Ice an Injury?

We’ve heard it for years from the medical community. Roll an ankle? Ice it. Pull a muscle? Ice it. Jam a finger? Ice it.

Those who have been involved in athletics or fitness are all too familiar with this advice. Adhering to it may be another issue altogether, but suffice it to say we have been instructed to do it. The question is: Should we?

Research over the past couple of decades has brought the therapeutic effects of RICE (rest, ice, compress, elevate) for soft-tissue injury into question. Does it actually help? Is it worth the time and discomfort? Are there other therapies, such as electrical stimulation (e-stim) or ultrasound, that are more efficacious in bringing about the tissue-healing process for acute soft-tissue trauma?

Some studies have even gone so far as to say that cryotherapy (ice) has a negative impact on tissue healing and can actually slow or negate some of the body’s natural healing processes for recovery.

The truth, not surprisingly, lies somewhere in the middle.

Local physical therapist Tom Walters, DPT, CSCS, notes that “For acute musculoskeletal trauma due to surgery or injury, the practice of RICE still holds value. Numerous studies are available that show the positive effects of RICE, particularly with regard to ice and compression during the inflammatory phase of healing (first 24-72 hours after injury).” Further, he describes that the exact application technique, total icing/compression time, and number of applications per day varies depending on the size and severity of the injury.

As a rule, however, 15-20 minutes of application (particularly that of crushed ice) several times daily with at least an hour between applications is still sound advice.

Where does the confusion lie, then? Why are some arguing against it? Primarily in the research evaluating cryotherapy effects past the inflammatory phase. Here the information is equivocal at best. Certainly there are enough studies to suggest (and most likely add credibility) to the theory that icing beyond this initial phase of 24-72 hours may actually limit the body’s natural healing response. However, Walters points out, “One must remember that if [he/she does] not rest the injured area, the inflammatory process may be lengthened beyond 72 hours.” In this situation, further icing therapy may be warranted.

Okay then, what about e-stim (electrical stimulation) and ultrasound? Interestingly, while both of these have been fairly common practices in therapy regimens in various clinics (physical therapy, chiropractics, athletic training, etc.), the research appears equivocal at this point. Walters suggests that while there is a need for more research, currently, uses are primarily for pain relief (both) and increasing muscle strength (e-stim) but have limited support for tissue healing and repair.

In short, e-stim and ultrasound appear to offer very little (if any) additional benefit to tissue repair and the healing process.

Where does that leave us? RICE. Still good advice according to the literature … at least for the first 72 hours.

One stone remains unturned, however: how long is it going to take the tissue to heal beyond the 72 hours and what should we do until then?

We find that many of the clients in our performance center struggle to simply allow tissue repair to take place and often reengage in activities beyond tissue capacity far too soon, thinking, “it doesn’t hurt anymore so it must be healed.” Understanding that injuries are unique, and blanket statements can’t be made about healing processes, I asked Walters to offer a general timeline and plan of action for a typical ankle sprain based on the latest research. Here’s what he suggests:

Phase 1: Inflammatory Phase (24-72 hours)

1. If unable to bear weight or have point tenderness along the malleoli (ankle bones), see physician to rule out fracture.

2. Begin RICE ASAP (assuming no fracture) and continue for 24-72 hours (depending on severity).

3. Keep ankle as inactive as possible to avoid reinjury.

Phase 2: Fibroblastic Healing Phase (approximately four weeks)

4. Increase range of motion, strength and proprioception (balance and neuromuscular control) using pain as guide (if pushed into pain, the tissue will regress into the inflammatory phase again).

Grade I sprains (least severe) may be healed and allow regular sports participation between two weeks – two months.

Grade II usually require between three-six months to be pain-free with all activities.

Grade III sprains (most severe) may require >six months to heal and may ultimately require surgery if instability remains.