What’s the Deal With Icing Injuries?

Cryotherapy or “cold therapy” has been used for decades to help treat pain and swelling associated with soft tissue injures. Following the RICE protocol, which stands for rest, ice, compression and elevation, many practitioners instructed those suffering from an acute injury to do just that. But where did the concept that icing an acute injury was beneficial to the healing process originate from? For that answer, we have to travel back to the early 1960’s.

On May 23, 1962 in Somerville, MA, a 12 year-old boy by the name of Everett Knowles was involved in a train accident that almost completely severed his right arm. He was rushed to Massachusetts General Hospital where it was initially presumed that he would lose the limb. That is until he was seen by chief resident surgeon, Dr. Ronald Malt. Dr. Malt believed he could save Everett’s arm and assembled a “dream team” to help complete the limb reattachment surgery. A successful limb reattachment procedure had never been done before but that‘s just what Dr. Malt and his team achieved.

When asked about how the procedure was successfully completed, one detail seemed to resonate with reporters and the public alike. That is that Dr. Malt ordered Everett’s arm be placed on ice to preserve the severed tissue. This belief that ice helps delay tissue death started to be adopted as a viable treatment for less severe soft-tissue injuries.

As news continued to spread about this success story, a protocol soon emerged for treatment for soft-tissue injuries that was coined by Dr. Gabe Mirkin. The name of this protocol? RICE! Dr. Mirkin explained this protocol in a book that was published in 1978 titled “The Sportsmedicine Book”. Now we have literature in higher education citing the advocation of ice to be used in the treatment and recovery of soft-tissue injuries.

So now you might be wondering, “What’s the problem with ice?” Well for starters, there’s never been empirical evidence that has validated the use of ice to shorten the recovery time for sports/soft-tissue injuries. Sure, ice does help reduce pain and swelling momentarily but new evidence over the past decade has started to reveal that ice may not be speeding up recovery time. In fact, ice may be doing the exact opposite and prolonging recovery!

Let’s look at this through a basic physiological lens. What happens to our bodies in a cold environment? Our blood vessels constrict or become smaller. Through vasoconstriction, blood is shunted toward our center mass for use by our heart and vital organs. This is simply a means of self-preservation. Well the same goes for applying a bag of ice to an injured extremity! The blood vessels constrict and push blood away from the injury. The problem is that we need blood to deliver the macrophages, cytokines and white blood cells to heal the damaged tissue.

If this is news to you, imagine being the one to inform athletes, their parents and grandparents that ice is no good after an injury. Many questionable stares have been given to me over the last handful of years. Trust me, I get it. I followed the same RICE protocol when I played sports and suffered injuries. Even while going through grad school, there wasn’t any mention that ice may not be a viable treatment option for injuries and I graduated a short 9 years ago circa de 2013!

That’s the thing about science though, especially in orthopedics. It’s always changing! We can argue whether it’s for the better or not but our job as healthcare practitioners is to follow the latest science and research. Another thing happened in 2013 besides me graduating. Remember Dr. Mirkin who popularized the RICE protocol? Yeah well he apologized to the medical community and informed the public that ice may not be the best treatment for injuries after all. Credit goes to him for stepping up and recanting his previous statements about ice as it’s never easy to admit you had it wrong!

With the science shifting, why is ice still so popular for treating minor injuries? The same reason it was popular to begin with. Ice is cheap, readily available and easy to use. Just set it and forget it! Protocols have changed over the past several years to adopt this new shift away from ice. RICE was changed to RCE, easy no “I”, then POP (protect, optimally load, pain management) and maybe my favorite, PEACE & LOVE! Let’s take a second to unpack this acronym. PEACE & LOVE stands for:

Protection

Elevation

Avoid anti-inflammatories. (Wait! No ibuprofen either?! More on that next time)

Compression

Education

&

Load

Optimism

Vascularization

Exercise

In a nutshell, we want to protect the injured body part from any further damage while beginning to safely move the area to prevent scar tissue formation and improve blood flow all while managing pain and educating the athlete/client about their injury and recovery process.

So what’s the deal with ice? Well I can assure you of two things: 1) Ice is not as popular among the sports medicine community for treating injuries as it has been the past 4+ decades and 2) the science is bound to change again!

Takeaways: In a pinch, apply ice immediately after injury for no more than 15-20 min. Limit subsequent icing to 15 min and only as necessary for pain. Ice should be disregarded after six hours following injury. Avoid anti-inflammatory medication. Try to avoid sugary foods as this will cause excessive inflammation. Consume more anti-inflammatory foods and spices like pineapple and turmeric. Implement safe movements as soon as tolerable! Talk to a healthcare professional like an orthopedic physician, certified athletic trainer or physical therapist for a safe exercise prescription.

References:

HPAcct (2020, March 14) RICE No More POP is the Best Method to Recover Faster. Healing Motion PT. https://healingmotionpt.com/2020/03/14/rice-no-more-pop-is-the-best-method-to-recover-faster/

Available at: https://www.thesomervilletimes.com/archives/36886

Domenic Scialoia & Adam J. Swartzendruber (2020 October 30) The R.I.C.E Protocol is a MYTH: A Review and Recommendations. The Sport Journal. https://thesportjournal.org/article/the-r-i-c-e-protocol-is-a-myth-a-review-and-recommendations/

Dillon L Caswell, PT, DPT, SCS (2022, September 7) The Truth About Icing Injuries. The [P]rehab Guys. https://theprehabguys.com/the-truth-about-icing-injuries/#

Aaron Goodrich, MAT, AT, MT, CES is a licensed athletic trainer and massage therapist and owner/operator of AMG Manual Therapy, LLC. He has worked full-time as an athletic trainer covering high school athletics since 2013 and has been providing massage therapy part-time along the way. For the past decade, he has gained professional experience working in the traditional high school athletics setting before deciding to start his own business, AMG Manual Therapy.

Throughout his career, Aaron has gained the confidence to treat people by providing manual therapy and education to improve the client’s quality of life. He has also had a passion for working with athletes of all ages, especially at the high school level. During his time working as an AT within the high school setting, Aaron noticed a gap with the current model and that is too many athletes, not enough time! AMG Manual Therapy aims to fix this gap by providing 1-on-1 treatment with his clients/athletes. Aaron is committed to providing the highest quality service through AMG Manual Therapy.

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.