By Dr. James Ho BHSc, DC
A recurring question asked by patients is whether they should ice and how. Until recently, the efficacy and common use of ice (cryotherapy) was rarely questioned. However, with the popularity of the Crossfit workout program and movement, a physiotherapist, Kelly Starrett, on his well followed website and blog, MobilityWOD, boldly stated that icing was no longer recommended and in fact, argued that icing not only reduces, but can prevent the recovery from injury.
Needless to say, I spent many hours discussing this topic with follow therapists, and a few national level T&F coaches. After a lot of discussion and further research into Kelly Starrett’s argument and cited research, the conclusion I reached was that like many things “scientific”, though there are conflicting studies; there was no definitive answer or reason to abandon the use of ice for injuries.
In the end, the question of icing boils down to the type of injury that happened, and the proper and thorough diagnosis of the injury. But for the purposes of this blog, we’ll discuss icing for the more common injury types and basic approaches to treat them if you can’t make it to a sports medicine clinic. Suffice it to say, treating and rehabbing any injury at home is an “at your own risk” approach. It is greatly beneficial to be diagnosed and treated by qualified health care professionals such as Athletes’ Care Chiropractors, who can determine the functional nature of the injury, its’ effects on the local biomechanics and to a greater extent, the impact on global biomechanics to prevent secondary and compensatory injuries. Facilitate inhibited muscles whether through medical and functional acupuncture, optimizing soft tissue tone and texture via Active Release Techniques, and design a strengthening and stretching program that is specific to your sport and activities.
What does Ice do?
Research suggests that when ice is applied soon after an injury, that it can mitigate secondary hypoxic cell damage, or in other words, prevent the deficient delivery of oxygen to the body’s cells. The swelling that occurs after an acute injury is the result of edema, which is the spilling of blood and metabolic waste to the area from damaged blood vessels and cells.
If ice can be applied soon after injury, the temperature of the damaged tissue can be reduced, and likewise, the amount of blood flow to the affected area can slow through increasing the permeability of the blood vessel walls, also removing extracellular debris and proteins from the damaged tissue. This in turn prevents the secondary hypoxic cell damage.
It’s important to apply ice as soon as possible after the injury, in 10-15 minute durations, repeatedly for up to 3 days. Obviously, the greater the injury, the closer to the 3 day period will be helpful, however, most injuries that won’t require further therapy from a professional can be treated to 2 days or less with ice as a modality.
Of note, if icing increases the swelling or pain to the injured body part, it’s important to stop immediately, and seek out the help of a health professional for both diagnosis and further treatment to ensure a complete and thorough recovery, and safe return to your sport or activey.
Contrast as the name suggests, is the alternating use of heat and cold, which can include ice baths and hot showers, usually in a pattern similar to 3 minutes of a hot shower followed by a minute submerged in an ice bath, repeated three times. Used as a way to improve systemic recovery and reduce general inflammation, Matt Brisson, 2012 Canadian 110mh champion, tells me every time that, “it feels great, and allows me to feel fresh and compete the next day like I didn’t just run heats and the finals the day before”, is believed to help in increase circulation of nutrients and oxygen to affected areas while removing metabolic byproducts such as lactic acid, as well as reducing inflammation and micro-tears to the injury.
However, “contrast” can also be applied in a local manner to a single location or body part to help to the same effect to treat acute inflammation. Used sometimes by therapists in clinics, it’s heavily recommended by oral surgeons and dentists to deal with the aftermath of having dental work done such as wisdom teeth removed, is surely an effective and quick way to reduce stubborn inflammation to a local area. Ice and heat are applied for 10-15 minutes alternately, and ending in an ice phase, is believed to open and close the lymphatic channels causing a “pump”-like effect and removing inflammation from the affected area, which is why it is effective for both system/whole body or acute local injuries.
