Does ice or heat help for pain, swelling, or inflammation after soft tissue injuries?
When our children bumped their heads we used to reflexively put ice on their bumps for 2-3 minutes just to numb the pain a little and to make myself feel like I was being a useful and caring parent. For many years when we encountered an acute ankle sprain on the field, we would again instinctively and immediately place an ice pack on the sprained ankle for 20 minutes to numb the pain and improve recovery by minimizing inflammation …at least that’s what we were taught and assumed to be correct.
There is certainly anecdotal and clinical evidence that ice has a temporary pain reducing and localized numbing effect (Hubbard et al 2004); therefore if ice is applied to simply numb an area post injury, then I guess it’s alright.
However what about the claims that ice helps reduce inflammation? What about the claim that ice helps the healing process post acute injury?
Even though there are some animal studies supporting the hypothesis that icing may have an effect on various inflammatory events at a cellular level (Bleakley et al 2010), that still does not support the belief that many have that icing is actually beneficial in humans in real clinical settings. In fact clinical trials on the efficacy of RICE (Rest, Ice, Compression, Elevation) have supported the use of compression but have found no value in icing
(other than the temporary numbing effect already mentioned) (Hubbard et al 2004).
In this short but likely controversial article we will be sharing with you the crazy idea that ice is not only ineffective, but may even be counterproductive to proper natural healing following acute soft tissue injuries.
Going back to basic physiology, we are all aware of the three phases of healing following an acute injury- inflammatory, proliferation and remodeling. Describing the detailed physiology behind each phase is way beyond the scope of my knowledge and this article. Inflammation is an inevitable and an essential biological response following acute soft tissue injuries. It is a protective attempt by the body to remove the damaging stimuli and to begin the healing process.
The build up of fluid, swelling or edema at the site should be considered a positive reaction as it increases
sensitivity to pain (to prevent us from further injuring the tissue), restricts movement (to prevent us from further injuring the tissue) and allows the inflammatory process to progress (to help us repair the injured tissue).
Our only concern is that if we artificially “fiddle around” with the initial inflammatory phase of healing, are we not potentially influencing the final remodeling phase? It turns out that we may be negatively effecting tissue remodeling through our obsession to get rid of inflammation with icing and the use of non-steroidal anti inflammatory drugs (NSAIDs).
Does the body really need help in reducing inflammation? The lymphatic system naturally and slowly removes all the waste products and excess fluid buildup caused by the inflammatory process. While the circulatory system relies on the heart for continuous transport of blood through its vessels, the lymphatic system does
not have a “heart” and therefore primarily relies on movement, skeletal muscular contraction and breathing for lymphatic drainage; this may be assisted by elevation and compression. Icing has been shown to reduce skeletal muscle contraction (Bleakely et al 2012) which may temporarily reduce optimum lymphatic drainage at the injury site.
Icing of sore muscles after a hard athletic workout is commonly thought to help recovery and promote earlier return to activity. This experimental study in fact demonstrated the opposite to occur (Tseng et al 2013). After performing 6 sets of heavy eccentric triceps workout, half the athletes were randomly allocated to receive either 15 minutes of cooling ice pack or a sham pack. After 2 and 3 days the icing group had significantly greater creatine kinase and myoglobin (signs of muscle overload) and the athletes subjectively reported of having
more triceps fatigue than the sham ice group. Here is a quote from the above-mentioned paper published in the Journal of Strength & Conditioning Research,
“These data suggest that topical cooling, a commonly used clinical intervention, seems to not improve but rather delay recovery from eccentric exercise-induced muscle damage”. (Tseng et al 2013) Are you kidding me? We’ve been putting ice on thousands of professional and amateur athletes, and on thousands of kids in school playgrounds. You mean to tell me after all these decades we don’t yet have a single study to support the use of ice with respect to enhancing tissue healing and hastening recovery? Could it be that the use of ice has
been way overrated? We have all been somehow duped to believe that ice is so effective that it did not even require scientific scrutiny and supportive evidence.
So what about icing for patients post-op? A meta-analysis of seven clinical trials on cryotherapy post ACL surgery concluded that icing added no additional benefit with respect to reducing swelling or improving ROM;
however icing did significantly lower post-op pain and potentially reduced the use of pain meds (Raynor et al 2005).
The Cochrane database and another meta-analysis of eleven clinical trials concluded that cryotherapy post total knee arthroplasty (TKA) resulted in small improvements in ROM but provided no benefits on pain, analgesia use, swelling or functional outcomes (Adie et al 2010, 2012).
There are always patients who find the cooling and compression post-op very soothing which may help them sleep better after major knee surgery. Perhaps even with the lack of evidence, pos-op patients may benefit simply from the numbing benefits of cold compression tools. Based on the evidences presented in this paper, a paradigm shift is proposed for the automatic, instantaneous and frequent use of ice post acute soft tissue injuries.