The ICE Debate – Is Icing your injury still the right thing to do?
There has been a lot of media controversy over the past few years into whether the widely used RICE management (Rest, Ice, Compression, and Elevation) is in fact not the best and most evidence based practice in acute injuries. Most people in the community participating in sport are aware of and abiding by the RICE principle which includes resting and icing. See image below:
(Image thanks to Verywellhealth.com)
But is this method supported by the research?
For many years we have all been taught that if something hurts or is swollen we should ice. If you sprain your ankle the normal thing to do straight away is to grab an ice pack and place it around the area. It’s always been thought that this will help reduce the “harmful” swelling as well as reducing the pain.
There is actually limited research to support that ice actually helps the healing process but there is a large amount of evidence suggesting the opposite – that it is harmful to the healing process by delaying recovery and impacting on long term healing.
What about Immobilisation/Rest?
Long periods of immobilisation/rest is something that physiotherapists haven’t been encouraging for quite some time as there is a lot of research to suggest in many acute soft tissue injuries that movement and load are actually beneficial. Resting for the first few days is often necessary when there is a lot of pain and limping or when there is a significant injury such as fracture but for soft tissue sprains and strains once you’re able to move gently it is actually beneficial. Those that immobilise for too long often end up very stiff longer term and lose more muscle mass.
Here is a summary of the research on these two components of the RICE principle and our take on this debate:
Despite ice being widely used by many clinicians in acute soft tissue injuries there is actually no high-quality evidence for its efficacy. There is evidence for ice providing an analgesic effect but there is actually an abundance of research to suggest that ice could be detrimental to healing and recovery due to suppressing the normal immune response. The research shows icing disrupts inflammation, delays neutrophil and macrophage infiltration as well as the anabolic hormone Insulin-like growth factor (IGF-1) that sparks the next phase of the healing process, muscle repair and regeneration.
What’s our Opinion?
After discussing the latest research with the Head Sports Physician from the Geelong Cats and agreeing that there is more evidence for no longer recommending ice we both also acknowledged the strong cultural norm to use ice in Australia. We have begun educating our patient’s on the latest research and possible negative effects to healing but also informing them that if they need the analgesic effect to use for smaller time-frames such as 5 minutes.
Immobilising is not ideal for many soft tissue injuries and is something that physiotherapists haven’t been doing clinically for quite some time. There is lots of evidence for exercise based therapy and that loading damaged tissues with proper exercises as soon as possible following injury actually accelerates healing of both muscles and bone. The muscle activation helps the lymphatic system to clear any excessive swelling, reduces joint stiffness and prevents disuse atrophy of the muscles.
However, it is still important not to overload injuries in the acute stages, especially when there is a lot of pain. There still needs to be some time for rest but in some injuries poor advice is often given such as (bedrest for 2 weeks after an acute back injury or to use crutches for 2 weeks post ankle sprain). It is the excessive rest we want to avoid when it is not clinically necessary and your physiotherapist will be able to guide you the best on when it’s safe to move and how to move.
Our Modified RICERR Management:
Reduce Load and then Reload – Rest from strenuous activities when painful including walking long distances if you are limping but slowly start to build up movement. Discuss with your physiotherapist the best exercises to get your injury moving more again.
Ice – Know that there is actually limited evidence to support icing and that it may actually be detrimental to the overall healing process. You can use ice for analgesia/pain relief effects if needed but try to stick with 5 minutes. Avoid taking non steroidal anti inflammatory medications such as ibuprofen especially in the first 3 days.
Compression – wear a compression sock or tubigrip over swollen areas.
Elevate: Keep your injured limb up above your heart height whenever possible in the first 2-3 days. If it were your foot/ankle or arm you can elevate overnight by placing on cushions. This helps to reduce excess swelling from pooling in the injured area and helps the lymphatic drainage.
Referral: See a medical professional such as a GP, physiotherapist or sports doctor to determine the diagnosis and order any imaging that may be required to rule out more sinister injuries which may require more immobilisation etc.
Rehabilitation: Our role as physiotherapists is to help diagnose and advise patients in the acute stages, manual therapy techniques to help reduce pain and increase joint range of movement but also guide you on how to start building up your load and exercise safely. Building load gradually is crucial to help facilitate recovery but also helps get you back to your functional goals such as walking long distances, running and playing sport. It is also very crucial for preventing recurrence as once the ligaments are stretched or muscles strained there is a much higher recurrence rate due to their weakness. We help by providing rehabilitation and strength programs to also help prevent future injuries.
A proposed new Acronym from researchers:
This acronym has been released by two scientific sports researchers who have developed this model based on the latest research.
It’s a nice model that focuses not only on the acute stages of injury but also optimising long term recovery.
(Photo credit to Dubois & Esculier, 2019, BJSM)
Interested in Reading more about this topic?
To Read more on this topic here are another two detailed blogs on the topic covering the history of icing for acute injury management and a recent researcher opinion piece based on the latest evidence posted on the British Journal of Sports Medicine.