To Ice Or Not To Ice An Injury?

Ice is an extremely hot topic in sports medicine and acute injury rehab, and for good reason. The way of treating sport injuries is continually changing as per the evidence-based practice. And no wonder there is so much confusion around.

When someone sprains their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. Ice appears to be an ingrained part of the acute injury management process, but does this align with the latest research?

The earliest documentation of ice as protocol for acute injury management dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was first coined by Dr Gabe Mirkin. His aim behind using ice was to minimise the inflammatory response of the injured tissue in an attempt to accelerate healing. This initial protocol became deeply rooted in our culture and for 20 years we were ‘RICE-ing’ injuries before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE.

The reason for this change?

Since research has identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration in the early stages. Subsequently, Rest (R) is detrimental to the recovery process.

But what about icing?

There is certainly a consensus throughout the literature that ice acts as a great analgesic by cooling down the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unaltered from topical ice application.

Most people report ice makes injuries “feel better”. But what impact does immediately icing an injury have in the mid to long term?

In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his “’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping”.

What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process.

Ice was finally removed in 2019 from the injury management process with the latest acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise).

But the question is:

‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’

Probably not.

I will, however, conclude this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema puts unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function.

In these circumstances, ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it. In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be of benefit in the early stages (or at all) during injury management.

In the cases where swelling will likely be the limiting factor for recovery, ice may be beneficial in the early stages only.

What then should be our primary focus?

Encouraging people to return to movement safely again, as soon as it is practical.