Why Do People Still Ice Injuries?
For decades, the go-to advice when treating an injury was the acronym RICE, rest, ice, compression, elevate. We’ve all heard it before, if you get hurt, you ICE that injury right away! But as athletes, coaches and rehab professionals, we need to stop blindly buying into dogmatic modalities and start asking the tough questions like is there actually any real tangible science or data to prove this sexy sounding self treatment recommendation? RICE was created 40 years ago in 1978 by Dr. Gabe Mirkin, so it’s about time we debunk the method and who better to debunk it than Dr. Mirkin himself?
Dr. Mirkin went on record in 2014 to go over his own findings to the ice portion of the RICE acronym for acute myoskeletal injury management. He mentioned that the use of ice did not aid in the healing process but actually delayed it all together. Moreover, while he was at it, he also recommended a new approach for complete rest and mentioned: “with minor injuries, you can usually begin rehab the next day.” Said Mirkin.
So, the doctor that authored the best selling “The Sports Medicine Book” and created the RICE method is saying that actually RICE acronym should be renamed CE. Why are we still restricting movement and icing injuries?
Should You Use RICE to Treat Injuries?
In a recent study, athletes exercised at such a high intensity that they developed severe muscle damage that caused extensive domicile onset muscle soreness. Although cooling delayed swelling, it did not help with recovery from this muscle damage (The American Journal of Sports Medicine, June 2013). Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells of inflammation (Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014). The blood vessels do not open again for many hours after the ice was applied. Which delays the healing process and is counterproductive to the initial thought of aiding recovery.
Healing Requires Inflammation
This may sound a little bit counterintuitive at first, but it makes perfect sense, you need inflammation to heal. When you damage tissue through trauma or develop muscle soreness by exercising very intensely, you heal by using your immunity. This is called inflammation. When muscles and other tissues are damaged, your immunity sends cells and protein to the damaged tissue to promote healing. The response to both infection and tissue damage is the same. Inflammatory cells rush to injured tissue to start the healing process (Journal of American Academy of Orthopedic Surgeons,1999). The inflammatory cells called macrophages release a hormone called Insulin-like Growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal. However, by applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1. As most bodybuilder knows “the gains” come after the workout hence why this is a crucial part of recovery.
Dr. Mirkin also mentions in his new findings that anything that reduces your immune response will also delay muscle healing. Thus, healing is delayed by:
- cortisone-type drugs
- almost all pain-relieving medicines, such as non-steroidal anti-inflammatory drugs like ibuprofen
- immune suppressants that are often used to treat arthritis, cancer or psoriasis
- applying cold packs or ice, and
- anything else that blocks the immune response to injury
Healing Requires Compression, Elevation… Exercise?
We are left with the acronym CE, which stands for compression and elevate, but what about exercise? After all, we are here to talk about potentially renaming this method? A summary of 22 scientific articles also found almost no evidence that ice and compression hastened healing over the use of compression alone, although ice plus exercise may marginally help to heal ankle sprains (The American Journal of Sports Medicine, January, 2004)
Dr. Rusin has been an advocate for prioritizing the compression and elevation of acutely injured areas after sustaining a low to moderate injury. Rusin mentioned flossing and reestablishing a movement pattern to be a superior way to hastened healing.
Nearly all extremity injuries in athletes will benefit from rehabilitation programs that include therapeutic exercise. Restoring joint range of motion, muscle strength, and neuromuscular coordination should be emphasized as should normal gait mechanics. A graduated return to physical activity that includes sports-specific exercises is recommended with the primary goals being to allow a safe return to sport while minimizing the risk of recurrent injuries. (Chinn, 2009)
When should I use Ice or Heat?
The question whether to use ice or heat on an active or chronic injury is one of the most highly debated topics in acute pain management. While there are a host of factors which will more definitively determine the proper course of action based on individual presentations that account for co-factors in the use of any agent, there are some general ice and heat recommendations that have shown promise across broader scopes.
When to Use Ice
So is ice the bad guy? NO! What we have been talking about in this article so far is icing in terms of localized ice to treat injuries. The science of cryotherapy is very real, and I would advise you to read THIS article that offers some in-depth scientific knowledge on the systemic approach of cryotherapy and how it actually would be beneficial in helping your immune system.
