Over the last month I’ve participated in a couple local competitions doing injury screens and spending time with the fitness community. At some point in every event I attend somebody will hobble over to my table with a bag of ice strapped to their shoulder, their knee, or whatever body part has been victimized.
It usually sparks a conversation about ice and it’s effectiveness/ purpose in the recovery process.
Let’s have that same discussion.
Let’s start with a little history. The term R.I.C.E was coined by Dr. Gabe Mirkin in the 1970’s. Since that time it’s been the cultural standard for acute and subacute injury recovery. As we know, just because something is ingrained in culture doesn’t mean that it’s healthy or helpful. In 2015 the same Dr. Mirkin posted an article on his website stating that ice instead delays recovery and recanting his original R.I.C.E methodology. The current research supports that ice is no better than simple compression in regards to tissue recovery and in fact may be more harmful than helpful.
In 2015 even more damning evidence was published after reviewing literature around icing injuries. This publication expressed that icing delays tissue healing by inhibiting growth factors that aid in tissue repair. It also found that icing may promote scar tissue formation. They conclude “Human studies have generally found little beneficial effect of icing on indices of muscle recovery or repair, following exercise-induced muscle damage”. Yikes.
So if this is true, why is this so common?
That’s a good question. However, as with all things in life, the correct answer is usually not in the extreme viewpoints. So where and how should we practically use ice?
There is one non-disputable characteristic of icing injuries. It has been well studied and documented that ice is a consistent analgesic agent.
AKA it can help control pain.
For that reason, it has it’s place in the injury scene within a relatively tight window. It can be useful in instances of severe acute pain (think immediate ankle sprain or immediately post surgery) when the primary goal is PAIN control.
If you’ve ever been in severe pain, you probably weren’t worried about the inflammatory process or optimal tissue healing. You have one goal and that is to decrease pain. This is where ice belongs in the recover equation. For that reason, ice is likely a reasonable and viable option for pain control in acute injuries within the first 24 hours.
If you choose to continue icing far beyond that acute window understand that you are choosing delayed tissue healing in the process.
So if ice isn’t a great solution to musculoskeletal injuries after 24 hours, what should I do?
Glad you asked friend.
Instead of the R.I.C.E principle, we instead need to follow the acronym “PEACE and LOVE” which was coined in 2020 in the British Journal of Sports Medicine.
This principle is a more updated and research supported method for dealing with acute injuries.
P: Protect
Avoid activities that exacerbate pain
E: Elevate
This advice from the original R.I.C.E protocol has survived the
test of time
A: avoid NSAIDs
For the same reasons that ice is not recommended, we don’t
want to inhibit the body’s natural way of fighting injury beyond the first 24-48 hours.
C: compress
Remember that compression can decrease pain and is equally
effective as ice without the negative effects
E: Education
The more you understand about your injury and it’s process the
less overwhelming it becomes. This is why you should reach out to your local healthcare provider early in this process!
AND
L: Load I’ve preached this from my clinical pulpit more times that I can express. Tissue responds greatly to load. Even in the presence of acute injury tissues can and do benefit from loading. Again, this is why seeing a PT can be so beneficial. They can help you find the correct amount of load and stimulus for your specific injury.
O: Optimism This plays in with education. The brain is a powerful tool for healing and can be our greatest asset or enemy. For more in depth info on this, check out our blog “I have pain, is it all in my head?”
V: Vascularization
Get the juices flowing! Improved blood flow helps shuttle resources to damaged cells. This is why movement is essential EARLY in recovery both in acute injury and post operative.
E: Exercise If you haven’t picked it up already, exercise is a way to promote and provide load, optimism, and vascularization. Specific exercise is an essential and perhaps the most important part of recovery.
In my opinion, the negatives of icing injuries outweigh the marginal benefits. I personally don’t use ice and I do not recommend it clinically to my patients. However, there is a time and a place for ice in the spectrum of acute injury. Once you’re beyond the first 24-48 hours of injury, you’ll better serve yourself with a hefty dose of “PEACE and LOVE” instead.
Stay kinetic friends.
Sources:
1. Tiidus PM. Alternative treatments for muscle injury: massage, cryotherapy, and hyperbaric oxygen. Current reviews in musculoskeletal medicine. 2015;8(2):162-7
2. Hsu JR, Mir H, Wally MK, Seymour RB; Orthopaedic Trauma Association Musculoskeletal Pain Task Force. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. J Orthop Trauma. 2019
May;33(5):e158-e182. doi: 10.1097/ BOT.0000000000001430. PMID: 30681429; PMCID: PMC6485308.
3. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
Dr. Levi Kerby is a physical therapist, orthopedic certified specialist, and owner of Kinetic Performance and Rehab in Winston-Salem, NC. He enjoys fly fishing, guitar, various forms of fitness, and treating active and motivated individuals.
If you're dealing with an injury or pain, you can contact Kinetic Performance and Rehab directly below.