Don’t Ice, Walk it Off!

What I’m going to say may shock you. It may even anger some of you. The statement I’m going to make flies in the face of what many in the medical field have been preaching for decades, but it’s something you need to hear.

You need to STOP using ice on injuries and sore muscles.

Now before you throw your hands up in disbelief and scream at the top of your lungs how ridiculous that statement is, hear me out. Ice is not what you think it is. It is not helping the healing process from injury and in fact an overwhelming amount of research shows it does the opposite! Other than temporarily numbing the sensation of pain, ice delays healing and recovery. But before you take my word for it, let’s take a deep dive into the history of icing and why its use became “conventional wisdom.”

From a young age we’re taught that if something hurts, you put ice on it. If you sprain your ankle at soccer practice, wrapping a bag of ice tightly around the injured area is the first step to feeling better. We do this because we’ve been told icing helps reduce harmful inflammation and swelling and even kick starts the recovery process after intense workouts.

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It’s not uncommon today to see the best athletes in the world doing post-game interviews with bags of ice wrapped around their knees or shoulders. With a simple Google search you can easily find photos of Michael Jordan with ice on both knees. Of course, we all started to use ice! As the saying goes, we all wanted to “Be like Mike.”

As a competitive weightlifter, I commonly used ice on my sore knees and back after intense training sessions. I was told this was a “normal” part of being a strength athlete. I would even jump in an ice bath after intense squat sessions to help kick start the recovery process…or at least that’s what I thought I was doing.  

In the rehabilitation world physical therapist, athletic trainers and chiropractors use ice every day in clinics and training rooms across the world. In my early career as a physical therapist, it wasn’t uncommon that every one of my patients would get a cold pack wrapped tightly around their injury after their rehab session.

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However, the profession that has been using ice the longest is the medical field. Published articles dating back to the early 1940’s explain that doctors would commonly use ice to help decrease infection rates, block pain and reduce the rate of dying on the operating table during amputation surgeries.²⁷ This is because ice slows down cellular metabolism, allowing surgeons to keep as much muscle tissue alive as possible. While ice was originally intended to preserve severed limbs and decrease complications in the operation room, it would eventually sneak its way into being used for all injuries.

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In 1978 Harvard physician Dr. Gabe Mirkin coined the term RICE (Rest. Ice. Compression. Elevation.) as the recommended treatment for sports injuries in his landmark ‘The Sports Medicine Book.’¹ Since this time, the medical community has religiously used this protocol for the treatment of all acute injuries.

Now if you were to ask a medical doctor today why they recommend ice for the common ankle sprain or back ache, they’ll likely say it helps alleviate pain, reduce inflammation, and restricts swelling. In fact, this is why some surgeons insist their patients use ice for months on end after surgery.

If literally everyone is using ice, how are we so wrong about it?

There is no denying that ice provides temporary pain relief. Slap an ice pack on an area of your body that is in pain and instantly you’re going to start feeling better. In fact, if you look at the scientific research out there on the use of ice (called cryotherapy) a reduction in pain is the number one benefit! But here’s the deal. Just because the pain is decreased does not mean you’re fixing the injury. In fact, you’re actually doing more harm than good.

What may blow your mind is that Dr. Gabe Mirkin (the man who invented the RICE protocol) came out in 2013 in the forward to the second edition to the groundbreaking book “Iced! The Illusionary Treatment Option” by Gary Reinl and withdrew his original statement! Admittedly, he wrote, “Subsequent research shows that ice can actually delay recovery. Mild movement helps tissue to heal faster, and the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury.”⁸

I hope by now I’ve caught your attention. Let’s now dive into how ice actually affects the body.

Inflammation & Swelling

We’ve always been told that inflammation and swelling are bad things that we need to stop as soon as possible. I’m here to tell you today that these are not bad things. In fact, inflammation and swelling are normal responses to injury.

Ask any medical professional what the three phases of healing are and they’ll all tell you the same thing: inflammation, repair and remodel. Don’t believe me? Check any medical textbook and you’ll find the same answer. Inflammation is the first stage of the healing process no matter the location or severity of the injury in the body. If this is a normal response to injury, why do we want to prevent it?

