Almost every patient who walks into my office will inevitably ask me, “Should I ice or should I heat?” The answer that I use has changed since graduating from chiropractic school because what is taught in undergraduate and graduate programs simply is not supported by scientific research. There are times when ice can be beneficial but when should we not be using ice, and why is it so popular? I hope to answer these questions in the following paragraphs that will help you make an educated decision whether you just injured yourself, pitched six innings, or are trying to recover from a workout.
Why is icing popular?
Icing was made popular through the work by Dr. Gabe Mirkin who coined the term RICE protocol which stands for Rest - Ice - Compress - Elevate and is now used for most acute injuries such as an ankle sprain, muscle tear, etc. but was originally conceived after saving a child’s severed arm for reattachment in 1962. Fortunately, I don’t think the majority of RICE protocols are being used on severed arms. I was taught to use the RICE protocol for injuries in my exercise science courses at UCSB and my rehab courses in chiropractic school (on still attached limbs). However, this is not supported by scientific research and scientific journals actually recommend against using the RICE protocol for injuries, but the medical and sports medicine communities have been slow to embrace such a change. Part of the reason is that this is how it’s been done for the last 60 years, and the biggest athletes are usually the ones seen sitting in an ice bath or with ice bags taped to their knees and shoulders. Interesting to note though, is that the inventor of the RICE protocol, Dr. Mirkin, now says, “...my RICE guidelines have been used for decades, but new research shows rest and ice actually delay healing and recovery.”
What Does the Research Say?
Ice is an analgesic, that much can’t be denied and this is why it feels good to put ice on a painful or injured area because it decreases the pain. However, the pain comes right back when the ice is taken off and what is it actually doing for inflammation? A study in 1986 in Sports Medicine found that icing causes a backflow of fluid into the interstitial space which causes an increase in swelling, not a decrease. Another study in 2015 in Knee Surgery, Sports Traumatology, Arthroscopy found that icing narrows blood vessels continues after taking off the ice which restricts blood flow and can kill healthy tissue. This means that you will actually experience more pain and a longer recovery period when using ice. My classes taught me that icing decreases the oxygenation needed of the affected tissue, which is true and will then decrease the inflammatory response. However, a 2010 study in Federation of American Societies for Experimental Biology Journal found that the inflammatory response is necessary for the healing of damaged tissue and repairing muscle. With all of this research against icing, what should we be using instead?
What Should We Use?
The simple answer is MOVEMENT. A 1995 study in the Iowa Orthopedic Journal along with many other studies promote the use of movement and/or controlled load to promote healing and recovery. For example, if you are able to walk on a sprained ankle you should because this will allow for particle evacuation through the lymphatic system which is dependent on movement to function. This also means that your dad yelling at you to “Walk it off!” might not be that bad of advice. Gary Reinl, the author of ICED!, works with many professional athletes and says that 10 out of the 30 MLB teams no longer ice their pitchers and instead use a combination of electrical stimulation and light exercise for their pitchers, and the number is growing. This also puts a musculoskeletal expert such as a sports chiropractor or physical therapist into the forefront of injury repair because we are the ones who can guide our patients to make safe choices in movement and exercise to facilitate healing. So my answer to, “should I use ice or heat,” is usually “do neither, MOVE!”