Ice bath and cryotherapy chambers have there place in the recovery aspect, but these tools should be used hours after or before a workout and not around the workout as this would lower inflammation to the muscles.
Now regarding treating injuries ice has shown to relieving pain, by numbing the injured area, it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, apply heat and repeat the 10-minute application once or twice. This method also called contrast therapy has been shown to be a better option than ice alone in treating injuries.
When to Use Heat
Before, advice on whether to heat or ice was generally split, and it was considered a matter of personal preference or whatever was available. In recent years, however, several heat therapies and evidence that supports them have emerged. Heat can help penetrate muscular pain, as well as conditions like chronic back pain where pain emerges from a trigger point. This is because of its relaxing abilities, which make heat especially beneficial for stiffness and muscle aches. Athletes, bodybuilders, and people with stiff or aching muscles may also apply heat before working out or stretching to prevent further injury, hence warming-up. Additionally, recent research shows that heat might even encourage the healing process.
Types of Heat Therapy
Heat therapy treatments are also referred to as thermotherapy. It involves the application of heat in different ways, each intended to create a specific effect. In this section, we’ll learn about four common applications of heat therapy, including sauna and infrared sauna, hot tub therapy, sunlight therapy, and the application of topical heat agents.
Sauna and Infrared Sauna
Both sauna and infrared sauna can be used to create heat around your entire body. A sauna works by warming the air around your body, create indirect heat. An infrared sauna uses a more direct approach, using light to warm your skin. Infrared light therapy also penetrates deep down, which makes it a good choice for conditions like rheumatoid arthritis.
A study published in 2009 tested the effects of infrared sauna therapy on ankylosing spondylitis and rheumatoid arthritis. In general, the patients saw a significant reduction in stiffness and pain in the short-term. Muscle and joint fatigue were relieved. Additional studies showed that repeated treatments resulted in long-term relief of symptoms from rheumatoid arthritis. Sauna therapy has also been studied and proven effective, especially for relaxing muscles all over the body. This is useful as a pre or post workout to relieve pain from tight or stressed muscles.
The heat coming from the light in infrared sauna therapy penetrate the skin more deeply than applying dry heat alone. The benefits of infrared heat therapy have been tested for more than just muscle pain. Infrared light therapy has also been studied for its effects on healing, including when healing serious skin wounds and ulcers, such as those caused by Type 2 diabetes. While additional studies are needed, infrared sauna has also been tested on conditions like congestive heart failure, high blood pressure, rheumatoid arthritis, headache, Alzheimer’s disease, testosterone production, and dementia. Sauna therapy has also been studied as a possible treatment for many of these conditions, with varying degrees of effectiveness. One of its major benefits is the way that it pulls heat to the surface of the skin, which boosts circulation and blood flow. This can allow critical proteins and nutrients to flow through the body that promotes healing.
One of the great things about infrared sauna therapy is that while the studies done so far have not concluded the entirety of its effectiveness, none have had adverse side effects. Unlike medications like steroids and NSAIDs (non-steroidal anti-inflammatory drugs), infrared heat therapy does not cause damage to the liver or other organs, cause nausea or irritation, or damage the lining of the stomach.
Hot Plunge Therapy
Hot plunge or hot tub therapy has the benefit of being moist heat, which is more easily absorbed deep down into the skin. This lets it penetrate past the epidermis layer of skin (the outermost level) and seep into muscles and deep tissue. The depth of the penetration allows hot tub therapy to relax muscles throughout the body with the use of moist heat, much like the way a sauna does. However, hot tub therapy involves the water being highly concentrated on the skin as you are soaking, whereas the heat used in sauna therapy in is the air around you.
The Journal of Physical Therapy Science published one study on the effectiveness of hot tub therapy in 2013. The patients tested suffered from osteoarthritis of the knee caused by a chronic stroke condition, generally complaining of pain and stiffness. This was significant because knee osteoarthritis caused by stroke generally presents with sensory abnormalities caused by nerve damage and changes in the soft tissue and cartilage of the knee. The results showed significant improvement in the group that used a whirlpool bath before performing their usual exercises, compared against a control group that only performed the exercises.
