Why Do People Still Ice?
“...So how about asking these two questions instead: (1) Is the body’s healing response to injury a mistake? (2) Does icing help my body remove the congestion from the injury?
Even without a doctoral degree and a truckful pathophysiology coursework, the answer to those questions is a pretty clear ‘no.’”
Key Takeaways
Just because icing isn’t the most effective treatment the majority of the time doesn’t mean it’s wrong.
There are plenty of valid reasons and situations to use ice in the recovery process, including:
Limitation of excess tissue damage
Prevention of secondary injury
Playing a potential role in return to sport
Patients believe in it
The ultimate goal is to choose the most appropriate treatment based on the strength of the supporting evidence and the individual goals of the patient.
Acronyms such as PEACE and LOVE, POLICE, and ARITA may all be more appropriate than RICE
The final word: Ice is not evil nor a panacea, it always depends.
Full Story
“It just doesn’t add up. If John said icing doesn’t work, why do I see LeBron James and Tom Brady on the sidelines wrapped in the stuff? The best athletes in the world use ice, surely it must be an effective treatment.”
Did you have a similar reaction to last week’s article on why icing should not be the go-to treatment? I wouldn’t be surprised. LeBron James and Tom Brady are the most successful athletes of our generation and have a decorated staff of sports medicine doctors, PTs, and athletic trainers at their service, and I’m just some guy! I’d take their side as well.
To clear up a few important points:
Just because icing isn’t the most effective treatment the majority of the time doesn’t mean it’s wrong.
There are plenty of valid reasons and situations to use ice in the recovery process
If I was LeBron James’ or Tom Brady’s PT and they asked me for ice, even if I knew it wasn’t the best for their recovery, 100/100 times I’d be running as quickly as possible to fetch the nearest ice pack.
In physical rehabilitation, no treatment decision is ever completely “right” or “wrong.” Because many interventions can be effectively employed to improve a patient’s function, “it depends” is almost always the correct answer when analyzing a recovery protocol. The ultimate goal is to choose the most appropriate treatment based on the strength of the supporting evidence and the individual goals of the patient.
There are many studies, anecdotes, and professional opinions that support the use of ice in the recovery process. In fact, here is a very well written 2020 article that dismantles many of the arguments I made last week (2).
Whether or not you agree with my stance, taking a moment to read this article is well worth your time. The use of ice to treat musculoskeletal injuries is an especially nuanced and highly debated topic - there are no right answers. Not even mine!
Today we’ll discuss the counterarguments I suspect many would make in response to my previous article and explore the reasons that ice is still a widespread treatment, used by everyone from LeBron James to the stars of your local dad softball league. Finally, we’ll address possible fallacies in my argument and wrap up with a look at new acronyms that may take the place of the hackneyed and outdated “RICE.”
What would opponents say?
“Correct, inflammation is necessary for healing. But in the acute phase, uncontrolled amounts of inflammation do more harm than good.”
Ice cream and puppies are good. But if you eat ice cream for every meal and fill every square inch of your apartment with puppies, you’re bound to run into some problems. Is the same true with inflammation?
As we know from the harmful effects of chronic inflammation, the answer over the long term is a resounding “yes!” In regard to acute inflammation, I’m not sure. We’ve discussed that inflammation is a necessary component of the healing phase, but the question is, “when does too much of a good thing become a bad thing?”
Oftentimes with an acute trauma the injury is localized to one or two tendons, ligaments, etc. And if you’ve ever seen an ankle blow up to three times its original size after a sprain, you know that inflammation can spread far beyond the injured area.
Is ice helpful to prevent harm to the uninjured structures, even if it may slow down the healing process of the injured site? In the acute phase of severe injuries, it appears so….
2. “Ice should be used to limit tissue damage and prevent secondary injury.”
Secondary injury is a destructive change in cells and tissues that leads to dysfunction after initial injury (3). If applying ice to an injury decreases the magnitude of secondary injury, it follows that ice treatment would be warranted in the acute phase.
Dr. Ken Knight, well known for his research on the effectiveness of ice to treatment, argues that ice reduces the harmful effects of inflammation and, through vasoconstriction, reduces the accumulation of waste material (4). Others support Dr. Knight’s position and have shown that ice does, in fact, reduce the severity of secondary injury (5 -8).
