Back on the 26th August I wrote an article for our newsletter entitled “Don’t Inhibit Your Inflammation” and it is interesting to see there has been some media coverage of this exact topic since then (co-incidental of course, I don’t think my article stimulated the recent discussions)!

For those that haven’t read my original blog or the recent article in the Sydney Morning Herald they are well worth a read (links at end of article). We all know the positives and negatives of social media, and I find Instagram and Linked In are two very valuable, simple and enjoyable educational mediums. What I do find annoying though is the outlier opinions – one says an object is blue, the other says it is red, then they start abusing each other. It never ceases to amaze me is how dogmatic many people can get with their absolute opinions, when in reality, perhaps the truth lies somewhere in the massive middle area of grey, if only they could agree to find this common ground.

And so I think the same is true with icing and injury management. Following my article, I had a few people say “So I shouldn’t ice an injury”? And the same statements came after the Sydney Morning Herald article: “I’ve just read an article that says ice is bad for injury management”. So in the “blue” corner are the advocators of never icing an injury; in the “red” corner are the people who say that ice has always worked and should continue to be used. But the “grey” area is the message I am trying to get across to people, and hopefully I can make this grey area a little clearer below!

For decades now, the RICE (Rest; Ice; Compress; Elevate) acronym has been a household term, and the accepted injury management regime for literally every acute injury. Even within this acronym, it is only the “I”, or ice, that people turn to – the first thing grabbed in the sporting field after an injury is the ice pack.

As explained in both my blog and the newspaper article, the inflammation following an acute injury is not only a natural response, but a necessary response in the healing process. So if ice has an inhibitory effect on inflammation (as the blue corner would say) we need to have a good think about why we would ice and be able to justify the purpose of applying ice, rather than just accepting the years old habit of reaching immediately for ice!

Let me backtrack and just look at the simple effects of inflammation and ice:

INFLAMMATION: there is no doubt that inflammation is a natural and necessary component of the healing process. In response to injury or trauma, blood vessels dilate, blood flow increases and white blood cells flow to the injured area to promote healing. Chemicals are also released that bring in your body’s immune cells, hormones and nutrients to start the repair process. Other hormones are also released to create blood clots to control any bleeding. As the body heals, the acute inflammation gradually subsides – or that’s the theory! We need inflammation to heal.

ICE: in a nutshell, ice cools the skin and superficial tissue above the injury. Cooling causes a vasoconstriction (narrowing) of the blood vessels, and dampens the metabolic process of the body, slowing how hard the injured tissue has to work in this acute phase.

So in the “red corner” are the icers, saying that that applying ice will control bleeding whilst at the same time reducing swelling and inflammation and pain. The red corner theory is that inflammation and swelling is an impediment to healing and must be controlled as much as possible. It has been accepted and often recommended that this ice process to continue for a minimum 48 – 72 hours after injury, and often a lot longer if swelling persists.

In the “blue corner” are the anti-ice proponents who say that “icing doesn’t work,” and that ice impedes healing by reducing the necessary inflammatory process. And by reducing the inflammatory process, the anti-icers will say that there is actually an increase in swelling (or oedema) as the build-up of waste products cannot be moved away from the area (but the white corner could quite easily argue that the vasoconstriction effect of ice and reduced metabolism reduce the amount of waste product produced in the first place – gets confusing doesn’t it when you hear it from both corners).

So what do we believe and what should we do? I’m going to try and be the referee in the grey area and give you my thoughts!

There appears to be no significant evidence that ice inhibits the healing process by reducing inflammation after injury. And you may recall the following from my original blog on this topic: “Research tells us however that swelling is only influenced if we reduce metabolism and for this to happen, ice would need to reduce the tissue temperature at the injury site down to between 5 and 10 degrees – at depth, not on the surface. No study has been able to demonstrate this at a depth of even 2cm below the skin tissue, and there is no evidence for the ability of ice to reduce metabolism in the human tissue. What ice does definitely do is reduce pain, so perhaps the best use for ice is pain reduction”!

I stand by this previous statement and say that probably the biggest use of ice is for pain management. Ice probably does cool the tissue a little bit, and maybe marginally slows metabolism, but not enough to have a detrimental effect on the body’s inflammatory process. There seems to be no direct evidence that ice impedes healing after acute trauma or return to activity, so the red corner win this argument. However there is a thought that the pain we feel following injury is the instigator for the release of insulin growth factor 1 (a healing hormone), so if ice reduces pain then maybe we are inhibiting the release of this healing hormone – the blue corner win this argument! And I could go on and on comparing the various arguments, and this is why I think in many cases, such as in this ice debate, somewhere in the middle ground lies the best course of action.

Where I think we do perhaps go wrong is icing for too long – sometimes people are icing for weeks and months after injury in the thought it will reduce swelling. Whilst the inflammatory process can become quite biologically stubborn, and linger long after most healing has concerned, it’s probably not ice therapy that is going to help the most.

So where do I stand as the referee in this debate, keeping in mind that the evidence really is inconclusive? Yes, ice probably is over-used, and isn’t the sole miracle intervention we thought it was. However statements like “Ice should never be used” or “ice is harmful” are misleading and inaccurate. My personal view is that ice does have some benefit in the very acute phase immediately after an injury has occurred: slowing the athlete down (you can’t return to play with an ice pack strapped on); superficial reduction in blood flow; and definitely for pain relief for those really painful injuries. But compression and elevation are likely to be just useful, if not more useful in early injury management. And most importantly the sooner we can safely progress the athlete to gentle movement and muscle activation techniques, the less likely they are to need ongoing ice therapy.

Until the evidence tells us conclusively that ice is harmful to healing I believe it still has a role in the management of acute injuries, but only for a brief period of time. Then we must turn to other modalities to ensure optimal healing!

Anthony Lance
SSPC Physiotherapist

References available on request
SSPC Blog August 26th ;
Sydney Morning Herald October 16th;