DON’T ICE, WALK IT OFF!
Posted on March 23, 2020 by Dr. Aaron Horschig
What I’m going to say may shock you. It may even anger some of you. The statement
I’m going to make flies in the face of what many in the medical field have been
preaching for decades, but it’s something you need to hear.
You need to STOP using ice on injuries and sore muscles.
Now before you throw your hands up in disbelief and scream at the top of your lungs
how ridiculous that statement is, hear me out. Ice is not what you think it is. It
is not helping the healing process from injury and in fact an overwhelming amount of
research shows it does the opposite! Other than temporarily numbing the sensation
of pain, ice delays healing and recovery. But before you take my word for it, let’s take
a deep dive into the history of icing and why its use became “conventional wisdom.”
From a young age we’re taught that if something hurts, you put ice on it. If you sprain
your ankle at soccer practice, wrapping a bag of ice tightly around the injured area is
the first step to feeling better. We do this because we’ve been told icing helps reduce
harmful inflammation and swelling and even kick starts the recovery process after
intense workouts.
It’s not uncommon today to see the best athletes in the world doing post-game
interviews with bags of ice wrapped around their knees or shoulders. With a simple
Google search you can easily find photos of Michael Jordan with ice on both knees.
Of course, we all started to use ice! As the saying goes, we all wanted to “Be like
Mike.”
As a competitive weightlifter, I commonly used ice on my sore knees and back after
intense training sessions. I was told this was a “normal” part of being a strength
athlete. I would even jump in an ice bath after intense squat sessions to help kick
start the recovery process…or at least that’s what I thought I was doing.
In the rehabilitation world physical therapist, athletic trainers and chiropractors use
ice every day in clinics and training rooms across the world. In my early career as a
physical therapist, it wasn’t uncommon that every one of my patients would get a cold
pack wrapped tightly around their injury after their rehab session.
However, the profession that has been using ice the longest is the medical field.
Published articles dating back to the early 1940’s explain that doctors would
commonly use ice to help decrease infection rates, block pain and reduce the rate of
dying on the operating table during amputation surgeries. 27 This is because ice slows
down cellular metabolism, allowing surgeons to keep as much muscle tissue alive as
possible. While ice was originally intended to preserve severed limbs and decrease
complications in the operation room, it would eventually sneak its way into being
used for all injuries.
In 1978 Harvard physician Dr. Gabe Mirkin coined the term RICE (Rest. Ice.
Compression. Elevation.) as the recommended treatment for sports injuries in his
landmark ‘The Sports Medicine Book.’1 Since this time, the medical community has
religiously used this protocol for the treatment of all acute injuries.
Now if you were to ask a medical doctor today why they recommend ice for the
common ankle sprain or back ache, they’ll likely say it helps alleviate pain, reduce
inflammation, and restricts swelling. In fact, this is why some surgeons insist their
patients use ice for months on end after surgery.
If literally everyone is using ice, how are we so wrong about it?
There is no denying that ice provides temporary pain relief. Slap an ice pack on an
area of your body that is in pain and instantly you’re going to start feeling better. In
fact, if you look at the scientific research out there on the use of ice (called
cryotherapy) a reduction in pain is the number one benefit! But here’s the deal. Just
because the pain is decreased does not mean you’re fixing the injury. In fact, you’re
actually doing more harm than good.
What may blow your mind is that Dr. Gabe Mirkin (the man who invented the RICE
protocol) came out in 2013 in the forward to the second edition to the groundbreaking
book “Iced! The Illusionary Treatment Option” by Gary Reinl and withdrew his original
statement! Admittedly, he wrote, “Subsequent research shows that ice can actually
delay recovery. Mild movement helps tissue to heal faster, and the application of cold
suppresses the immune responses that start and hasten recovery. Icing does help
suppress pain, but athletes are usually far more interested in returning as quickly as
possible to the playing field. So, today, RICE is not the preferred treatment for an
acute athletic injury.”8
I hope by now I’ve caught your attention. Let’s now dive into how ice actually affects
the body.
Inflammation & Swelling
We’ve always been told that inflammation and swelling are bad things that we need
to stop as soon as possible. I’m here to tell you today that these are not bad things.
In fact, inflammation and swelling are normal responses to injury.
Ask any medical professional what the three phases of healing are and they’ll all tell
you the same thing: inflammation, repair and remodel. Don’t believe me? Check any
medical textbook and you’ll find the same answer. Inflammation is the first stage of
the healing process no matter the location or severity of the injury in the body. If this
is a normal response to injury, why do we want to prevent it?
When injury occurs (such as a sprained ankle) inflammatory cells called white blood
cells naturally rush to the site of pain to kick start the healing process. Specifically,
tiny cells called neutrophils are deployed to destroy bacteria (if there is an open
wound) and others called macrophages come to remove the damaged tissue cells
caused by the initial trauma. Macrophages are like Pac-Man swarming in and
chomping down and consuming all the tiny dots (in this case the cells that died off
due to the initial trauma). At the same time these cells also release an anabolic
hormone called Insulin-like growth Factor (IGF-1) into the surrounding area that
sparks the next phase of the healing process, muscle repair and regeneration.
Plain and simple, healing requires inflammation. It is an essential biological response
following an injury. It isn’t a bad thing like you’ve been told your entire life. While
chronic levels of inflammation can clearly play a role in certain diseases (such as
autoimmune disorders like rheumatoid arthritis or lupus), it is extremely beneficial to
muscle regeneration directly after an acute muscle injury. In fact, a lack of
inflammation blunts the healing process and contributes to poor muscle
regeneration!2-6 This “blunting” of the healing process occurs when you use ice!
Placing ice on an injury essentially places a roadblock in front of the white blood cells
trying to get to the injured area and stunt the natural inflammation process from
occurring. While you think you’re helping the healing process by placing a bag of ice
on your body, you’re actually delaying it from ever starting by preventing the body
from doing what it wants and needs to do.7
Think about it like this. A car accident just occurred and there’s debris (shattered
glass, shards of metal, etc) scattered all over the road. 9-1-1 has been called and
emergency vehicles are on their way. All of a sudden, a barricade is set up in the
middle of the highway putting an immediate halt to all incoming traffic.
What do you think is going to happen to the people involved in the accident and the
mess sprawled out on the highway? The ever-important white blood cells with the
sole purpose of cleaning up damaged tissue will not arrive on time and the
production of IGF-1 (whose job to spark muscle repair and regeneration) will be
delayed as well. To make matters even worse, “pressing the pause button” on this
process ultimately restricts blood flow to the surrounding healthy tissues leading to
additional cellular damage on top of the initial injury!9
But what about swelling? Isn’t ice great for that?
If you ask any medical doctor why they use ice for swelling, they’ll likely tell you it’s
because “excessive” swelling can lead to increased pain, decreased range of motion
and lengthen recovery time. This is true. If swelling is allowed to stay in a joint, it can
have negative effects. However, swelling itself isn’t a good or bad thing. It’s simply
the end response of the inflammatory cycle. It’s what we do about it that makes all
the difference.
You see, following injury the surrounding blood vessels dilate as part of the
inflammatory response and the small capillaries surrounding the damaged tissue
“open up” to allow white blood cells to arrive. This rush of white blood cells out of the
capillaries also pulls additional fluid into the surrounding tissue (we call this
accumulation “swelling”).
Swelling however is there for a reason. It contains the waste byproduct of the initial
damaged tissue. The fireman, ambulance and policemen have arrived at the site,
begun cleaning up the damage and they need a way to remove it from the roadway.
Unfortunately, the additional fluid that now contains waste can’t leave the same way
they came in (through the circulatory system). It has to be evacuated through an
intricate network of vessels in your body called the lymphatic system.
You see, your body has a few different pathways to move fluid from place to place.
Your circulatory system (composed of arteries and veins) pump blood cells and fluid
to and from your heart all day long. This continuous transport system works day and
night, when you’re resting and when you’re moving around.
The lymphatic system is another tube-like system that runs throughout your entire
body, except it doesn’t have an “engine” like your heart to transport fluids. The
lymphatic system is completely “passive.” This means you have to make it work.
When you contract your muscles, the lymphatic vessels deep inside your body are
squeezed and the fluid within is forced it to move (think about this like a cow being
milked).
Swelling therefore is merely the buildup of waste around the injured area that needs
to be evacuated through the lymphatic system. It is a natural response to injury
that only becomes a problem when it is allowed to accumulate. When you see an
athlete after a sprained ankle whose leg has ballooned two to three sizes the
following day, they don’t have a swelling problem…they have an evacuation problem.
