Hot Take - Icing Injuries Should NOT Be The Go-To Treatment
“Some say the world will end in fire,
Some say in ice.
From what I’ve tasted of desire
I hold with those who favor fire.
But if it had to perish twice,
I think I know enough of hate
To say that for destruction ice
Is also great
And would suffice.”
Key Takeaways
RICE (rest, ice, compression, elevation) became the go-to injury treatment after Dr. Gabe Mirkin created the acronym in 1978.
Recently, Dr. Gabe Mirkin has debunked his initial theory based on 4 key points:
Healing requires inflammation
Ice keeps healing cells from entering injured tissue
Anything that reduces inflammation also reduces healing
Ice also reduces strength, speed, endurance, and coordination
Healing does require inflammation, and ice does reduce inflammation
The majority of studies show that ice reduces rate of healing
RICE may be effective not because of icing but in spite of it
Full Story
“Hey John, hope you’re doing well in North Carolina! So I, like, rolled my ankle playing basketball yesterday and it hurts a lot. Should I put ice on it or something?”
A text I frequently receive, yet I am never confident in my ability to reply to this solicitation of free, amateur physical therapy advice. As a second year doctorate of physical therapy student, one would expect that by this point I’d have acquired the baseline knowledge to confidently reply with a treatment for the common ankle sprain. My initial instinct, instilled more by personal experience than by concrete evidence I learned in school, is to text back:
“All is well, thanks for asking! Sorry to hear that. You can’t go wrong with RICE- rest, ice, compression, and elevation.”
I have, in fact, sent this reply many a time. But my lack of certainty always lingers for days after I press that “send” button and go on with my day. “Can’t go wrong with RICE”…
...”Can’t go wrong with RICE”…
...”Can’t go wrong with RICE” swirls around my head at night, haunting my dreams. What if everything we have been told is wrong? What if you CAN go wrong with RICE?
After some introspection, I realized I haven’t the faintest idea why RICE is the go-to recovery protocol. I can regurgitate information that I’ve memorized, such as that RICE:
Decreases inflammation
Reduces swelling
Reduces pain
Hastens recovery
Prevents further injury
But the simple question of “how?” renders me speechless. I don’t know! My confusion can only mean one of two things:
I didn’t study well enough to remember
The supporting evidence is not substantiated by research or just doesn’t exist
Trust me - 99 times out of 100, my subpar study habits are to blame. With RICE, I’m not so sure. RICE may very well decrease swelling, inflammation, and pain, but I am very skeptical about its ability to accelerate healing. In fact, because ice reduces swelling and inflammation, two integral components of the body’s natural healing process, it may actually slow down recovery rather than enhance it. Have we been hoodwinked? Let’s find out.
Background
The story begins in 1978 with Dr. Gabe Mirkin, the author of the best selling “The Sports Medicine Book” and creator of the RICE acronym (1). At the time, Dr. Mirkin had believed that RICE was best for treating athletic injuries because it reduced pain and swelling. For the next 40 years, this brief explanation was sufficient for the acronym to sweep the country, and for everyone, from little league coaches to doctors, to recommend it as fact. Sprain an ankle, pull a hammy, or tweak your back? The answer was always RICE.
RICE became a panacea for youth athletes and professionals alike, and why shouldn’t it have been? It was simple, catchy, and even supported by a well-known sports medicine physician. Who were we to question the effectiveness of RICE? Luckily, we didn’t have to - because the founding father of RICE himself has questioned it for us! That’s right. Dr. Mirkin now believes that RICE does more harm than good. On his website, he states:
“Coaches have used my “RICE” guideline for decades, but now it appears that both ice and complete rest may delay healing, instead of helping.”
The reasons that RICE is a suboptimal recovery tool, Dr. Mirkin explains, is because:
Healing requires inflammation
Ice keeps healing cells from entering injured tissue
Anything that reduces inflammation also delays healing
Ice also reduces strength, speed, endurance and coordination
As intriguing as it sounds to simply drop the mic here and trust that Dr. Mirkin has it all figured it out this time around (it sure would save me some effort and free up time to get back to watching Game of Thrones), I just can’t bring myself to do it. If there’s anything I learned from, well, Dr. Mirkin himself the first time, it’s that we cannot blindly trust a physician, or any person of power for that matter, without assessing the validity of his/her message.
