Challenging conventional wisdom — Should we use ice to treat injuries?

by Maria Fermoile, PT, DPT, OCS
Alliance Rehabilitation, Fresno, CA

Challenging conventional wisdom — Should we use ice to treat injuries?

There is and has been a long-term debate about the merits of using heat or ice as a treatment after injury. Despite years of research, education, and even anecdotal evidence from healthcare professionals and trainers, much confusion has surrounded the issue.

To this day, the conventional thinking has been that ice should be used in the first 24-48 hours after injury to decrease inflammation (swelling) and pain. In 1978, Dr. Gabe Mirkin coined the term “R.I.C.E.” (Rest, Ice, Compression, Elevation), and this concept became the standard in treatment of acute injuries and post-surgical patients.

Recently, however, many studies have been performed to investigate what exactly the role of ice is in decreasing inflammation and pain, and whether or not it does in fact aid in recovery of tissues. Like so many other previously held beliefs, very good contemporary research over the last decade has been progressively disproving this conventional wisdom. Unfortunately, new information is slow to spread, and it is always challenging to change long-held paradigms and to shift to the more current thinking.

A 2013 study showed that although icing delayed swelling, in the end, it did not improve recovery time from muscle injury.What is becoming increasingly evident is that healthcare professionals may have gotten it wrong over the last several decades of using ice as the “go to” post-injury application. Even Dr. Mirkin is changing his course of thinking, and current research is backing him up. A 2013 study showed that although icing delayed swelling, in the end, it did not improve recovery time from muscle injury. As far back as 10 years ago, a 2004 research review comparing recovery after ankle sprains found that ice and exercises may result in quicker recovery, but there was no evidence that ice and compression alone resulted in faster healing times.

So what does all of the research say on why we should not ice?

Damage to tissue from trauma, injury, or even overuse and soreness from intense exercise triggers natural physiological processes that promote healing of the injured tissue. This event is called “inflammation.” Although it has carried a negative connotation, inflammation starts the healing process by bringing cells to the injured area that release a hormone called insulin-like growth factor (IGF-1). This hormone sets in motion the healing and the recovery phase for injured tissues. Applying ice during this time and reducing swelling may potentially delay or slow healing by preventing the release of IGF-1.

Icing also constricts blood flow to the area, thereby reducing the flow of healing cells and the nutrients they bring. And delayed healing is not relegated just to the use of ice; research has confirmed that any anti-inflammatory, such as NSAIDs or cortisone, may also delay the healing process.

Dr. Mirkin’s current recommendations post-injury are as follows:

  • If you get injured, stop exercising immediately.If you get injured, stop exercising immediately.

  • If the pain is severe and you cannot move the injured part, or if you have had loss of consciousness, seek medical attention.

  • Rule out broken bones before beginning to move the injured area. Open wounds should be cleaned and checked.

  • Elevate the injury in order to use gravity to help minimize swelling naturally.

  • If the injury is limited to muscles or other soft tissue, compression may be helpful in reducing pain and minimizing swelling.

  • It is OK to apply ice for up to 10 minutes, then remove for 20 minutes, repeating once or twice. There is no reason to apply ice more than six hours after injury.

  • If the injury is severe, follow your healthcare practitioner’s advice on rehabilitation. It is important to get moving as soon as possible after injury.

Maria Fermoile, PT, DPT, OCS Maria Fermoile, PT, DPT, OCS, is a doctor of physical therapy at Alliance Rehabilitation, a Physiquality network member in Fresno, California. With more than 26 years of experience, Maria has focused her practice and expertise on manual therapy and therapeutic exercise of the spine and extremities. In addition to being an expert clinician, Maria is a guest lecturer for Fresno State’s Physical Therapy and Kinesiology Programs and a clinical educator for physical therapy students.

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For further information:

Fermoile, Maria. The Hanford Sentinel.

Mirkin, Gabe.

Khoshnevis, Sepideh, Natalie K. Craik, and Kenneth R. Diller. Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee Surgery, Sports Traumatology, Arthroscopy, February 2014.

Crystal, Naomi J., David H. Townson, Summer B. Cook, and Dain P. LaRoche. Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise. European Journal of Applied Physiology, October 2013.

Ye, Fan, Sunita Mathur, Min Liu, Stephen E. Borst, Glenn A. Walter, H. Lee Sweeney, and Krista Vandenborne. Overexpression of insulin-like growth factor-1 attenuates skeletal muscle damage and accelerates muscle regeneration and functional recovery after disuse. Experimental Physiology, May 2013.

Hot or cold? How to decide whether to use heat or ice when treating an injury. Physiquality, May 16, 2012.

Rest, Ice, Compression, Elevation (RICE). WebMD, October 11, 2012.

Coombes, Brooke K, Leanne Bisset, and Bill Vicenzino. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, November 2010.

Ziltener JL, S Leal, and PE Fournier. Non-steroidal anti-inflammatory drugs for athletes: an update. Annals of Physical and Rehabilitation Medicine, May 2010.

Bleakley, Chris, Suzanne McDonough, and Domhnall MacAuley. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. American Journal of Sports Medicine, January-February 2004.

The material and information contained on this Web site is for information only and is not intended to serve as medical advice or consultation.

Consult your personal physician before beginning any exercise program or self-treatment.