Cryotherapy for treating soft tissue injuries in sport medicine: a critical review

Key Points

1. Cryotherapy offers short-term pain relief but does not enhance tissue healing in humans.
2. Animal studies suggest cryotherapy may delay muscle and tendon regeneration in severe injuries but may aid in minor injuries.
3. Use cryotherapy cautiously, limiting application to the first six hours post-injury to reduce pain, and avoid prolonged use beyond 12 hours to prevent delayed healing.

BACKGROUND & OBJECTIVE

Cryotherapy, a widely used treatment in sports medicine, is primarily applied after soft tissue injuries to reduce pain, inflammation, and secondary damage (1-3). Cryotherapy is one of the basic principles of the RICE protocol (Rest, Ice, Compression, Elevation) and similar iterations (PRICE (Protect+RICE) and Protect, Optimal Loading instead of Rest) taught and applied as a sport medicine standard.

The review's objective was to critically evaluate the evidence supporting cryotherapy's effectiveness, particularly its role in tissue healing and regeneration. The authors sought to determine if human studies support cryotherapy's use beyond short-term pain relief, given that much of the current understanding relies on animal studies. This review aimed to clarify the appropriateness of cryotherapy based on available evidence and highlight its limitations in clinical practice.

Cryotherapy, a widely used treatment in sports medicine, is primarily applied after soft tissue injuries to reduce pain, inflammation, and secondary damage.

For minor injuries, cryotherapy may still offer some regenerative benefits by limiting the spread of damage and controlling inflammation.

METHODS

• The authors conducted a systematic review, screening 452 studies from databases such as Medline and Web of Science.

• They focused on research where cryotherapy was used post-acute soft tissue injury in muscles, tendons, or ligaments, excluding combined treatments.

• A total of 27 studies were included: one on humans and 26 on animals, assessing the effects of cryotherapy on muscle injury and inflammation, regeneration, and healing.

• The literature was critically analyzed for both positive and negative outcomes, and the transferability of findings from animal models to human applications was evaluated.

RESULTS

• The review found limited human evidence supporting cryotherapy’s efficacy in enhancing tissue healing or regeneration.

• While cryotherapy provides short-term pain relief, its benefits in reducing inflammation, swelling, or secondary injury were not demonstrated in humans.

• Animal studies suggested cryotherapy could impair long-term tissue regeneration, particularly in severe injuries. However, it may accelerate healing in cases of minor muscle injury by limiting the spread of necrosis.

• Overall, more human studies are required to provide definitive guidelines.

LIMITATIONS

• The primary limitation is the lack of high-quality human studies on cryotherapy for soft tissue injuries. Most of the findings are based on animal models, which may not fully replicate the nature and characteristics of human injuries.

• Additionally, there is variability in cryotherapy protocols across studies, such as cooling methods and durations, making it difficult to generalize the results.

CLINICAL IMPLICATIONS

Cryotherapy plays a critical role in acute injury management, particularly for pain relief within the first six hours post-injury. Its primary benefit lies in reducing pain by lowering tissue temperature, which can improve patient comfort and potentially limit the need for pain medication. Additionally, cryotherapy may help manage early hematoma formation by controlling local blood flow, though this effect is primarily observed in animal studies and requires further confirmation in humans.

However, beyond the initial 12-hour window, the use of cryotherapy becomes more contentious. Animal studies suggest that prolonged cryotherapy can disrupt essential inflammatory processes, such as macrophage activation and tissue clearance, which are critical for muscle and tendon regeneration. For severe injuries, excessive cooling may delay healing and lead to compromised tissue recovery. Therefore, clinicians should avoid extended use of cryotherapy after the acute phase and be cautious when applying it beyond 12 hours, especially in more significant injuries.

In contrast, for minor injuries, cryotherapy may still offer some regenerative benefits by limiting the spread of damage and controlling inflammation. In such cases, it can be part of a short-term strategy to accelerate recovery, but it should not replace active rehabilitation or optimal loading.

Clinicians must recognize that cryotherapy is not a cure-all for tissue healing and should be applied thoughtfully as part of a broader injury management plan. Relying on it beyond its immediate pain-relief benefits could impede natural healing processes. Thus, cryotherapy should be personalized based on injury severity, with close monitoring to balance its short-term analgesic effects against potential long-term risks.

+STUDY REFERENCE

Racinais S, Dablainville V, Rousse Y, Ihsan M, Grant M, Schobersberger W, Budgett R, Engebretsen L (2024) Cryotherapy for treating soft tissue injuries in sport medicine: a critical review. Br J Sports Med, Published online first.

SUPPORTING REFERENCE

1. Kwiecien SY, McHugh MP. The cold truth: the role of cryotherapy in the treatment of injury and recovery from exercise. Eur J Appl Physiol. 2021;121:2125–42.
2. Bleakley CM, Glasgow P, Webb MJ. Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting? Br J Sports Med. 2012;46:296–8.
3. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54:72–3.