Here, I am going to do just that - assess the evidence supporting RICE and delve into the 4 reasons Dr. Mirkin lists to debunk his initial theory. When it’s all said and done, we may just find reason enough to throw away the ice packs and retire RICE once and for all.
Healing Requires Inflammation
What comes to mind when you hear the word inflammation? Most likely, the color red floods your vision and you picture a hot, fiery pit of pain and despair. You may think of all the headlines you’ve come across such as “Tips for Decrease Inflammation and Preventing Disease” and “Anti-inflammatory diet - Foods that Reduce Inflammation” (3, 4). Perhaps your medicine cabinet comes to mind, chock full of over-the-counter meds such as Advil and Aleve that promise to stop inflammation dead in its tracks. Contrary to popular belief, inflammation is not the villain it’s been made out to be.
It may surprise you to learn that it is a widely accepted theory across the medical community that healing takes place across three phases:
Inflammation
Repair
Remodel (5).
Many overlook an entire third of this near fact when they unjustifiably demonize all inflammation. Don’t believe everything you’ve been told about inflammation - it is a GOOD thing!
Don’t get me wrong, chronic inflammation is harmful and plays a role in development of conditions such as rheumatoid arthritis, type 2 diabetes, and cancer. But acute, localized inflammation is your body’s 911 emergency response to injury. It is our secret healing weapon, the life-saving ace up our sleeve developed by millions of years of human evolution.
After an injury, inflammatory white blood cells rush to the problem area. These white blood cells, including neutrophils and macrophages, not only clean up the harmed tissue but also release IGF-1, a hormone that initiates regrowth and repair (6, 7, 8). Inflammation plays an integral role in the healing process. It follows, then, that essentially blocking inflammation with ice would delay healing - and it’s backed up in the literature (9).
“...inflammation can occur without healing, but healing cannot occur without inflammation.”
2. Ice Keeps Healing Cells From Entering Injured Tissue
Ice is great for skating, hockey, and keeping beverages cool, but is it an effective treatment we should be using in the clinic? Once you consider that ice actually delays the healing process, the answer becomes quite clear.
How does applying ice delay the healing process? Simply put, the reason that ice reduces the effectiveness of the body’s natural repair system is because it slows everything down. Researchers have found time and time again that icing an injury reduces local inflammation (10-14).
Ice exposure reduces inflammation by causing blood vessel constriction and restricting the flow of cells that promote healing. Worst of all, this vasoconstriction and delayed healing lasts for quite a while - it appears that ice exposure reduces local inflammation for up to hours after it has been removed (15). This prolonged vasoconstriction reduces blood flow and blocks the inflammatory cells that heal the injury, effectively delaying the healing process.
Applying ice to an injury is not unlike a drawn out trip to Costco. All you want to do is get in and out, but a packed parking lot, unhurried shoppers moseying up and down the aisles, and a never-ending self checkout line delays the entire process. When the body is unencumbered by ice, the parking lot, store, and line are all empty. The inflammatory stage takes full effect and healing cells are free to enter, streamlining the process and facilitating efficiency.
3. Anything That Reduces Inflammation Also Delays Healing
Let’s recap -
A. Healing requires a robust inflammatory response
B. Ice prevents inflammation
Drawing on the transitive property from freshman math class, it follows that anything that reduces inflammation, i.e. ice, delays healing! This leap sounds reasonable in theory, but is it supported by the research?
Do studies show that ice delays healing?
In a word, yes. On a cellular level, these researchers showed that cold exposure decreased the levels of vascular endothelial growth factor (repair cells) (16). And these authors concluded that icing injuries may be related to a “delay in muscle regeneration, impairment of muscle regeneration, and redundant collagen synthesis” (17). It makes sense. Once again, if you decrease inflammation, you reduce the effectiveness of the body’s repair process (18).
Many, many studies have found similar results:
This study found that cold exposure does not enhance the healing process and may even delay it (19).
This one from 2013 found that topical cooling delays healing from eccentric exercise (20).
Similarly, these findings even suggest that icing can slow down and impair muscle regeneration and lead to excessive collagen deposition at the site of the injury (21).