This study in mice found that ice prevented microvascular and endothelial dysfunction and resulted in less inflammation and swelling after soft-tissue injury (9). Moreover, the researchers found that ice reduced the development of acute microvascular injury and decreased secondary tissue damage.
Along the same lines, this other mice study found ice does not delay healing despite effectively reducing inflammation (10). Ice may also prevent the development of post injury hematoma, though the evidence is relatively weak (11).
In the case of severe swelling following acute trauma, it appears that the use of ice in the short term (<48 hours) is effective for reducing secondary injury and preventing undue harm to tissue surrounding the site of injury (12).
3. “Ice reduces return to sport times.”
To an athlete that has suffered an injury, there is no goal more important that returning to sport as quickly as possible. This small, relatively weak systematic review found that ice may reduce return-to-sport times (13).
This study found the immediate use of ice to be more effective than heat or delayed ice in reducing return to activity time, but the ice treatment was coupled with compression (14). Was it the ice or the compression, or a combination of the two, that reduced return to sport time? I don’t know, and neither do the researchers.
On the other hand, this 2018 review concluded that, in spite of its inflammation reducing effects on a cellular level, the available evidence does not support the use of ice for treating musculoskeletal injuries (and, as an extension, does not appear to reduce return-to-sport times) (15).
On a cellular level, ice has been shown to reduce inflammatory markers (prostaglandins) associated with pain after knee surgery (16, 17). Though ice reduces local inflammation and slows metabolism thus indicating a decreased rate of healing, perhaps the analgesic effect of the ice is effective in allowing the patients to more quickly begin active recovery?
The use of cold to facilitate exercise, commonly referred to as “cryokinetics”, is an idea that supports the use of ice in a return to sport situation (18, 19, 20). If ice does reduce pain enough to facilitate more movement and blood flow, it's plausible that it could be beneficial in the early stages of rehab.
Why do people still ice?
There are many possible answers. The most likely options that come to mind include:
Because it’s how we’ve always done it
Do you know when Hippocrates lived? Neither do I, but it was a very long time ago and it’s when people began using ice to treat injuries (21). Once concepts have taken a foot hold in society it is tough for us to let them go.
“What we’ve always done” is comfortable and safe, but if we always chose this option we’d make no progress in the physical therapy profession. Without change there is no room for evolution, improvement, or innovation.
Because it reduces pain
Ice does reduce pain, but is the juice worth the squeeze (22)? Ice provides a numbing effect and thus reduces the sensation of pain. If your pain is so intense that it causes extreme psychological distress or interferes with your ability to carry out daily tasks, then ice is by all means an effective short term strategy.
Ice has even been shown in some studies to reduce the amount of prescription pain killers needed post-surgery (23, 24). But if the pain is manageable and the goal is to return to full strength as quickly as possible, skip the ice.
Because patients like it
Another worthy answer. If patients believe that ice will improve their healing, who are we to tell them otherwise? After all, our goal as PTs is to reduce pain and improve function.
If ice gets the patient where they need to be, whether it be because of the placebo effect or otherwise, it is an effective treatment (25). Once again, though, we need to do a cost benefit analysis and decide if ice is benign or causing serious setbacks in the recovery process.
Call the POLICE or show PEACE and LOVE?
Dr. Mirkin may have been mistaken with his initial treatment protocol and we have reason to be upset! Should we call the POLICE or accept his new remarks with PEACE and LOVE (or ARITA)?
Call the POLICE -
Protection
Optimal loading
Ice
Compression
Elevation (26).
Very similar to RICE, but instead of suggesting complete rest and inactivity this acronym stresses the importance of loading. The authors argue - and I agree - that replacing rest with a graded exposure approach to loading is the best treatment to encourage a quick recovery. The creators of POLICE argue that it is not simply a recovery reminder but an invitation to think critically and seek out innovative treatment for acute soft tissue injuries.
Accept with PEACE and LOVE-
Protection
Elevation
Avoid anti-inflammatories
Compression
Education and
Load
Optimism
Vascularisation
Exercise (27).
It may be a tad ambitious to ask the majority of patients to remember an acronym as comprehensive as PEACE and LOVE, but it may be the most well-rounded plan for those seeking to take every measure to return to sport as quickly as possible (28). Unlike POLICE, the authors of this acronym decided to exclude ice altogether and even devoted an entire to letter to make their position on anti-inflammatories very clear: AVOID them. In regard to ice, they state:
“Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft-tissue injuries. Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay
neutrophil and macrophage infiltration as well as increase immature myofibres. This may lead to impaired tissue repair and redundant collagen synthesis.”
Finally, the authors make a fantastic point that the goal of soft tissue injury management is to treat the person, not the injury. Regardless of the specific treatment protocol or acronym, we can never go wrong by prioritizing the patient’s history, current abilities, and future goals.
Finally, we’ll finish up the easiest one to remember:
ARITA
Active
Recovery
Is
The
Answer (29).
Short, sweet, and memorable. Perhaps a bit too simplistic, but it stresses the most important aspect of recovery - movement and blood flow to facilitate the healing process.
Where I May Have Gone Wrong
I’m not a PhD, MD, and not yet a physical therapist - I am, by no means, an expert. I do my best to take an unbiased approach and draw reasonable conclusions based on the available evidence. While making my argument, I could have fallen victim to a few fallacies:
Confirmation Bias
Definition: The act of selectively considering evidence based on your own belief.
In this case: Because I am more inclined to think that ice delays healing, I would focus my attention on research that supports that stance. I tried to take an unbiased approach, but I’m sure I’m at least a bit guilty.
False Equivalencies
Definition: The act of drawing an equivalence between two topics based on flawed reasoning (30).
In this case: Comparing healing (the primary outcome we’ve been assessing) with muscle soreness, return to sport times, pain levels, etc. I certainly did this.
Sampling Bias or “Cherry Picking”
Definition: Pointing to individual studies that support one’s stance while ignoring data that shows otherwise
In this case: Only sharing studies that support the position that ice is harmless or effective. I’d argue I did a good job at not doing this.
False Logic
Definition: If A=B and B=C, then A+C.
In this case: Claiming that since ice reduces inflammation and inflammation is necessary for healing, ice reduces the healing process. I did exactly that, and I don’t think it’s too great of a leap to make.
There you go, 100% transparency! You are now armed with the knowledge to make your own informed decision, regardless of any one person’s specific stance.
Wrap Up
To ice or not to ice? It depends! Specifically, whether or not ice is the appropriate treatment depends on the:
Patient’s goals
Patient’s prior level of function
Patient’s history
Patient’s beliefs
Nature of the injury
Duration of the injury
How much time has passed since the injury
Timetable of return
Just to name a few! The bottom line is that pain and injury recovery are complex, nuanced topics. Ice may be a beneficial treatment if:
The injury is severe and secondary injury is a concern
<48 hours post injury
Pain is unbearable
It reduces swelling enough to facilitate active recovery
The evidence is inconclusive! More research is needed to clearly define the most effective protocols for ice. The final word: Ice is not evil nor a panacea, it always depends.
Remember - if you’re ever 100% sure of something, you’re probably wrong.
More Resources
If you’re interested in learning more about the ice debate, here are a few informative and thought-provoking resources:
Discussion between Gary Reinl and Dr. Kelly Starrett (31).
The opinion of Dr. Phil Page via PT Mike Reinold’s website (34).
The opinion of PT Aaron Horschig (35).
Actually read the sources and articles I referenced in this post
“Ice Ice Baby” by Vanilla Ice (36).
Sources:
https://members.thereadystate.com/blogs/trigger-warning-youve-got-to-stop-icing/
Knight, K.L., The Effects of Hypothermia on Inflammation and Swelling. Athletic Training.Athletic Training, 1975. 11(1): p. 7-10.
Merrick, M.A., et al., A preliminary examination of cryotherapy and secondary injury in skeletal muscle.Med Sci Sports Exerc, 1999. 31(11): p. 1516-21.
Dr. Michael Reiman, Duke DPT
https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect
https://www.spartan.com/blogs/unbreakable-focus/alternative-to-the-rice-method
https://www.logicallyfallacious.com/logicalfallacies/False-Equivalence
https://www.amazon.com/ICED-Illusionary-Treatment-Option-Fascinating/dp/0989831914
https://squatuniversity.com/2020/03/23/dont-ice-walk-it-off/
