain recovery continues to follow the general guidelines. Sprains are classified as Grades 1 to 3. Grade 1 sprains are minor injuries and take about 1-3 weeks to heal. Grade 2 sprains incur partial tears to the ligaments and take 3-6 weeks to heal. Grade 3 is the most severe with a full tear of the ligament. A Grade 3 sprain can take months to heal and actually requires medical intervention.
The severity of a sprain depends on the damage level and how unstable the joints have become. The more severe, the longer it will take to heal. To be clear, there hasn’t been any conclusive evidence that RICE is bad and that it actually delays healing.
In fact, a research study indicated that although icing does slow down the inflammatory response, it’s not enough to affect muscle regeneration. In other words, recovery wasn’t affected or slowed down. Sprains still follow the general rule of recovery even as you ice as recommended. And for that matter, not icing hasn’t made recovery any faster either. For example, there’s no research that we’ve found that shows grade 3 strains can heal in 1-3 weeks versus months.
MOBILIZATION AS PART OF RECOVERY
Ice is just the initial process of recovery. Critics of icing indicate immediate mobilization is better than icing.
However, trying to move through pain or severe swelling is contraindicated as it can cause more damage. Typically, 48 hours after the injury, when pain and swelling have significantly improved with icing…protection, heat and mobilization become the second important part of recovery.
While some critics are confounding the idea that bed rest or total immobilization is needed for recovery, that’s not the general guidance from medical professionals.
Protecting the injured area from re-injuring, restoring the normal range of motion of the joint and strengthening its ligaments and supporting muscles is the ultimate goal. Studies have shown that people return to their normal activities sooner when their treatment emphasizes restoring normal function rather than immobilization. This strategy is known as functional treatment, involves three phases: 1. The RICE regimen in the first 24 hours to reduce pain, swelling, and risk of further injury; 2. Range-of-motion and strengthening exercises within 48–72 hours; 3. Improve strength endurance and balance once recovery is well under way.
However, when swelling and pain is allowed to persist, it delays recovery because weight-bearing, range of motion and balance drills, which are so critical in the second phase of injury care, can’t be performed without altered mobility due to the pain and swelling, leading to risk of further injury.
ICING “IS” AN APPROPRIATE TREATMENT APPRROACH
With the recent literature indicating that suppressing inflammation with icing hinders the recovery process – actual scientific data hasn’t been as conclusive to the actual effects of icing as people believe. Here’s what IS conclusive without a doubt:
- Ice helps reduce pain and inflammation
- Chronic, low-level inflammation leads to tissue damage
- Icing should can be done up to 72hours after injury
- Icing 10-20minutes 3 times a day will help prevent overexposure effects of ice
- Ice bags or packs should be wrapped with a towel to avoid direct contact with the skin
- Mobilization after pain and swelling have subsided is necessary part of recovery
- Protecting the injury from re-injury is critical
- Icing isn’t necessary if there is little to no inflammation or pain
- Icing is contraindicated in patients who suffer from open wounds, peripheral neuropathy, and diabetes
- There is NO evidence that quantifies icing delays to recovery. For example, icing for 10 minutes leads to a delay of x number of hours, days, months.
The take away, if you have pain and severe swelling after soft tissue trauma, ice properly! As Dr. Mirkin endorsed in his own retraction statement – “Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs.”