Another common application of hot tub therapy for treating long-term injuries like an ankle sprain that never healed properly and continually cause pain is contrast therapy. Contrast therapy involves soaking the affected area in a hot tub bath before moving it to a cold bath. The hot-and-cold action causes the muscles to relax and contract, facilitating movement and encouraging blood flow to the area. This can relieve pain and help stimulate the healing process. This technique is commonly used before and after physical therapy. A review of literature compiled in 2013 showed an increase in results using heat therapy before physical therapy and cold therapy afterward. However, the results in this particular review were similar to the effects produced by some other conventional methods used for treatment during physical therapy.
Like sauna and infrared sauna therapy, there have been indications for the use of hot tub therapy in the management of diabetes and cardiovascular conditions. One downside is that it cannot be used to treat slow-healing wounds like other types of therapy, as the water of the hot tub applies direct heat to the skin that can further damage wounds or cause infection.
Various types of light therapy have been around since the beginning of time, with light therapies being practiced in India, Greece, Egypt, and China. The benefit from sunlight therapy, when compared against the photobiomodulation of infrared sauna therapy, is the wider spectrum of light waves that you are exposed to. Each light wave has a unique vibrational frequency that coincides with a certain area of the body because of its frequency, as well as how deeply it can penetrate the skin.
Light therapy is not just an ancient technique. It has been studied using more modern techniques since the creation of electrical light, which allowed light strength to be isolated and monitored. One of the ways it works is by destroying viruses, bacteria, and other microbes that can cause infection and slow down the healing process. In the early 1900s, a Swiss doctor named Auguste Rollier made it common practice to expose patients to the sun after surgery. He treated patients for nearly five decades with great results that showed that sunlight increased the speed that wounds healed at. He also used sunlight as a treatment for tuberculosis with greater success than some of the antibiotic phases used today.
Since then, modern practitioners have turned to sunlight therapy, or phototherapy, as well. It is understood that in addition to the anti-germ effects of sunlight, the different light waves create a biochemical reaction in the body that promotes balance. Anything that throws the system out of balance, be it the smallpox virus, a wound, or even cancerous cells, is neutralized using light therapy. Many of the studies conducted on phototherapy involve its use to treat certain skin conditions, including dermatitis, psoriasis, and acne. Additionally, light therapy has shown promise in work with the skeletal muscles. A 2013 review published in the Journal of Athletic Training showed that the studies falling into the criteria generally showed positive effects of phototherapy on the contractile function of the muscle. The improved abilities of the muscle to contract increases post-exercise recovery of strength and function and prevents exercise-induced damage on the cellular level.
The biggest downside of sunlight therapy is potential exposure to UVA and UVB rays from the sun. This can be minimized by using artificial light or limiting sun exposure to the amount of time recommended by your physician.
Topical Heat Agents
Topical heat agents describe a wide variety of treatments that may be applied topically, or to the skin, of the affected area. One of the most common ingredients included in topical heating agents is capsaicin, which is made from a key ingredient found in chili peppers. It does this by depleting the level of chemicals found in the nerve cells, disrupting the signal of pain that is sent to the brain. Other common ingredients found in topical applications for heat include salicylates, which contain pain-relieving ingredients similar to that found in aspirin, and counter-irritants like camphor or menthol that cool down the effects of the capsaicin.
Ingredients like capsaicin work similar to the way an analgesic would in blocking the signals of pain in the body. As the capsaicin penetrates the nerves around the injured area, it depletes the neurotransmitter responsible for sending the pain signal to the brain. This successfully disrupts the signal, working similar to the way that many pain relievers do. Another way that topical heating agents work is by encouraging blood flow to the affected area. Warmth increases blood flow to the affected area, which redirects critical healing factors and nutrients. The body can use this to encourage the natural healing process. You should note, however, that the addition of cooling ingredients like camphor or menthol can negate the effects of the capsaicin or warming agent and decrease the temperature of the surface of the skin, which reduces blood flow.