When injury occurs (such as a sprained ankle) inflammatory cells called white blood cells naturally rush to the site of pain to kick start the healing process. Specifically, tiny cells called neutrophils are deployed to destroy bacteria (if there is an open wound) and others called macrophages come to remove the damaged tissue cells caused by the initial trauma. Macrophages are like Pac-Man swarming in and chomping down and consuming all the tiny dots (in this case the cells that died off due to the initial trauma). At the same time these cells also release an anabolic hormone called Insulin-like growth Factor (IGF-1) into the surrounding area that sparks the next phase of the healing process, muscle repair and regeneration.

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Plain and simple, healing requires inflammation. It is an essential biological response following an injury. It isn’t a bad thing like you’ve been told your entire life. While chronic levels of inflammation can clearly play a role in certain diseases (such as autoimmune disorders like rheumatoid arthritis or lupus), it is extremely beneficial to muscle regeneration directly after an acute muscle injury. In fact, a lack of inflammation blunts the healing process and contributes to poor muscle regeneration!^2-6 This “blunting” of the healing process occurs when you use ice!

Placing ice on an injury essentially places a roadblock in front of the white blood cells trying to get to the injured area and stunt the natural inflammation process from occurring. While you think you’re helping the healing process by placing a bag of ice on your body, you’re actually delaying it from ever starting by preventing the body from doing what it wants and needs to do.⁷

Think about it like this. A car accident just occurred and there’s debris (shattered glass, shards of metal, etc) scattered all over the road. 9-1-1 has been called and emergency vehicles are on their way. All of a sudden, a barricade is set up in the middle of the highway putting an immediate halt to all incoming traffic.

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What do you think is going to happen to the people involved in the accident and the mess sprawled out on the highway? The ever-important white blood cells with the sole purpose of cleaning up damaged tissue will not arrive on time and the production of IGF-1 (whose job to spark muscle repair and regeneration) will be delayed as well. To make matters even worse, “pressing the pause button” on this process ultimately restricts blood flow to the surrounding healthy tissues leading to additional cellular damage on top of the initial injury!⁹

But what about swelling? Isn’t ice great for that?

If you ask any medical doctor why they use ice for swelling, they’ll likely tell you it’s because “excessive” swelling can lead to increased pain, decreased range of motion and lengthen recovery time. This is true. If swelling is allowed to stay in a joint, it can have negative effects. However, swelling itself isn’t a good or bad thing. It’s simply the end response of the inflammatory cycle. It’s what we do about it that makes all the difference.

You see, following injury the surrounding blood vessels dilate as part of the inflammatory response and the small capillaries surrounding the damaged tissue “open up” to allow white blood cells to arrive. This rush of white blood cells out of the capillaries also pulls additional fluid into the surrounding tissue (we call this accumulation “swelling”).

Swelling however is there for a reason. It contains the waste byproduct of the initial damaged tissue. The fireman, ambulance and policemen have arrived at the site, begun cleaning up the damage and they need a way to remove it from the roadway. Unfortunately, the additional fluid that now contains waste can’t leave the same way they came in (through the circulatory system). It has to be evacuated through an intricate network of vessels in your body called the lymphatic system.

You see, your body has a few different pathways to move fluid from place to place. Your circulatory system (composed of arteries and veins) pump blood cells and fluid to and from your heart all day long. This continuous transport system works day and night, when you’re resting and when you’re moving around.

The lymphatic system is another tube-like system that runs throughout your entire body, except it doesn’t have an “engine” like your heart to transport fluids. The lymphatic system is completely “passive.” This means you have to make it work. When you contract your muscles, the lymphatic vessels deep inside your body are squeezed and the fluid within is forced it to move (think about this like a cow being milked).

Swelling therefore is merely the buildup of waste around the injured area that needs to be evacuated through the lymphatic system. It is a natural response to injury that only becomes a problem when it is allowed to accumulate. When you see an athlete after a sprained ankle whose leg has ballooned two to three sizes the following day, they don’t have a swelling problem…they have an evacuation problem.