Ice does not facilitate clearance of swelling through the passive lymphatic system.
While resting and icing may feel good in the short term, you’re actually trapping
debris around the injury and stunting the natural healing process from occurring!
But what about the science? There has to be research to back up the use of ice!
Wrong.
For example, a 2011 study looked into the effects of ice after a muscle injury (one
group received ice for 20 minutes following the injury, the other did not). 6 The injuries
were then closely followed for the next 28 days. The results were not what you would
think.
During the initial few hours following injury it is common to see macrophages (aka the
“cleanup crew) flood the area. The researchers found several within the damaged
muscle fibers of the “no icing” group however, those who had been given ice showed
almost no signs of macrophages.
At three days post-injury, the “no-icing” group already showed signs of regenerating
muscle cells. Yet in the icing group these cells were nowhere to be found. At four
days out, regenerated muscle cells were found in both groups but those in the “noicing” group were significantly larger than those in the icing group.
At 28 days post-injury, the regenerating muscle of the “no-icing” group was 65%
larger than the icing group! In addition, the researchers found significantly more
scarring compared to the untreated muscles. The authors of the study concluded,
“Judging from these findings, it might be better to avoid icing, although it has been
widely used in sports medicine.” Despite “conventional wisdom” that tells us ice is a
good idea, research shows that ice actually delays muscle repair after injury gives us
direct evidence that ice can ultimately lead to increased scarring!
To make matters even worse, the way in which we use ice also has the potential for
decreasing muscle strength and size! Remember the common protocol of RICE
(Rest. Ice. Compression. Elevation)? When most people have an injury, they wrap a
bag of ice tightly around the painful joint or muscle and stop moving. We do this
because we’ve always been told moving the injury will cause further damage.
However, immobilizing your injury is actually doing more harm than good!
When you stop moving for an extended period, your body responds by shutting down
the essential processes that regulate your muscle mass. For example, previous
studies have estimated we can lose 0.5% of muscle per day and up to 5% in a week
period.10 This shrinkage in muscle size (called disuse atrophy) is one of the major
complications following severe injuries and those that require surgery.
But what about directly after surgery? There clearly has to be evidence that ice is
helpful after that…right?
Wrong. Studies on the use of ice to promote healing have shown little to no benefits
at all!
In 2005 researchers conducted a meta-analysis (meaning a study of all available
studies) on the use of cryotherapy directly after ACL reconstruction surgery. 11 They
concluded that the only benefit was in lowering pain. Icing did not improve how much
the person could move their knee or lead to any decreases in swelling.
Swelling is no doubt a significant concern after any surgery (especially those in the
lower body such as an ACL reconstruction). When swelling builds in and around the
injured area and remains it can lead to a cascade of problems (decreased mobility,
blunted strength, increase in pain, etc.).12 But remember, icing does not help facilitate
the pumping action of the “passive” lymphatic system, which is the only way to
remove swelling!
Gary Reinl gave me a great analogy on this concept I want to share with you. If you
knew it was going to snow 2 inches every hour for the next 12 hours, what would you
do? You’d likely open your front door and brush off a small amount of snow with a
broom every hour. If you procrastinate and wait until the next day, you’ll open the
door to find 24 inches of accumulated snow. Imagine how much more difficult it is to
shovel 2 feet of snow all at once!
Case in point, the reason swelling accumulates around an injured area of your body
is because we stop moving! It’s not because there is “excessive swelling” but rather
because we aren’t doing anything to facilitate lymphatic drainage to pull it away.
Instead of trying to block swelling from accumulating in the first place by icing (which
clearly has detrimental healing effects), we need to be proactive and work on
improving the evacuation of the fluid and waste that does accumulate! No matter if
you sustained a small injury like a sprained ankle or just got out of a knee surgery to
repair a torn meniscus, you need to turn your attention to evacuating swelling, not
preventing it.
But, how do we facilitate this evacuation?
We move.
Remember when you fell down as a child and your dad yelled, “Walk it off!” It’s quite
possible that your dad was right all along about keeping it moving after getting
injured! Too quick do we instruct athletes to shut it down completely after an ankle
injury or knee injury. Keep in mind, moving too much and too aggressively may make
things worse. I am merely proposing that we stop and consider kicking off the healing
process with light movement and active recovery.
