Should You Be Icing Post Injury?

To ice or not to ice an injury. Icing has been a subject of scientific debate for decades. If scientists cannot agree, then it’s no surprise many of us are unsure about our options.

Fortunately, some areas of science are progressing. Today, the investigations are more sophisticated, and the conclusions are more strict. Additionally, the underlying specifics of how the body reacts after an injury and the internal signalling needed to promote recovery are mapped in finer detail.

As a result, more options, other than ice, exist to promote recovery after an injury.

Indeed, there was a time when the RICE acronym, Rest, Ice, Compression, and Elevation, flooded mainstream media as the go-to protocol for managing an injury. But times are changing.

The optimal time to apply ice after an injury

When considering what is known about how the body responds after an injury, the optimal window for applying ice is relatively immediate. That means following a soft tissue or muscle injury within the first few hours and as soon as possible (Merrick and McBrier 2010).

When applied in this window, subsequent tissue damage can be reduced (Merrik et al., 2010).

The initial damaged tissue caused by an injury sends secondary signals that promote additional cellular damage hours after the initial injury.

Although research supports using ice in the more immediate window, there is less evidence promoting the long-term application of ice. Applying ice on the days following injury will relieve pain by slowing the speed of neural signals but adds little benefit to injury (van den Bekerom et al., 2012).

Instead, emerging research suggests that icing too long and too often can blunt recovery. Now, this may seem absurd; everyone uses ice, don't they?

In some way, yes.

Generally speaking, to promote recovery, ice should be based on the injury timeline and repair process, consistent with applications in 20-30 minute intervals within the first 12 hours post-injury (Kwiecien SY, 2023).

What is the scientific basis for applying ice immediately after injury?

The scientific basis for administering ice, or any form of cryotherapy, is to reduce the local energy needs and inflammation at the injury. But it’s important to note that this reasoning comes from examining injuries in animal studies.

Applying ice over an injured site reduces the blood flow as the local temperature drops and vessels constrict. From here, we leap. When the blood supply is limited, the energy supply and supplements to the injured site also reduce. In turn, the pro-inflammatory response is shortened, and the anti-inflammatory phase is reached sooner, promoting muscle regeneration. 

While this may sound positive, results from animal models caution that if extreme muscle cooling is achieved following injury, it might delay repair and increase muscle scarring. 

So, there is a delicate balance to be achieved and consideration given to the scale of the injury. 

Like those achieved in the muscle during high-intensity interval training (HIIT) or strength training, microtraumas typically do not involve a high count of cell death, unlike in an ankle sprain. It is the magnitude of the injury that determines if, when and how ice should be used to promote recovery (Nagata et al., 2023).

When to use icing or cooling more frequently to promote recovery?

There is a growing trend recommending against icing following injury so as not to blunt the natural healing response and potentially cause further damage (Bleakley, McDonough, and MacAuley, 2004). But that does not mean we should ignore the other performance or recovery insights gained from applying local icing or cryotherapy approaches altogether. 

What is gaining traction in cryotherapy is the selective cooling of body regions to help remove excess heat during training to improve overall performance—and or adopting whole-body cooling to reduce delayed onset muscle soreness (DOMS).

We know that thermoregulation is vital for working muscles to perform optimally. As elegantly argued by Andrew Huberman, PhD, in his Supercharge Exercise Performance & Recovery with Cooling | Huberman Lab Podcast #19.

Huberman further explains that if you get too hot, your ability to contract muscles stops. Circulating ATP, our energy resource, helps generate muscle contractions but begins to stop working as internal muscle temperature rises from intense exercise. 

He then shares insight about strategically applying local cooling, like icing, to the glabrous parts of the body, such as our hands, soles of feet, and face. As these body regions release the most heat, cooling them allows our bodies to perform optimally longer. Cooling, in this way, targets the whole body rather than directly using ice to restrict blood flow to one site, as you would in an injury. 

The same notion is observed post-training with whole-body cooling.  Under the right conditions, cooling the body, rather than just the legs, for example, postexercise, can make notable differences in recovery and are most pronounced 96 hours later (Poppendieck et al. 2013).

But sometimes cooling alone can be insufficient or inaccessible. So, what other options exist to improve recovery and performance post-injury and post-exercise?

Alternatives to icing and cooling protocols for improving recovery

Immediately following an injury with an icing protocol is the best window for reaping the benefits of icing. But what options exist after that? Injuries can last days, weeks and even months. 

Alternative options you may consider are:

1. Compression garments
2. Kinesiology taping
3. Massage
4. Anti-inflammatory diet

Compression is one option investigated as an extension of the RICE guidelines.  But does it work?

