Ice is an extremely hot (or rather, cool) topic in sports medicine and acute injury rehab, and for good reason. The way we treat sports injuries is continually changing based on the most up to date research. Due to this, it’s no wonder there is confusion around whether ice is good, bad or indifferent for injured body parts.

When someone rolls 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?

What is the RICE method, and how has it changed?

The earliest documentation of ice as part of the acute injury management protocol dates back to 1978, when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin (1). His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate the healing process. This treatment method 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 (2).

The reason for the changes?

Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery (3).

What does icing an injury do?

But what does an icing session do for your body?

There is certainly a consensus throughout the literature that ice offers relief as a great analgesic (pain numbing agent) by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged from applying an ice pack on the skin.

What we are much less certain of now than we were in 1978 is its healing properties. Anecdotally (and likely due to the analgesic effect), most people report that applying ice to the injured area eases pain, at least in the short-term. But what impact does an immediate icing session have on your body in the mid to long-term?

In 2014, Dr Mirkin acknowledged changes in injury treatment research and, as any evidence-based scientist would, retracted ice from his initial method. 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” (3).

What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When an injury occurs, 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. But when we treat the injury with an ice pack, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process (3).

Ice was finally revoked in 2019 from the injury management process with the latest and most comprehensive acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise) (4).

Should ice be used for treating injuries?

With all of this new-found evidence on the negatives of icing injuries, it begs the question:

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

Probably not.

I will, however, caveat this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function (5).

This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.

How long should you ice an injury?

For more severe injuries, ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it (6).

In these circumstances, apply the ice pack to the injured body part with a barrier (such as a cloth) underneath to protect yourself from the cold. If you don’t have an ice pack, you can use a bag of frozen peas or corn on the affected area.

Don’t apply ice for more than 20 minutes at a time. Any longer can cause reactive vasodilation, or the widening of your blood vessels as your body tries to increase blood flow, which can reduce the benefits of the ice. Extended icing can also cause frostbite or cold-related nerve injury.

In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be as beneficial for minor injury management.

So for now, based on the current research, I’d keep ice in the freezer for the most part. As we currently understand it, ice is less important than we once thought. The exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, ice may be beneficial for reducing swelling 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.

Get back on track with Foundation Clinic

If you have experienced an injury and are looking to return to the field, Foundation Clinic can be your guide. Our qualified sports physiotherapists have extensive experience in managing injuries, bringing athletes back to top form through personalised rehabilitation and training programmes. Book an appointment or call us at 07 579 5601 today.

References

1. Mirkin, G. & Hoffman, M. (1978). The sportsmedicine book. (1st ed.). Little Brown and Co.
2. Bleakley, C. M., Glasgow, P. & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine. 46, 220–221.
3. Mirkin, G. (2014, March 16). Why Ice Delays Recovery. https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
4. Dubois, B. & Esculier, J-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine. 54, 72-73.
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.
6. Palmieri, R. M., Ingersoll, C. D., et al. (2004). Arthrogenic muscle response to a simulated ankle joint effusion. British Journal of Sports Medicine. 38, 26–30.