Plunging my sprained ankle into a bucket of ice, I cringe as the sharp chill needles into my foot and ankle. My whole body tenses up and I count down the seconds until my lower leg finally becomes numb. As an athlete, icing is something that I have always considered part of my injury rehabilitation. Besides, my desire to train and compete is much deeper than the temporary sting of the cold, so I dutifully ice without complaint.
Does it help? I am not sure, but for years I have been dedicated to the cold regimen. When I started to read about researchers questioning the effectiveness of icing an injury, I was surprised. I grew up thinking that icing an injury is like putting a Band-Aid on a bleeding cut. You don’t question it. It is simply the right thing to do.
What is your first response to an ankle sprain or other acute injury? Like myself, if you immediately reach for that bag of frozen peas then you are in good company. Rest, ice, compression and elevation or RICE for short, has long been used as the first step in treating acute injuries. However, icing acute injuries may not be as effective as we once thought. Research conducted in 2004 noted that many of the studies that support the use of ice lack methodological quality. Cold, hard evidence is shockingly sparse when it comes to cryotherapy (the therapeutic use of cooling modalities.)
Let’s Start With What We Know Icing Can Do
It is generally accepted that ice can decrease cellular metabolism, alter white blood cell activity, and reduce muscle necrosis and apoptosis (cell death).  Ice or cold water causes vasoconstriction (decreases the size of blood vessels), analgesia (pain relief) and can slow down the transmission of pain signals to the brain. In 2012, a research article noted that current icing recommendations are largely anecdotal and that it may be supremely difficult to significantly alter tissue temperature at depths greater than 2cm (which is where many muscle injuries are located). Furthermore, it it is extremely important to establish cryotherapy dosage instructions for type of modality used (ice bag vs. ice massage vs. crushed ice etc.) and depth of target tissue.
It is also acknowledged that ice can be used for tissue cooling, to reduce vasodilation (the expansion of blood vessels) reduce metabolic demand of tissues, and prevent secondary hypoxic injury. All of these things may or may not help your acute injury! Because cryotherapy instructions are thus anecdotally-based, the complete effects and mechanisms behind icing are not yet fully understood.
So where does that leave you? Should you ice or not? Now that we have a general idea of what happens when you ice, let’s take a look at some of the risks associated with cryotherapy.
Is it Worth It?
While icing is generally a low risk treatment, it is not completely risk-free. Bleakley et al. (2004) noted that skin burns and nerve damage may result, especially if care is not taken. I have watched numerous athletes push the boundaries of how much they are icing in the training room. It is common for athletes to disregard the potential negative effects icing can have on their bodies because they associate it with the hard-worker, “more is better” philosophy. Fortunately, I never ran the risk of icing too much, because I was always the first to ask when it could be over so that I could go take a hot shower!
So, Should You Ice?
In summary, icing an acute injury is still widely practiced in spite of a dearth of evidence supporting it’s use. While minimal contraindications exist, the risk of the mentioned side effects must be taken into account. Icing may not be as effective as once assumed, but the evidence has yet to conclusively support or reject it’s use.
Bleakley et al. (2004) noted that ice may be particularly helpful when used in conjunction with exercise because it can reduce pain, spasm, and neural inhibition which can allow for more aggressive exercises to be performed. However, how effective is it as a first response to a sports injury such as a sprained ankle or shoulder pain?
Does it hurt to ice? Probably not if you are careful with how long and how much ice you are applying. Does it help? Future research should emphasize the development of dosage instructions based on icing modality and tissue depth. Sound clinical decisions should be guided by the available evidence. Right now with ice, the evidence is mixed.
If you are like me, that conclusion just doesn’t cut it. I want a clear and definite answer, but unfortunately science doesn’t have one for us yet. The important lesson to be learned here is that not all conventional wisdom on injury treatment is based on scientific fact. That’s why it’s always a good idea to examine the reasons behind the treatment before you take it at face-value.
Bleakley, C., Glasgow, P., & Webb, M. (2012). Cooling an acute muscle injury: Can basic scientific theory translate into the clinical setting? British Journal of Sports Medicine, 46(4), 296-298.
Bleakley, C., McDonough, S., & MacAuley, D. (2004). The use of ice in the treatment of acute soft tissue injury. American Journal of Sports Medicine, 32(1), 251-261.
van den Bekerom, M., Struijs, P., Blankevoort, L., Welling, L., van Dijk, N., & Kerkhoffs, G. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47(4), 435-443.
Bleakley, McDonough and MacAuley (2004)
Bleakley, Glasgow and Webb (2012)
by Bleakley, Glasgow and Webb
Another researcher, van den Bekerom et al. (2012),