Author: Stephanie Biddell
It’s not uncommon if you’ve been in the position after an injury and debated whether ice would help the injury. Instinctively, when someone rolls their ankle, they’re wrapped in ice before they know it! Icing has been put into practice over the years and is very common in sports medicine or acute rehab. How clients are treated is continuously changing with the growing evidence- hence the confusion of whether icing is up to date with the latest research. This article will take you through the progression over the years on how to treat soft tissue injuries and lead you to the latest research.
Where it started 👇
Common principles which are still found in practice today date back to 1978 when Dr. Gabe Mirkin aimed to reduce the inflammatory response in aim to accelerate healing with the use of ice. It also tends to have an analgesic effect to numb pain by cooling the skin’s temperature. He documented the principle of RICE (Rest, Ice, Compression, Elevation). PRICE, shortly came after to emphasize P for Protection. This initiated the foundation for many protocols for acute injury management for decades.
It wasn’t until 14 years later that research revealed that optimal loading enhances recovery via cell regeneration in the early stages of injury. Thus, the policy POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) was identified which also acknowledged that “rest” was detrimental to recovery and thus not recommended. People report that ice tends to make injuries “feel better” in the short-term, but what about the long-term?
In 2014, Dr. Mirkin discovered more about the healing properties and therefore retracted Ice and Rest from his initial protocol as it appeared that these modalities were delaying healing. He noted that when an injury occurs, there is an initial inflammatory stage in which out body sends signals to our inflammatory cells that release a hormone insulin-like Growth Factor (IGF-1). These cells are important as they initiate healing by killing off damaged tissue. Dr. Mirkin found that when ice was applied, it may be that we are preventing the body’s natural release of IGF-1 and thus, delaying the initiation of the healing process.
Where we are now 👇
It wasn’t until 2019 when Dubois and Esculier proposed two new acronyms that highlight the complexity to the management of soft tissue injury: PEACE & LOVE (Protection, Elevation, Avoid Anti- Inflammatory Modalities, Compression, Elevation & Load, Optimism, Vascularization and Exercise). This acronym will be elaborated in another post shortly! They focused on not only immediate care, but guidance on subsequent management as well. It emphasizes the importance of patient education and addressing the psychosocial factors that aid to recovery. In addition, it makes note of the potential harmful effects of anti-inflammatory modalities and guidance to avoid it. Firstly, anti-inflammatory medications may impair long tissue healing as optimal tissue regeneration is supported with the inflammatory stage (this was elaborated in a previous blog post on the 4 stages of healing). Secondly, they revoked the use of ice as it is mostly analgesic and although it has been widely accepted in practice, there is limited high quality evidence on soft tissue injuries. Ice has the potential to disrupt the inflammation stage, angiogenesis and revascularisation as well as delay macrophage infiltration and impair tissue regeneration.
With ice out of the injury management process after scientific evidence finding negatives on the use of ice, it leads to the question should we even be using it? There is an abundance of research that may advocate for ice. Some information may be used to aid in recovery, however too much oedema is not good. Too much oedema leads to unwanted pressure on tissues, restricts movement, increases pain and may decrease muscle function. Severe joint sprains (such as the ankle) can lead to a huge increase in swelling in which range of motion is blocked. As well, post surgical patients (i.e after an ACL surgery) may highly benefit from ice due to excessive swelling. On the contrary, muscle tears may elicit a small amount of oedema and thus ice may not be of any benefit in the early stages.
In Conclusion 👇
With the progressing research over the years, it is now suggested to think twice about ice. With justification, ice can be used to aid in the reduction of swelling if that is the limiting factor or when injuries are severe. In these situations, ice may be beneficial in the early stages of recovery. However, the evidence is now showing that ice is less important than we once thought it was. The benefits of using ice for a pain inhibitor may not be worth the risk to delay tissue healing and thus, should be avoided! So then what? Through education and understanding of safe practical return to movement as soon as one can should be the focal point.
Mirkin, G. & Hoffman, M. (1978). The sport medicine book. (1st ed.). Little Brown and Co.
Dubois, B. & Esculier, J-F. (2020). Soft tissue injuries simply need PEACE and Love. British Journal of Sports Medicine. 54, pp. 72-73.
Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: from fundamental research to the clinic. Physical therapy. 2017 Aug 1;97(8):807-17.
Palmieri, R.M., Ingersoll, C.D., et al. (2004). Arthrogenic muscle response to a simulated ankle joint effusion. British Journal of Sports Medicine. 38, pp. 26-30.
van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. Journal of athletic training. 2012 Jul;47(4):435-43.
Vuurberg G, Hoorntje A, Wink LM, Van Der Doelen BF, Van Den Bekerom MP, Dekker R, Van Dijk CN, Krips R, Loogman MC, Ridderikhof ML, Smithuis FF. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug 1;52(15):956-.