Icing an acute injury – yay or nay?
(Image from google)
Common practice has told us to use ice for acute injuries when there is swelling, warmth and redness whereas heat is normally aimed to relax muscles that are spasmed.
The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin. His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate healing. This initial protocol was practised diligently for 20 years before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE.
Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery. Avoiding aggravating movements as suggested under Protection (P) is more crucial to manage pain.
For years, most people report ice makes injuries “feel better”, at least in the short-term. But what impact does immediately icing an injury have in the mid to long-term?
In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his ’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping.
What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process.
In 2019, the latest injury management process came with the most comprehensive acronym:
PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise).
(image from google)
So then, this leads to the question:
‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’
Yes and no.
Yes in the acute stage. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function. This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.
In these circumstances, ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it so that movement can be slowly reintroduced to the injured area.
However, one should not be highly dependent on it. Compression and elevation are also options to control mild swelling after movements.
In a nutshell, ice does not reduce inflammation but somewhat numbs the pain. However, early appropriate movement is highly recommended to induce early tissue reparation and growth.
1. Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE?.
2. Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE.