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  • Writer's pictureGilda Gilak, DC, MS

To Ice or, Not to Ice? That is the question!

Updated: Jun 22, 2022

One of the hot topics in sports medicine is application of Ice in an acute injury and, for a good reason. In general, the way we treat injuries is constantly changing based on the most up-to-date research.

Therefore, the confusion remains around whether Ice is good, bad for injuries?

Utilizing Ice appears to be an ingrained part of the acute injury management process. The original date goes back to 1978 when the term RICE( Rest, Ice, Compression, Evaluation was founded by Dr.Gabe Mirkin. The intention behind this was to minimize the inflammation response to an acute injury. Later, P stands for protection, added to the RICE protocol, which became PRICE protocol.[1]

Many years later, the POLICE protocol developed, which stands for (Protection, Optimal Loading, Ice, Compression, Elevation, and has replaced the PRICE.[2]

The reason for the changes?

Research has since indicated that 'Optimal Loading' (OL) improves recovery through cell re-generation induced by light mechanical loading in the early stages. As a result, Rest (R) or a lack of movement is detrimental to recovery [3].



But what is the verdict on Ice? Does the application of Ice still align with the latest research?


There is certainly a comprehensive understanding throughout the literature; anecdotally, when patients apply Ice right after an injury, they report that it makes them feel better, at least in the short term. Ice acts as an excellent analgesic (pain numbing agent); it does that by cooling the skin's temperature. However, the impact of Ice on the underlying muscles is debatable as the muscle's temperature remains the same. There are more uncertainties than in 1978 on the mechanism in which the ice aids healing.

What remains for research is what impact immediately icing an injury has in the mid to long term?

Dr. Mirkin in 2014 stated that although coaches have been using RICE protocol for decades, it's more paramount now that both Ice and Rest may delay the healing process instead o helping it.[1]

He refers to the necessity for appropriate inflammation, a natrual body's response to the actual injury. As inflammatory cells( macrophages, Natural killer cells) approach the injured site, they release inflammatory cytokines such as IL-6 ( Interleukin), IGF-1 ( Insulin-like Growth Factor), which initiate healing by destroying the damaged tissue. The application of Ice may prevent the body's natural defense and delays healing.[5]

In 2019 Ice was removed from the management process, and another acronym got introduced PEACE & LOVE( Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularization, and Exercise).[4]

So the question is whether Ice delays healing even though it makes us feel better, should we still use it? The answer is it depends on the injury.

The caveat of too much edema also delays recovery, restricts movement and blood flow, increases pain, and decreases muscle function. We can see this in many joint sprains where the swelling is significant to prevent movement; in these circumstances, Ice may be a viable option as the goal is to balance the edema and induce activity in the joint.

Whereas in muscle tear, where we see less edema, Ice is most likely not beneficial.

So, for the time being, and based on the current research, I'd keep recommending Ice for specific injuries, but now we understand that Ice is less important than we once thought. The exception to this rule would be severe injuries and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, Ice may be beneficial in the early stages only. The primary focus would be to engage people to return to movement as soon as possible, and it is practical with safety in mind.



References:

  1. Mirkin, G. & Hoffman, M. (1978). The sportsmedicine book. (1st ed.). Little Brown and Co.

  2. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012 Mar;46(4):220-1. doi: 10.1136/bjsports-2011-090297. Epub 2011 Sep 7. PMID: 21903616.

  3. Mirkin, G. (2014, March 16). Why Ice Delays Recovery.

  4. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020 Jan;54(2):72-73. doi: 10.1136/bjsports-2019-101253. Epub 2019 Aug 3. PMID: 31377722.

  5. Scott, A., Khan, K. M., et al. (2004). What do we mean by the term "inflammation"? A contemporary basic science update for sports medicine. British Journal of Sports Medicine. 38, 372–380.


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