Sometimes, topical heating agents may be used with light therapy. This increases the effects of the light, though this also creates potential side effects like photosensitivity. Topical NSAIDs may also be used with topical heating agents, especially in the case of chronic cases of musculoskeletal pain or rheumatoid arthritis where the pain is location-specific and exists deep within the body. In addition to treating conditions like arthritis and musculoskeletal pain, generalized muscle soreness can be treated using a topical heating agent.
One of the downsides of topical applications of heat is that they cannot be used in the case of wound injury since the chemical composition can cause more harm than the healing it promotes. Additionally, topical heat agents often take longer to feel the full effect than an NSAID or other common pain relievers. While some relief may be felt within an hour or two of applying the agent, the greatest effects will be felt after a week or two of use. At this time, the agent has usually been applied enough that it successfully disrupts all the pain signals in the area.
RICE has been debunked by its own creator; therefore, we need to be educating ourselves instead of repeating old and outdated methods. Like the saying goes “old habit dies hard” but this habit needs to die now, with more studies coming out on how compression and elevating should be prioritized to start exercising as soon as possible.
When it comes to the age-old battle between ice and heat to treat an injury, heat should be prioritized to treat a minor to moderate injury; ice can be used as a way to numb the pain but no more than 10-minute application. With that said ice should not scare anyone participating in ice bath and cryotherapy modalities in which research shows they can be a great recovery tool when used at an appropriate time.
While more research needs to be done, the current evidence shows that there may be an indication for long-term improvement with certain conditions when treated with thermotherapy.
About The Author
Kevin Masson MS, CSCS, NSCA-CPT, USAW
is a strength conditioning coach, exercise physiologist, and functional training specialist in Florida. His primary focus is working with athletes and general populations to increase athletic performance but also enhancing biomechanics. Kevin’s passion is focused on enhancing overall quality of life and pain-free performance for his clients.
Forsyth, A. L., Zourikian, N., Rivard, G.-E. and Valentino, L. A. (2013), An ‘ice age’ concept? The use of ice in the treatment of acute haemarthrosis in haemophilia. Haemophilia, 19: e393–e396. doi: 10.1111/hae.12265
Drmirkin.com. (2018). Dr. Gabe Mirkin on Health, Fitness and Nutrition. | Why Ice Delays Recovery. [online] Available at: https://www.drmirkin.com/fitness/why-ice-delays-recovery.html [Accessed 6 Nov. 2018].
Oosterveld, F., Rasker, J., Floors, M., Landkroon, R., van Rennes, B., Zwijnenberg, J., van de Laar, M. and Koel, G. (2008). Infrared sauna in patients with rheumatoid arthritis and ankylosing spondylitis. Clinical Rheumatology, 28(1), pp.29-34.
McCarty, M., Barroso-Aranda, J. and Contreras, F. (2009). Regular thermal therapy may promote insulin sensitivity while boosting expression of endothelial nitric oxide synthase – Effects comparable to those of exercise training. Medical Hypotheses, 73(1), pp.103-105.
Lim, K., Lee, D. and Shin, W. (2013). The Effects of a Warm Whirlpool Bath on Pain and Stiffness of Patients with Chronic Stroke Induced Knee Osteoarthritis. Journal of Physical Therapy Science, 25(7), pp.873-875.
Bieuzen, F., Bleakley, C. and Costello, J. (2013). Contrast Water Therapy and Exercise Induced Muscle Damage: A Systematic Review and Meta-Analysis. PLoS ONE, 8(4), p.e62356.
Azeemi, S. and Raza, M. (2005). A Critical Analysis of Chromotherapy and Its Scientific Evolution. Evidence-Based Complementary and Alternative Medicine, 2(4), pp.481-488.
Asad, A., Seah, S., Baumgartner, R., Feng, D., Jensen, A., Manigbas, E., Henry, B., Houghton, A., Evelhoch, J., Derbyshire, S. and Chin, C. (2016). Distinct BOLD fMRI Responses of Capsaicin-Induced Thermal Sensation Reveal Pain-Related Brain Activation in Nonhuman Primates. PLOS ONE, 11(6), p.e0156805.
Derry, S., Conaghan, P., Da Silva, J., Wiffen, P. and Moore, R. (2016). Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews.