To Ice Or Not To Ice An Injury?
Ice is an extremely hot (or rather, cool) topic in sports medicine and acute injury rehab, and for good reason. The way we treat injuries is continually changing based on the most up to date research. Due to this, it’s no wonder there is confusion around whether ice is good, bad or indifferent for injuries.
When someone rolls their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. Ice appears to be an ingrained part of the acute injury management process, but does this align with the latest research?
The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin (1). His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate healing. This initial protocol became deeply rooted in our culture and for 20 years we were ‘RICE-ing’ injuries before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE (2).
The reason for the changes?
Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery (3).
But what about ice?
There is certainly a consensus throughout the literature that ice acts as a great analgesic (pain numbing agent) by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged from topical ice application. What we are much less certain of now then we were in 1978, is it’s healing properties. Anecdotally (and likely due to the analgesic effect) most people report ice makes injuries “feel better”, at least in the short-term. But what impact does immediately icing an injury have in the mid to long-term?
In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his “’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping” (3).
What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process (3).
Ice was finally revoked in 2019 from the injury management process with the latest and most comprehensive acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise) (4).
With all of this new-found evidence on the negatives of icing injuries, it begs the question:
‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’
I will however caveat this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function (5).
This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.
In these circumstances ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it (6). In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be of benefit in the early stages (or at all) during injury management.
So for now, based on the current research, I’d keep ice in the freezer for the most part. As we currently understand it, ice is less important than we once thought. The exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, ice may be beneficial in the early stages only.
What then should be our primary focus?
Encouraging people to return to movement safely again, as soon as it is practical.
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- Mirkin, G. & Hoffman, M. (1978). The sportsmedicine book. (1st ed.). Little Brown and Co.
- Bleakley, C. M., Glasgow, P. & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine. 46, 220–221.
- Mirkin, G. (2014, March 16). Why Ice Delays Recovery. https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
- Dubois, B. & Esculier, J-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine. 54, 72-73.
- Scott, A., Khan, K. M., et al. (2004). What do we mean by the term “inflammation”? A contemporary basic science update for sports medicine. British Journal of Sports Medicine. 38, 372–380.
- Palmieri, R. M., Ingersoll, C. D., et al. (2004). Arthrogenic muscle response to a simulated ankle joint effusion. British Journal of Sports Medicine. 38, 26–30.
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If you have a question, suggestion or a link to some related research, share below!
With regards to ice application, the PEACE & LOVE authors cited a research study on rats with 1 ice application of 20 minutes applied 5 minutes after a contusion injury was inflicted on them. The results of this study cannot be applied to different types of injury, let alone a human population. And in fact, when you read the discussion of the cited study, they seem to have overlooked / not reported other important statements. This misreporting / representation of research is irresponsible as it leads to propagation of inaccurate information such as this article.
This was a very informative blog. Great info about using ice for physical injuries. If you are facing any other problems regarding physiotherapy and related, I suggest Medintu.
Medintu is a great platform to connect with great physiotherapist doctors who help us with affordable prices and great service.
Interesting ..I also looked on it and find it in delaying heeling process..
But interesting as initially it only limits inflammation and pain through vasoconstriction followed by vasodialation that helps in healing ..
nice so to avoid excessive swelling and pain use ice. A deeper question perhaps is does ice really prevent the release of macrophages and the inflammatory response (maybe it does for 5 minutes but then it comes back afterwards). Seems like until we see what it actually does we are just making educated guesses
Hi, just wondering if a bridge of nose injury occurs, (breakage Unknown) would ice still be held back?
Interesting Sports physicians recommend ice at the time of acute injury and no longer than two days post injury
I’ve looked up the research studies cited and I’m not seeing an actual study that confirms that supports the article. the brittish journal of sports medicine article you sited even says to ice in their study.
Shhhh, everybody online knows that folks won’t look up the references so there’s no need to make them actually apply or support what is being claimed.
could there be an argument that, if applying ice for 10 minutes every few hours, you could be kickstarting the process each time – and therefore enhancing it? shutting it down by applying ice so supercharging the response in the few hours in between?
Exactly. This is just a reactionary throwing out the baby with the icewater. In the immediate post injury phase you’re not healing anything and need to shut down runaway inflammation. Just don’t use it forever like they used to do. Even Mirkin’s website article is talking more about long-term use than the immediate acute injury phase.
Great article and something I have been trying to tell people for a minute, without much avail 🙁
My question, however, is about using ice with gross swelling. I was under the impression, from an old article in the late 70’s 0r early 80’s, that indicated the application of ice actually increased lymphatic permeability and in result would dump any inflammation that was removed right back to the area of swelling. Thoughts???
There is no single research refenced about using ice on injury in reference 😛
Thank you very interesting . Just one question. Why is ICE not been recommended anymore as we want the inflammatory process but elevation and compression is still recommended ? Thank you
@ginnyschniewind to remove swelling that causes unwanted pressure and pain. Inflammatory cells comes with blood but we can remove the lymph 🙂
Very interesting and it changed my thoughts about the ice 👍👍