Here’s a unique question to consider:

Should you still use ice to treat an acute injury?

For decades, the answer has been a pretty emphatic yes. Ice has dominated the initial injury management landscape to the point that the RICE protocol (rest, ice, compression, elevation) has become one of the most widely recognized and practiced protocols in modern medicine.

But what if we’re missing the point here a little? What if there’s a disconnect between what ice does and what we actually want to happen to speed up the healing process?

It’s an interesting topic of conversation and one we’d like to take a look at from a theoretical and logical standpoint.

Our goal as Physical Therapists is to always give the best care possible and that sometimes includes re-assessing what we do and how we do it, no matter how ingrained it may be.

So please read on with an open mind and let’s discuss whether we need to re-assess our use of ice to treat acute injury.

Why Do We Ice?

As mentioned above, our use of ice stems from the RICE protocol. Interestingly, the RICE acronym was created by Dr. Gabe Mirkin – a Doctor of Sports Medicine from the University of Harvard well over 40 years ago. Dr. Mirkin created this protocol to reflect the best practice in early injury management.

The RICE protocol is as follows:

1. Rest from activity

2. Ice the injured area for ~15 minutes

3. Compress constantly

4. Elevation of the injured area above the heart

5. Pain and/or anti-inflammatory medication to complement the protocol

We apply this protocol in an attempt to limit pain, swelling and inflammation and ultimately speed up the healing process and hasten our return to pre-injury activity.

We specifically use ice because of it’s ability to decrease pain and blood flow to the injured area.

But here’s the thing.

Does this approach actually match what our body is trying to achieve post-injury? And in order to answer this, let’s look take a basic look at what happens immediately after an injury.

The Body’s Natural Healing Response

As soon as injury occurs, our body begins a pre-programmed cascade of events.

1. Inflammation:

The first phase is the inflammatory response where the following occur:

• Blood clotting

• Local vessel constriction

We also see dilation of the surrounding vessels to allow the ‘repair and clean up crew’ to come in and repair/remove injured tissue.

Interestingly, the bi-product of this acute inflammatory response is swelling. And despite it’s general perception, swelling is neither good or bad. It’s just an accumulation of waste yet to be evacuated from the area. This process takes place via the Lymphatic System - a passive system that requires our muscles to actively ‘pump’ in order to create this evacuation.

Another prominent feature of the inflammatory process can be the presence of pain. Essentially, it’s role is to help us understand the nuances of what we should and should not do with the area, ultimately protecting the integrity of this initial healing response.

2. Tissue Repair and Remodeling

The nest step in the healing process is regeneration and remodeling of the injured tissue. We see scarring, wound closure and new blood vessel growth.

As time goes on, the newly repaired tissue remodels itself to respect movement and use. This helps optimize the function of the once-injured area.

So as you can hopefully appreciate, the body has a very particular response to an acute injury. One that happens each and every time damage occurs.

Furthermore, the pain, swelling, and inflammation we try so hard to prevent with ice are important for the body’s natural healing response.

So why are we trying so hard to limit these processes?

And this raises a very important question that we perhaps haven’t asked ourselves much if at all over the last 40-50 years…

If we are very clear on the reasons why we ice an injury, yet those reasons contradict what needs to happen for the injury to heal, why is ice still so popular?

In fact, when we look at the effect ice has on the processes responsible for healing, does it actually hinder our ultimate goal?

Does Ice Delay the Healing Process?

Let’s take a quick, logical look at the effect of ice on the healing process.

Firstly, we know ice restricts blood flow (ischemia). However this same blood flow is responsible for carrying the cells needed to power the inflammatory and healing processes. Are our efforts rewarded here considering this pre-determined process automatically ramps back up again once the ice is removed and the tissue re-heats? Are we essentially hitting the pause button instead of fast forward?

Furthermore, we know ischemia can create accidental cell death, and that injured tissue needs oxygen-carrying blood to revive and survive. Logically, using ice to consciously restrict blood flow to an injured area may be counterproductive to the healing process.

Following on from this, does ice make swelling less viscous and therefore harder to effectively remove? Much like putting a tube of toothpaste in the freezer, ice may make the normal order of things a little more complicated, not less.