Exercises performed in a relatively pain-free manner not only accelerate swelling
removal through muscle contraction but also optimizes the healing process without
causing additional damage! Now it may seem counterintuitive that we want to move
an injury but that’s actually the best thing to do! Loading damaged tissue with proper
exercises as soon as possible following injury actually accelerates healing of muscle
and bone.13 The last thing you want to do is wait around and see how you feel
tomorrow or the following day.
Performing pain-free exercise following injury has countless benefits. To start, muscle
contraction enhance the inflammation process by improving macrophage function
(the clean-up crew) and allowing these essential white blood cells to remove
damaged cells.14 It also boosts muscle repair and regeneration and limits scar tissue
formation through activation of stem cells (called satellite cells).15,16
Directly after injury, the goal with movement is to facilitate healing without causing
additional damage. Exercise too intensely and place too much load on the body and
you’re only going to make things worse. This is why it’s not a good idea to perform
heavy back squats one day after spraining your ankle or attempting to run 4 weeks
after ACL reconstruction surgery.
Loading the body in a pain-free manner allows us to find the crossroads between
efficient and safe recovery. One of the safest muscle contractions for acute injuries
and postop cases is isometrics. An isometric describes the action of muscle
contraction without joint movement. Try this now, first straighten your knee out. Then
squeeze your quad muscle as hard as you can for 10 seconds. You just completed
an isometric contraction for this muscle group! In the early rehabilitation stage (1-4
weeks) following ACL reconstruction surgery, I’ll often prescribe isometric quad sets
to my patients to restore quad strength, decrease pain levels and guess
what…evacuate swelling!
The smallest amount of muscle contraction can help remove swelling through the
passive lymphatic system, prevent disuse atrophy by increasing muscle protein
synthesis (helping you preserve muscle mass while you recover), and decrease pain.
This is why simple exercises like ankle pumps can be so helpful for athletes directly
after sustaining an ankle sprain.
As pain decreases, load should be increased to facilitate optimal healing. For
someone with knee pain, this may mean progressing bodyweight squats from partial
depth to full depth, and eventually adding a weighted barbell.
The question always arises, “What about those who cannot physically contract their
muscles because of significant weakness or when weight bearing exercises are
limited due to post-op surgical precautions?”
While voluntary exercise is undoubtedly the most effective way to preserve muscle
mass, reduce swelling and kickstart the healing process after injury, neuromuscular
electrical stimulation (NMES) devices come in a close second. NMES devises work
by stimulating muscle contraction through electricity. Place the electrode pads on
your quad, turn up the intensity and suddenly your muscles will begin to contract all
by themselves!
NMES devices have multiple uses that can be helpful for the athlete recovering from
injury. One of the best-known uses is the ability to reduce swelling.17-19 By involuntarily
stimulating muscle contraction, NMES devices help pump excess fluid/waste out of
the injured area through the passive lymphatic system and dilate blood vessels to
bring nutrients and other helpful white blood cells to enhance the healing process.
Because swelling build up can also create pain and lead to muscle atrophy (as most
people don’t want to move a painful area of the body), NMES has the ability to
decrease symptoms and avoid loss of muscle mass while in the early stages of
recovery.10 In fact, research has shown that a single session can increase muscle
protein synthesis by 27%.20
The other great feature of NMES devices is their ability to also eliminate pain through
sensory modification. This allows the athlete recovering from severe injury or surgery
to safely manage pain without having to rely on heavy narcotic medications. Simply
put, after injury we want to promote movement (even if it’s as little as stimulated
muscle contractions through the use of an E-stim device) in order to optimize healing
and safely return to the sports we love to perform.
So, we’ve touched on how ice can hinder the natural healing process after small and
large injuries, but what about using ice after an intense workout?
Elite athletes around the world are always searching for the best techniques to
accelerate recovery and gain an edge on their competition. In this continuous search,
many swear by jumping in a cold ice bath or wrapping some ice packs across their
legs after heavy training. I’ve personally known many weightlifters who claim that ice
baths are the only recovery technique that allowed them to get through a highvolume squat cycle. But what does the science say?
When you have a hard workout, the muscles of your body sustain tiny amounts of
micro-damage. This “trauma” sparks inflammation similar to what happens after an
acute injury (like a sprained ankle). The rush of inflammatory cells to the site of
“damage” help kick start recovery by first eliminating damaged cells. They then
recruit stem cells from surrounding tissues to help repair and regenerate new muscle
cells.
