The Best Time to Ice Sports Injuries
Category: Sports Injury
For nearly 40 decades, ice packs have been the go-to first aid tool on athletic fields and training rooms around the world. It has become an unquestioned first step in the treatment of soft tissue sports injuries. It’s easy, cheap and readily available, but is the application of ice for sports injuries good medicine? The fact is, up until a year ago, I regularly advised my patients to apply ice therapy to injured low backs, knees, shoulders and any other overuse or acute injury. It was during one of my visits to the Baltimore Orioles spring training facility that started to change my thinking about ice. While there, a player was receiving treatment for an injury he sustained the night before. He had torn is ACL or Anterior Cruciate Ligament. As the trainers worked on him, I noticed they weren’t using any ice on his knee. When I asked why, they stated something that completely challenged my long-held belief that you have to use ice to treat the swelling, pain and inflammation of an injury. They simply stated; “We don’t use ice to treat injuries anymore.” Wait. What? What do you do about the inflammation? What about the swelling?
After I composed myself, they went on to go over the physiology and the stages of the healing process of soft tissue injuries. It all made sense, but I needed more. So, I began to research the history of the use of ice for soft tissue sports injuries and went back to my physiology books from school (they were dusty). During my research, I went to the source and creator of the treatment protocol R.I.C.E. In the landmark book, The Sportsmedicine Book written in 1978 by medical physician, Dr. Gabe Mirkin. In the book, Dr. Mirkin coined the acronym R.I.C.E. or, Rest, Ice, Compression and Elevation. However, by 2014, Dr. Mirkin changed his tune stating in a post on his own website; “Coaches have used my R.I.C.E. guideline for decades, but now it appears that both ice and complete rest may delay healing instead of helping.”1 It is apparent that the only benefit of using ice for an injury is to decrease pain, but by reducing the temperature of the tissue, ice delays the healing and recovery of the injury. Further research on the effects of ice or cryotherapy on muscle damage from weight training indicated that, “…topical cooling, a commonly used clinical intervention seems to not improve but rather delay recovery from eccentric exercise-induced muscle damage.”2
The effects of ice on ligament tissue
Ligaments, the soft tissues that help stabilize the joints of the body have very poor, if any, direct blood supply. They have a slow metabolism and are prone to injury. Due to this poor blood supply and metabolism, when injured, ligaments heal very slowly. In addition, following “recovery”, ligaments are typically permanently compromised. Further decreasing the blood supply to damaged ligaments by applying ice decreases the healing potential of the injury.
The negative effects of ice on athletic performance
One of the most surprising findings was the effect that ice therapy has on athletic performance. A study performed in 2009 revealed the cellular level effects of ice-pack application on the hormones and inflammatory mediators on athletes. Scientists measured the anabolic (growth) hormones, catabolic (damage) hormones and anti-inflammatory components. By testing blood samples at various times before, immediately after and 60 minutes after a 4 x 250 meter treadmill run at 80% of maximal speed with and without local cold-pack application. The results were revealing when they stated; “Local ice therapy immediately following sprint-interval training was associated with greater decreases in both pro- and anti-inflammatory cytokines and anabolic hormones supporting some clinical evidence for possible negative effects on athletic performance.3
What about the inflammation?
When exploring the wisdom of applying ice to injured tissue, it’s important to make the distinction between inflammation and swelling. First, inflammation is necessary. Inflammation is the very first stage of the healing process when there is tissue damage. When tissues of the body are damaged, an acute inflammatory process begins with the purpose of clearing away the damaged cells and specialized immune system cells scavenge the area to start the healing process.4 However, when ice is applied to the injured tissues, the restricted blood flow prevents this process from starting. In fact, research shows that even after the ice is removed, this restricted blood flow will last for several hours further delaying the recovery and healing process.5 Delaying and interfering with the inflammatory process will ultimately interfere with the remaining phases of healing, namely the repair phase and remodeling phase. So, we understand that the inflammation is necessary.
What about the swelling?
The swelling associated with an injury is something that needs to be addressed. Left unchecked, swelling will cause further damage to the surrounding tissues and cause pain and stiffness. So, the question is: Does icing tissue reduce swelling? The answer is no. Clearing away the buildup of fluid is the responsibility of the lymphatic system of the body. The lymphatic system is a completely passive system and requires muscle contraction and movement to squeeze the lymph fluid through the system. When we look at Dr. Mirkin’s statement about ice and complete rest delaying the healing process, it is apparent that the absence of muscle contraction while resting eliminates the “pump” that clears the swelling away from the damaged structure. So, what to do about the swelling? It’s important to move the tissue as much as possible without further pain. Muscle contractions are an important mechanism to encourage the movement of the fluid from swelling away from the injured site.
So, the question when is the best time to ice a sports injury? The answer is only when you want to delay the healing of your injury. Although ice will provide some temporary pain relief, it will delay the healing and recovery of injured tissues, lead to further localized tissue damage and incomplete tissue repair.
1. Mirkin G. Why Ice Delays Recovery. March 16, 2014. http://drmirkin.com/fitness/why-ice-delays-recovery.html. Accessed February 24, 2016.
2. Tseng CY, Lee JP, Tsal YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. J Strength Cond Res. 2013; 27(5):1354-61. doi:
3. Nemet D, Meckel Y, Bar-Sela S, Zaldivar F, Cooper D, Eliakim A. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. European Journal of Applied Physiology. November 2009, Volume 107, Issue 4, pp 411-417.
4. Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999
5. Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014