“Contrast” icing can be a messy and timely ordeal that many non-elite athletes find unsuitable to fit into their daily lives. However, though not likely as effective as contrast icing, applying just ice to the injured area can still garner great benefits to reduce inflammation and decrease the pain to the injured area.
Whether it’s a bag of peas, a blue gel icepack from a pharmacy, or literally a bag of ice, it’s important to not leave the ice on for more than 10-15 minutes at a time (the smaller the body part, the less time required) and never put ice directly on the skin. Repeating 2 to3 times, allowing for the area to warm up a bit in between. Research has shown that prolonged use of ice, such as more than 30 minutes, can cause superficial tissue damage or nerve palsy, and in fact increase edema in an area, which negates the purpose of what we’re trying to achieve with ice.
If possible, it would also help to wrap the ice to the injured body part using ACE bandages, or in a pinch, Plastic cling food wrap. This step can help hold the ice pack to the injured area allowing you to reclaim use of both hands (assuming your hand isn’t what’s injured) or improve your ability to move around, and can give a compression like effect to further reduce the inflammation.
Of course Icing should not be used alone without another method of rehab. And for the purposes of this blog, the RICE protocol works well. Resting the injury immediately after the injury is important for moderate to severe injuries, as a return to movement, and progressively increasing that movement is needed to properly rehab an injury by placing positive stresses on injured tissues and re-educate the neuromuscular patterns and pathways, movement too soon can further an injury should it be a tear or significant strain. Elevation can be helpful in letting gravity do its thing in clearing lymphatic waste, and preventing the pooling of both the waste and blood, and ultimately edema. Compression, like massage, can help especially in conjunction with elevation, in reducing the extracellular waste by literally squeezing the edema out of the injured areas.
Chronic Soft Tissue Injuries
Chronic soft tissue injuries are those that last weeks and months, if not years. Generally, ice is not used to treat chronic soft tissue injuries, as often, these types of injuries are a result of improper healing of the original injury, altering biomechanics, and leading to scar tissue formation and adhesions to form between different tissues, and secondary or compensatory injuries. To identify and treat such injuries, it is recommended to get it looked at by a professional to identify and resolve the underlying causes preventing the injury from healing.
However, If working out, training, or participating in the activity with a chronic soft tissue injury, then you can think of it as re-injuring the injury, and icing immediately after can help. Likewise, if rehabbing your injury aggressively employing self massage to break down adhesions and scar tissue, icing post rehab can also help. Employ the 10-15 minutes ice directly on the injured area, followed by a period of moving the injury through a comfortable range of motion to increase circulation to the area; an incredibly important step in recovering from chronic injuries.
Moreover, icing a chronic injury regardless of how aggressive you are with self massage can help by acting as an analgesic. A little less pain, can obviously allow you to move the injured part through a range of motion, contracting the muscles and tendons, increasing the circulation of blood and removal of edema, and put a positive stress on all the above.
The topic of this blog started when multiple coaches and patients brought to my attention that they have been hearing and reading, ‘not to ice injuries’, a statement that runs counter to what has always been done and anecdotally accepted. After reading into the claim, researching, and discussing everything presented, I would put forth the common sense argument of; depending on what the nature of the injury is should determine how much, and when ice is used to treat injuries.
Whether you decide to use ice or not is entirely up to you. In most cases, it can be helpful, but in others irrelevant. It always was and still is, a single piece within a proper protocol of rehab most often best set out by qualified professionals such as the chiropractors and therapy team at Athlete’s Care Sports Medicine Clinics. Should Injury happen to you, and likely will, use ice! Compress and elevate it. After a day or two of rest, begin movement through the range of motion and put positive stress on the injury within your comfort levels. If it’s a little sore after rehab, it’s ok to use ice again. At the very least, I hope you can take away from this that ice can be effectively used as a part of a rehab protocol, and ultimately get back to the sport you love, a little better off.
James Ho, DC, BHSC
Active Release Techniques® Provider
Acupuncture McMaster University
Bachelor of Health Sciences (Honours