If you comb through the available science on the use of ice after intense workouts,
the main finding is that ice baths decrease your perception of muscle soreness by
changing how your body senses pain.21,22 As far as the effect of ice baths after
training on recovery of performance on your next session, research is split. Some
studies show a 5 to 10 minute plunge can assist with performance during the next
training session, some say it has no effect, and a few studies even say it can be
detrimental.23
Here’s my opinion, periodic use of an ice bath may assist some athletes when they
need to quickly recover from their performance between same day training sessions
and competitions. However, in the long term, regular use should be cautioned as the
continued use of ice can be harmful on the natural adaptation process for developing
muscle strength and hypertrophy. Let me explain why.
Muscle soreness and muscle fatigue are not the same thing. While you may feel less
soreness after icing, you’re not necessarily recovering any faster physiologically.
Remember there is a reason for soreness. It is a normal reaction to intense training
just like the inflammation cycle is to injury. However, the more accustomed an athlete
is to a particular style and intensity of training, the quicker they naturally recover
between sessions and the less soreness they feel.
This is why you feel so sore you can barely stand up from a chair the first day
following a high-volume squat session. However, two weeks into the same training
cycle you don’t feel nearly as sore following similar workouts. Your body learns to
adapt to the training stimulus (this is called the repeated bout effect). This is why a
majority of research on elite athletes has shown ice baths to not help at all with
recovery and performance.24
In fact, multiple research articles have shown that ice will actually interfere with the
normal adaptive response to exercise that helps us recover and gain strength. Here
is a direct quote from one such research article published in the Journal of Strength
and Conditioning Research, “These data suggest that topical cooling, a commonly
used clinical intervention, seems to not improve but rather delay recovery from
eccentric exercise-induced muscle damage.”25
Unless you’re looking for that instantaneous bounce-back the day of a competition,
you should be very cautious of the long-term effects of ice on recovery. When you
really take time to look at the science, using ice after a workout has the potential in
the long term to stunt the process for muscle growth and strength gains.
Instead of reaching for that ice pack or jumping in a tub filled with ice, I recommend
using an active recovery approach. This can involve going for a short 10-minute walk,
performing a light workout of bodyweight squats, or even going for a swim or a bike
ride (basically getting off the couch and doing any non-fatiguing exercise that gets
you moving and your blood pumping).
If you’re extremely sore the day after an intense workout, I recommended performing
a few minutes of soft tissue mobilization. Research has shown a few minutes of
rolling on a foam roller or small ball (like a lacrosse or tennis ball) can significantly
reduce delayed onset muscle soreness (called DOMS).28
Don’t have time to get in a light workout or you’re feeling a little under the weather, try
using an NMES device like the Marc Pro or Powerdot. These devices will mimic the
muscle pump of active movement. The use of such a device delivers non-fatiguing
muscle contraction without any effort that will lymphatic drainage to remove cellular
waste that accumulates after heavy training and increases blood flow to stimulate the
recovery and repair process.29,30
FINAL THOUGHTS
If by now you still aren’t convinced that the benefits of ice have been completely
overblown and flat out wrong in many cases, I offer you one last piece of evidence.
Every year a group of authors who are experts in the treatment of acute injuries
gather and comb over the current scientific literature and establish position
statements for the National Athletic Trainers’ Association (NATA). In 2013, they
released one such statement on the recommended treatment for ankle sprains (an
injury commonly addressed with the RICE protocol).26
After evaluating all of the available scientific literature on possible treatments for
ankle sprains, they assigned ratings from best “A” to worst “C.” Do you know which
rating icing got? A big fat “C.” They even wrote that “strong clinical evidence for
advocating cryotherapy is limited.”
Do you know the treatments that were assigned a rating of “A”? Functional
rehabilitation! With this position statement, the profession that sees a majority of
acute injuries among athletes acknowledged that icing is not as good as we all
thought and rather the best form of treatment is moving and loading the injured area
through rehabilitation exercise.
At the end of the day our approach to treating injuries and soreness after training is
quite simple. We want to get the good stuff in (white blood cells) and the bad stuff out
(swelling that includes cellular debris from the damaged tissue). I hope by now you
can see that this process is not optimized by using ice.
Dr. Aaron Horschig, PT, DPT, CSCS, USAW
Founder of Squat University
With
Dr. Kevin Sonthana, PT, DPT, CSCS
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