This one found that while cold exposure reduces swelling, it does not improve markers of muscle recovery (22).
These researchers concluded that, “There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries” (23).
This review, albeit one of questionable statistical strength, found that ice was not more effective than a control treatment for improving function after ankle sprains (24).
This 2012 review of randomized controlled trials found that “Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults” (25).
This study found came to a similar conclusion: “The physiological effects of cold therapy include reductions in pain, blood flow, edema, inflammation, muscle spasm, and metabolic demand. There is limited evidence from randomized clinical trials (RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness (DOMS)” (26).
Ultimately, the conclusion of this last study encompasses the overarching results of the vast majority of research: at the very least, cold exposure does not appear to accelerate healing and may even slow it down (27). Pretty damning evidence against the use of ice, if you ask me.
After diving into the research on ice and healing, two more interesting questions emerge:
A. Has RICE been considered effective only because of compression?
It’s possible that ice has been stealing the spotlight from a more deserving recovery tool, compression. As it appears likely that cold exposure does not improve healing, it stands to reason that if one does experience a benefit from the RICE protocol, compression may be the most important part of the equation.
Oftentimes, ice and compression are paired together in treatment, muddying the waters of which has the most significant healing effect. For instance, this study, which found immediate compression and ice to be more effective than delayed ice or heat therapy, illustrates the confounding variable situation of assessing the effectiveness of both compression and ice (28).
In studies that assess each treatment individually, the effects of ice alone compared to compression are unsurprisingly lackluster. This systematic review found that, in general, ice and compression after acute soft tissue injuries did not improve recovery more quickly than compression alone (29). The authors concluded that, “There was marginal evidence that ice plus exercise is most effective, after ankle sprain and post surgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients.”
Interestingly enough, the results of this study indicate that following an ankle sprain, treatment with compression increases rate of recovery while cryotherapy does not (30). Finally, this meta analysis discussed 8 studies that found little difference in patient outcomes of ice and compression compared to compression alone (31).
If compression is, in fact, more effective than ice, little league coaches and soccer moms (+ dads, no gender stereotyping here at Solokas Focus) should begin swapping out their readily-available ice packs for a sizable supply of ace bandages.
B. Is RICE effective only because it decreases pain?
While ice may reduce inflammation and pain, it likely does not improve function or markers of recovery.
These researchers found cryotherapy to be ineffective in reducing soreness after a training session (32).
This review found that cryotherapy following ACL surgery significantly reduced pain but did not improve range of motion or decrease swelling (33).
Along the same lines, though taking an ice bath may reduce feelings of soreness, it does not accelerate healing (34, 35).
Common themes begin to emerge after many studies report similar conclusions. In this case, the theory that ice reduces pain but does not accelerate healing seems all but certain.
4. Ice Also Reduces Strength, Speed, Endurance, and Coordination
Finally, Dr. Mirkin argues that while icing in the acute phase may reduce pain, it also decreases every aspect of athleticism. A 2011 review of 35 studies found that icing an injury for at least 20 minutes reduced strength, power, and speed immediately after treatment (36).
The authors recommend that if ice is warranted to decrease swelling, i.e. in the context of immediate return to action during a game, it be used only for 5 minutes and be followed by a dynamic warm up. Without a doubt, the use ice for more than a short period of time to improve immediate athletic performance is not supported by the evidence.
That’s It…For Now
As I tend to do, I’ve bit off more than I could chew and rambled on far too much. If you’ve made it to this point (I appreciate all three of you), check in next week for Part 2, where we will cover:
What supporters of ice would say in response to Part 1
Why people still use ice
New, better acronyms to guide you in treating injuries, now that you know that RICE is suboptimal
The final word on ice
Until next time, keep your ice packs in the freezer and save your RICE for sushi.
Sources:
https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
https://www.scripps.org/news_items/4232-six-keys-to-reducing-inflammation
https://www.webmd.com/diet/anti-inflammatory-diet-road-to-good-health#1
https://faseb.onlinelibrary.wiley.com/doi/full/10.1096/fj.06-7690com
https://www.sciencedirect.com/science/article/abs/pii/S027859192030507X
https://www.jscimedcentral.com/SportsMedicine/sportsmedicine-2-1015.pdf
