Why Ice and Anti-inflammatory Medication is NOT the Answer
By Josh Stone, MA, ATC, NASM-CPT, CES, PES, FNS on November 7, 2013
In July I posted a blog discussing the overuse of cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” It makes me scream. Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!
The Stigma of Inflammation Editor in Chief of The Physician and Sports Medicine Journal (Dr. Nick DiNubile) once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders; inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair, and remodel. You cannot have tissue repair or remodeling without inflammation. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1).
Researchers headed by Lan Zhou, MD, PhD, at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated “overwhelmingly, NSAIDs inhibit or delay fracture healing” (2). And you want to stop this critical process of healing by applying ice, because inflammation is “bad”?
The Anecdotal Rationale for Ice Somewhere along the line the concept that ice facilitates healing became conventional wisdom. Sorry, that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.” Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps works so well and removing swelling accumulation.
Besides, since when is swelling a bad thing? Swelling is a necessary component in the first phase of phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of “Iced! The Illusionary Treatment option gave me a good analogy. Take two tubes of toothpaste, one is under ice for 20 minutes, the other is warmed to 99 degrees. In which tube will the toothpaste flow fastest? It does not take an advanced physics degree to know that answer.
What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A foundational study published in 1986 found when ice is applied to a body part for a prolonged period of time; lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). Ice can increase swelling and retard debris removal!
Load Facilitates Repair The acronym RICE is bogus in my opinion. Rest is not the answer. Rest does not stimulate tissue repair. In fact rest causes tissue to waste. The other reason RICE is bogus is obvious, ice. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Ice does nothing to facilitate collagen formation.
Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscle.
Ice will not influence progenitor cells development. Ice does not regenerate tissue. Ice does not facilitate healing – it inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.
Closing thoughts Have you seen the video discussion between Kelly Starrett, DPT and Gary Reinl? If not I recommend you watch it. It’s fascinating. My goal is to get this trend reversed one clinician and one patient at a time. I am glad to have expert minds like Kelly and Gary in this fight with me. I ask Athletic Trainers and health care professionals to do one thing, just try it. Pick one athlete with chronic, unresolved inflammatory injury. Skip the ice, skip the NSAIDs and try to use light exercise as a repair stimulus. Then, try it with an athlete with an acute ankle injury. Rest, skip the NSAIDs, skip the ice, and use light massage and ankle pumps to facilitate lymphatic flow. The outcome might surprise you.
**Update**: I’ve had an enormous amount of feedback for this post. I greatly appreciate all of it – good and bad. I am adding this note in regards to a n overwhelming amount of questions / comments about acute injury. The comment goes something like this: ‘yeah, but for acute injury, you should still ice.’ The question goes something like ‘would you do this for an acute injury?’
My response is yes, skip the ice for both chronic and acute injuries!! Why do you feel like we must ice an acute injury but not ice the chronic? What is the benefit to halting the healing process of an acute injury? One could argue that it is even more important to skip ice with an acute injury. There is the argument for pain modulation and I agree, ice has pain modulating effects. But to this I ask, at what cost are we reducing the pain? The temporary (30 minutes) of pain reduction via ice also halts healing. In addition, ice causes a back flow of lymphatic drainage further increasing post-ice swelling and subsequently increasing pain after the ice has been removed. Find other methods to reduce pain for acute injury.
YES! I would skip the ice for an acute injury and a chronic injury!
1. Buckwalter, JA, and Grodzinsky, AJ. Loading of Healing one, Fibrous Tissue, and Muscle: Implications for Orthopedic Practice. Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999.
2. Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
3. Haiyan Lu, Danping Huang, Noah Saederup, Israel F. Charo, Richard M. Ransohoff and Lan Zhou. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal. Vol. 25 no. 1 January 2011. 358-369.
4. Guyton, AC and Hall, JE. Textbook of Medical Physiology 10th Ed., W. B. Saunders Company. 2000.
Meeusen, R. The use of Cryotherapy in Sports Injuries. Sports Medicine. Vol. 3. pp. 398-414, 1986.