Ice does not facilitate clearance of swelling through the passive lymphatic system. While resting and icing may feel good in the short term, you’re actually trapping debris around the injury and stunting the natural healing process from occurring!

But what about the science? There has to be research to back up the use of ice!

Wrong.

For example, a 2011 study looked into the effects of ice after a muscle injury (one group received ice for 20 minutes following the injury, the other did not).⁶ The injuries were then closely followed for the next 28 days. The results were not what you would think.

During the initial few hours following injury it is common to see macrophages (aka the “cleanup crew) flood the area. The researchers found several within the damaged muscle fibers of the “no icing” group however, those who had been given ice showed almost no signs of macrophages.

At three days post-injury, the “no-icing” group already showed signs of regenerating muscle cells. Yet in the icing group these cells were nowhere to be found. At four days out, regenerated muscle cells were found in both groups but those in the “no-icing” group were significantly larger than those in the icing group.

At 28 days post-injury, the regenerating muscle of the “no-icing” group was 65% larger than the icing group! In addition, the researchers found significantly more scarring compared to the untreated muscles. The authors of the study concluded, “Judging from these findings, it might be better to avoid icing, although it has been widely used in sports medicine.” Despite “conventional wisdom” that tells us ice is a good idea, research shows that ice actually delays muscle repair after injury gives us direct evidence that ice can ultimately lead to increased scarring!

To make matters even worse, the way in which we use ice also has the potential for decreasing muscle strength and size! Remember the common protocol of RICE (Rest. Ice. Compression. Elevation)? When most people have an injury, they wrap a bag of ice tightly around the painful joint or muscle and stop moving. We do this because we’ve always been told moving the injury will cause further damage. However, immobilizing your injury is actually doing more harm than good!

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When you stop moving for an extended period, your body responds by shutting down the essential processes that regulate your muscle mass. For example, previous studies have estimated we can lose 0.5% of muscle per day and up to 5% in a week period.¹⁰ This shrinkage in muscle size (called disuse atrophy) is one of the major complications following severe injuries and those that require surgery.

But what about directly after surgery? There clearly has to be evidence that ice is helpful after that…right?

Wrong. Studies on the use of ice to promote healing have shown little to no benefits at all!

In 2005 researchers conducted a meta-analysis (meaning a study of all available studies) on the use of cryotherapy directly after ACL reconstruction surgery.¹¹ They concluded that the only benefit was in lowering pain. Icing did not improve how much the person could move their knee or lead to any decreases in swelling.

Swelling is no doubt a significant concern after any surgery (especially those in the lower body such as an ACL reconstruction). When swelling builds in and around the injured area and remains it can lead to a cascade of problems (decreased mobility, blunted strength, increase in pain, etc.).¹² But remember, icing does not help facilitate the pumping action of the “passive” lymphatic system, which is the only way to remove swelling!

Gary Reinl gave me a great analogy on this concept I want to share with you. If you knew it was going to snow 2 inches every hour for the next 12 hours, what would you do? You’d likely open your front door and brush off a small amount of snow with a broom every hour. If you procrastinate and wait until the next day, you’ll open the door to find 24 inches of accumulated snow. Imagine how much more difficult it is to shovel 2 feet of snow all at once!

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Case in point, the reason swelling accumulates around an injured area of your body is because we stop moving! It’s not because there is “excessive swelling” but rather because we aren’t doing anything to facilitate lymphatic drainage to pull it away. Instead of trying to block swelling from accumulating in the first place by icing (which clearly has detrimental healing effects), we need to be proactive and work on improving the evacuation of the fluid and waste that does accumulate! No matter if you sustained a small injury like a sprained ankle or just got out of a knee surgery to repair a torn meniscus, you need to turn your attention to evacuating swelling, not preventing it.

But, how do we facilitate this evacuation?

We move.

Remember when you fell down as a child and your dad yelled, “Walk it off!” It’s quite possible that your dad was right all along about keeping it moving after getting injured! Too quick do we instruct athletes to shut it down completely after an ankle injury or knee injury. Keep in mind, moving too much and too aggressively may make things worse. I am merely proposing that we stop and consider kicking off the healing process with light movement and active recovery.