So not only may ice delay the healing process, but is there potential here for it to increase the risk of additional damage - despite our best intentions?

It’s something we really need to consider if we value the fastest and most optimal recovery post-injury.

The Role of Pain

One of the most compelling reasons we ice is to relieve pain. And it’s a noble cause, because it works. We know ice is effective at temporarily reducing our ability to feel pain, but at what cost?

Is it more important to know what we can and can’t do, so we don’t unintentionally make things worse? If we dull our perception of pain, does this make knowing we can and can’t do harder? Is it more important we know our movement boundaries given the body places such an importance on this to facilitate the removal of swelling?

Having said this, there is obviously a place for pain relief in acute injury management. Perhaps we just need to re-consider whether ice needs to be that modality given it’s potential downsides.

Dr. Gabe Mirkin Changed His Mind

Perhaps the most compelling reason to re-consider our use of ice to treat acute injury comes from Dr. Gabe Mirkin himself. Dr. Mirkin, who as you may recall coined the RICE acronym in the first place, has since publicly changed his mind.

In an article published on his website back in 2015, Dr. Mirkin outlined his change of heart-based on new insights and a broader perspective.

As of today he no longer recommends the use of ice for injury. Instead, he suggests we need to invest our time and energy into modalities that optimize our tissue’s ability to do its thing, rather than stand in its way.

What Can We Do Instead of Ice?

When proposing an ice-free approach, it’s important to clarify that this discussion is not ice or nothing. We still need viable alternatives that help the body do its thing, particularly when pain is involved. Thankfully, there are a number of other useful options.

1. Responsible Pain-Free Movement

Movement plays a crucial role in the healing process. Muscle activation drives the removal of swelling and congestion and limits the potential for muscle wastage. Clearly too much movement can be just as disadvantageous as too little, so we want a responsible middle-ground. The buzz word here is ‘relative rest’.

This is another reason why we should question our use of pain medication where possible. We want to be right up against our comfortable threshold for movement without encroaching on pain.

2. Massage

Massage is another useful technique. It’s important to note that an appropriate massage post-injury is not a deep tissue massage. Instead, we want a gentle, more superficial massage for two reasons:

• to down-regulate an acutely heightened nervous system for natural pain relief

• to assist removal of swelling

An appropriate massage is a powerful technique for those wanting to optimize their post-injury recovery.

3. Other Helpful Tools

Beyond movement and massage, there are a number of tools to use if wanting to replace the use of ice.

A Pneumatic Compression device like the Normatec can help optimize post-injury recovery. It uses a slow wave of segmental compression to help mimic the role of movement on the Lymphatic System, ultimately assisting the removal of swelling. It’s a fantastic tool we use in the clinic to facilitate an active recovery during the more passive moments.

Voodoo Floss is a really useful tool to use for the sub-acute stages of rehabilitating an injury. Voodoo Floss mixes short bouts of strong elastic compression with pain-free active movement to promote the removal of swelling, free up restricted tissue, and re-perfuse the recovering area.

Deep breathing is another helpful tool to assist in post-injury recovery. Not only can slow, controlled deep breaths help settle an acutely heightened nervous system associated with pain, but it can be an extremely simple way to hyper-oxygenate your body. We know the body uses oxygen to assist the healing process so deep breathing is often a simple way to serve this up on a platter.

Conclusion

The purpose of this article isn’t to drum up controversy or suggest the end of the “ice age”. But it does present a good opportunity to respectfully challenge an ingrained way of thinking.

And we need to ask ourselves one very important question:

If we understand how the body heals itself, does ice actually help or hinder this process? And if our perspective starts to shift, what then?

Thankfully, we do have other options at our disposal, ones that may support rather than oppose the body’s way of doing things.

This way of thinking may not yet be common place, but if there’s some truth to this idea, then we owe it to ourselves initiate a meaningful conversation. After all, there’s no point holding on to an old, out-dated idea if it isn’t actually helping us.

What are your thoughts? Is this something you’ve heard before? Or are you considering this information for the first time?

Let us know below!