The idea behind compression garments is to limit the build-up of oedema caused by the fluids released from injured tissues. This seems logical.  However, research shows compression garments fail to reduce swelling, oedema, and DOMS (Heiss et al. 2018).

An alternative would be to create rather than compress space around an injury using Kinesiology taping.

The tape, backed by various research studies, is multipurpose and can be used for more than improving balance or reducing pain. More specifically, Kinesiology tape can create space between the skin and connective tissues—the space allows fluids to drain more freely, as described in more detail here.

As drainage improves, the amount of inflammatory mediators released by damaged cells are cleared faster, reducing local stress and helping to reduce scarring (Kafa et al. 2015).

Kinesiology taping can be worn without risks to the injury itself and can help maintain drainage throughout recovery.

Plus, Kinesiology tape is easy to apply, as shown for the ankle in this step-by-step video.

Other options include massage (Zainuddin et al. 2005), which can help alleviate pain and reduce swelling. But, unlike Kinesiology taping, massage is a short-lived and costly approach.

It’s never too late to start adopting an anti-inflammatory diet, as it will serve you well now and in the future. The point is to make an informed decision about your health and find a solution to help you recover over the short and long term.

 

References

1. Bleakley, Chris, Suzanne McDonough, and Domhnall MacAuley. 2004. "The use of Ice in the Treatment of Acute Soft-Tissue Injury." Am J Sports Med 32 (1): 251-261. doi:10.1177/0363546503260757. https://doi.org/10.1177/0363546503260757
2. Heiss, Rafael, Thilo Hotfiel, Marion Kellermann, Matthias May, Wolfgang Wuest, Rolf Janka, Armin Nagel, Michael Uder, and Matthias Hammon. 2018. "Effect of Compression Garments on the Development of Edema and Soreness in Delayed-Onset Muscle Soreness (DOMS)." Journal of Sports Science & Medicine 17 (3): 392-401. https://www-ncbi-nlm-nih-gov.zorac.aub.aau.dk/pmc/articles/PMC6090402/pdf/jssm-17-392.pdf.
3. Hubermann, A. (2021, May 10th). Supercharge Exercise Performance & Recovery with Cooling | Huberman Lab Podcast (No. 19). In Huberman Lab. https://hubermanlab.com/supercharge-exercise-performance-and-recovery-with-cooling/
4. Kafa, Nihan, Seyit Citaker, Suna Omeroglu, Tuncay Peker, Neslihan Coskun, and Seyda Diker. 2015. "Effects of Kinesiologic Taping on Epidermal–dermal Distance, Pain, Edema and Inflammation After Experimentally Induced Soft Tissue Trauma." Physiotherapy Theory and Practice 31 (8): 556-561. doi:10.3109/09593985.2015.1062943. https://doi.org/10.3109/09593985.2015.1062943.
5. Kwiecien SY. Is it the End of the Ice Age? IJSPT. 2023;18(3):547-550.  doi:10.26603/001c.74273
6. Merrick, Mark A. and Nicole M. McBrier. 2010. "Progression of Secondary Injury After Musculoskeletal Trauma-a Window of Opportunity?" Journal of Sport Rehabilitation 19 (4): 380-388. doi:10.1123/jsr.19.4.380.
7. Nagata, Itsuki, Masato Kawashima, Anna Miyazaki, Makoto Miyoshi, Tohma Sakuraya, Takahiro Sonomura, Eir Oyanagi, Hiromi Yano, and Takamitsu Arakawa. 2023. "Icing After Skeletal Muscle Injury with Necrosis in a Small Fraction of Myofibers Limits Inducible Nitric Oxide Synthase-Expressing Macrophage Invasion and Facilitates Muscle Regeneration | American Journal of Physiology-Regulatory, Integrative and Comparative Physiology." American Journal of Physiology 324 (4). doi:https://doi.org/10.1152/ajpregu.00258.2022
8.  Poppendieck, Wigand, Oliver Faude, Melissa Wegmann, and Tim Meyer. 2013. "Cooling and Performance Recovery of Trained Athletes: A Meta-Analytical Review." International Journal of Sports Physiology and Performance 8 (3): 227-242. doi:10.1123/ijspp.8.3.227. https://journals.humankinetics.com/view/journals/ijspp/8/3/article-p227.xml
9. Zainuddin, Zainal, Mike Newton, Paul Sacco, and Kazunori Nosaka. 2005. "Effects of Massage on Delayed-Onset Muscle Soreness, Swelling, and Recovery of Muscle Function." Journal of Athletic Training 40 (3). PMID: 16284637