Exercises performed in a relatively pain-free manner not only accelerate swelling removal through muscle contraction but also optimizes the healing process without causing additional damage! Now it may seem counterintuitive that we want to move an injury but that’s actually the best thing to do! Loading damaged tissue with proper exercises as soon as possible following injury actually accelerates healing of muscle and bone.¹³ The last thing you want to do is wait around and see how you feel tomorrow or the following day.

Performing pain-free exercise following injury has countless benefits. To start, muscle contraction enhance the inflammation process by improving macrophage function (the clean-up crew) and allowing these essential white blood cells to remove damaged cells.¹⁴ It also boosts muscle repair and regeneration and limits scar tissue formation through activation of stem cells (called satellite cells).^15,16

Directly after injury, the goal with movement is to facilitate healing without causing additional damage. Exercise too intensely and place too much load on the body and you’re only going to make things worse. This is why it’s not a good idea to perform heavy back squats one day after spraining your ankle or attempting to run 4 weeks after ACL reconstruction surgery.

Loading the body in a pain-free manner allows us to find the crossroads between efficient and safe recovery. One of the safest muscle contractions for acute injuries and postop cases is isometrics. An isometric describes the action of muscle contraction without joint movement. Try this now, first straighten your knee out. Then squeeze your quad muscle as hard as you can for 10 seconds. You just completed an isometric contraction for this muscle group! In the early rehabilitation stage (1-4 weeks) following ACL reconstruction surgery, I’ll often prescribe isometric quad sets to my patients to restore quad strength, decrease pain levels and guess what…evacuate swelling!

The smallest amount of muscle contraction can help remove swelling through the passive lymphatic system, prevent disuse atrophy by increasing muscle protein synthesis (helping you preserve muscle mass while you recover), and decrease pain. This is why simple exercises like ankle pumps can be so helpful for athletes directly after sustaining an ankle sprain.

As pain decreases, load should be increased to facilitate optimal healing. For someone with knee pain, this may mean progressing bodyweight squats from partial depth to full depth, and eventually adding a weighted barbell.

The question always arises, “What about those who cannot physically contract their muscles because of significant weakness or when weight bearing exercises are limited due to post-op surgical precautions?”

While voluntary exercise is undoubtedly the most effective way to preserve muscle mass, reduce swelling and kickstart the healing process after injury, neuromuscular electrical stimulation (NMES) devices come in a close second. NMES devises work by stimulating muscle contraction through electricity. Place the electrode pads on your quad, turn up the intensity and suddenly your muscles will begin to contract all by themselves!

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NMES devices have multiple uses that can be helpful for the athlete recovering from injury. One of the best-known uses is the ability to reduce swelling.^17-19 By involuntarily stimulating muscle contraction, NMES devices help pump excess fluid/waste out of the injured area through the passive lymphatic system and dilate blood vessels to bring nutrients and other helpful white blood cells to enhance the healing process. Because swelling build up can also create pain and lead to muscle atrophy (as most people don’t want to move a painful area of the body), NMES has the ability to decrease symptoms and avoid loss of muscle mass while in the early stages of recovery.¹⁰ In fact, research has shown that a single session can increase muscle protein synthesis by 27%.²⁰

The other great feature of NMES devices is their ability to also eliminate pain through sensory modification. This allows the athlete recovering from severe injury or surgery to safely manage pain without having to rely on heavy narcotic medications. Simply put, after injury we want to promote movement (even if it’s as little as stimulated muscle contractions through the use of an E-stim device) in order to optimize healing and safely return to the sports we love to perform.

So, we’ve touched on how ice can hinder the natural healing process after small and large injuries, but what about using ice after an intense workout?

Elite athletes around the world are always searching for the best techniques to accelerate recovery and gain an edge on their competition. In this continuous search, many swear by jumping in a cold ice bath or wrapping some ice packs across their legs after heavy training. I’ve personally known many weightlifters who claim that ice baths are the only recovery technique that allowed them to get through a high-volume squat cycle. But what does the science say? 

