WHEN TO USE ICE? Orthopedic medical experts disagree on this topic.
Even among reputable sources, there is still disagreement on when to ice an injury. Advice on ice treatment varies greatly in terms of duration and interval, as well as when it is appropriate or not. To some clinicians, it is an essential component of treatment yet others have begun to question its usefulness as a therapy.
The Mayo Clinic, a major research and clinical institution, is still recommending RICE (rest, ice, compress and elevate) therapy for sprained ankles, according to their website in 2017. On the other hand, the very developer of this same RICE protocol has reversed his clinical opinion on the matter of icing. Gabe Mirkin, MD outlined the RICE protocol in his The Sportsmedicine Book, published in 1978. It eventually became the standard method for management of musculoskeletal injuries. However, in light of recent research showing that cold therapy actually slows healing time, he has changed his mind about the therapy he helped to make famous. His official position, as of 2016, is that “there is no reason to apply ice more than six hours after you have injured yourself.”
The pieces of information that contribute to this shift in strategy are two related findings. The first is that that the constriction of blood flow caused by cold therapy keeps immune cells (macrophages), which produce chemicals that promote tissue repair (like IGF-1) out of the damaged area where they are needed. The second is that this initial inflammatory response mediated by immune cells is essential for healing and delaying this response delays healing.
The rest of the medical field, however, is slower to integrate this new information. Sources differ on duration of ice application, ranging from less than 10 minutes up to to 30 minutes. The Mayo Clinic recommends 15-20 minutes at a time; Mirkin now recommends not more than 10 minutes. The Mayo Clinic provides no time restriction when it comes to ice application after injury but to “apply every two to three hours while you are awake.” As stated above, Mirkin would restrict use to the hours after injury, and to repeat “once or twice.”
Be wary, there is good reason to limit the amount of time you apply ice. Application for greater than 30 minutes at a time has been shown to cause nerve damage.
So the experts can disagree. But, what else do we know from the research?
Ice is an effective pain reliever and there is no argument that that is a good thing. Ice also decreases inflammation. In some ways, this is also an advantage, as swelling inhibits range of motion and contributes to discomfort. However, the inflammation that occurs in the immediate aftermath of traumatic injury is a natural and necessary response that initiates healing. Reducing inflammation in the case of traumatic injury has been shown to slow healing.
Interestingly, if you are an athlete looking to increase performance at an event, ice may not help you. It has been studied that reflex activity and motor function are impaired up to 30 minutes following ice treatment. It is no wonder that there is an increasing visibility of circulation-increasing modalities (like cupping) appearing as an alternative to direct icing.
Clinical studies have shown that ice and heat work equally well for pain relief. While there is no documented adverse effect to heat, if you’ve ever made the mistake of putting heat on a fresh injury, you know that it increases swelling and usually doesn’t feel very good. For this reason, save heat for injuries that are past the hot and swollen acute phase.
When deciding whether to ice or not, we must keep balance between two goals:
First, the need for relief of pain and reduction of swelling.
Second, the promotion of healing processes and avoidance of further damage.
What can we take away from this?
1 - Use ice if you must for pain relief, but not for too long at once. Ten minute intervals are a happy medium, and this study (https://www.ncbi.nlm.nih.gov/pubmed/23958608) agrees.
2 - Use ice the day or so after injury and not longer, unless specifically directed.
3 - Skip ice for old injuries.
Written by Beth Bloomfield, MS, L.Ac.