When you have a hard workout, the muscles of your body sustain tiny amounts of micro-damage. This “trauma” sparks inflammation similar to what happens after an acute injury (like a sprained ankle). The rush of inflammatory cells to the site of “damage” help kick start recovery by first eliminating damaged cells. They then recruit stem cells from surrounding tissues to help repair and regenerate new muscle cells.

If you comb through the available science on the use of ice after intense workouts, the main finding is that ice baths decrease your perception of muscle soreness by changing how your body senses pain.^21,22 As far as the effect of ice baths after training on recovery of performance on your next session, research is split. Some studies show a 5 to 10 minute plunge can assist with performance during the next training session, some say it has no effect, and a few studies even say it can be detrimental.²³

Here’s my opinion, periodic use of an ice bath may assist some athletes when they need to quickly recover from their performance between same day training sessions and competitions. However, in the long term, regular use should be cautioned as the continued use of ice can be harmful on the natural adaptation process for developing muscle strength and hypertrophy. Let me explain why.

Muscle soreness and muscle fatigue are not the same thing. While you may feel less soreness after icing, you’re not necessarily recovering any faster physiologically. Remember there is a reason for soreness. It is a normal reaction to intense training just like the inflammation cycle is to injury. However, the more accustomed an athlete is to a particular style and intensity of training, the quicker they naturally recover between sessions and the less soreness they feel.

This is why you feel so sore you can barely stand up from a chair the first day following a high-volume squat session. However, two weeks into the same training cycle you don’t feel nearly as sore following similar workouts. Your body learns to adapt to the training stimulus (this is called the repeated bout effect). This is why a majority of research on elite athletes has shown ice baths to not help at all with recovery and performance.²⁴

In fact, multiple research articles have shown that ice will actually interfere with the normal adaptive response to exercise that helps us recover and gain strength. Here is a direct quote from one such research article published in the Journal of Strength and 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.”²⁵

Unless you’re looking for that instantaneous bounce-back the day of a competition, you should be very cautious of the long-term effects of ice on recovery. When you really take time to look at the science, using ice after a workout has the potential in the long term to stunt the process for muscle growth and strength gains.

Instead of reaching for that ice pack or jumping in a tub filled with ice, I recommend using an active recovery approach. This can involve going for a short 10-minute walk, performing a light workout of bodyweight squats, or even going for a swim or a bike ride (basically getting off the couch and doing any non-fatiguing exercise that gets you moving and your blood pumping). 

If you’re extremely sore the day after an intense workout, I recommended performing a few minutes of soft tissue mobilization. Research has shown a few minutes of rolling on a foam roller or small ball (like a lacrosse or tennis ball) can significantly reduce delayed onset muscle soreness (called DOMS).²⁸

Don’t have time to get in a light workout or you’re feeling a little under the weather, try using an NMES device like the Marc Pro or Powerdot. These devices will mimic the muscle pump of active movement. The use of such a device delivers non-fatiguing muscle contraction without any effort that will lymphatic drainage to remove cellular waste that accumulates after heavy training and increases blood flow to stimulate the recovery and repair process.^29,30

Final Thoughts

If by now you still aren’t convinced that the benefits of ice have been completely overblown and flat out wrong in many cases, I offer you one last piece of evidence.

Every year a group of authors who are experts in the treatment of acute injuries gather and comb over the current scientific literature and establish position statements for the National Athletic Trainers’ Association (NATA). In 2013, they released one such statement on the recommended treatment for ankle sprains (an injury commonly addressed with the RICE protocol).²⁶

After evaluating all of the available scientific literature on possible treatments for ankle sprains, they assigned ratings from best “A” to worst “C.” Do you know which rating icing got? A big fat “C.” They even wrote that “strong clinical evidence for advocating cryotherapy is limited.”

Do you know the treatments that were assigned a rating of “A”? Functional rehabilitation! With this position statement, the profession that sees a majority of acute injuries among athletes acknowledged that icing is not as good as we all thought and rather the best form of treatment is moving and loading the injured area through rehabilitation exercise.

At the end of the day our approach to treating injuries and soreness after training is quite simple. We want to get the good stuff in (white blood cells) and the bad stuff out (swelling that includes cellular debris from the damaged tissue). I hope by now you can see that this process is not optimized by using ice.

Until next time,

With

References

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