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Why Ice is Not Always Nice (Part 2 of 2)

Why Ice is Not Always Nice (Part 2 of 2)

Thursday, December 4, 2016

Written by: Cora Tomowich

Hello again and welcome back to my discussion of ice therapy. In my previous piece, I spoke about ice not being a very helpful tool to manage inflammation in an acute injury. We learned that ice could in fact be harmful to you, as it can delay your healing, weaken your end-result tissue, and leave you open to repeat injury. The research evidence also does not support the use of ice to manage acute swelling, but did suggest its usefulness in managing acute post-operative pain. I also discussed my clinical uses of low-dose ice to help patients manage higher levels of pain or reduce nagging pains that get in the way of a good night’s sleep. But what about chronic swelling? Is ice helpful then? Well… read on MacDuff!

Once upon a time, we were told to follow “the RICE (rest, ice, compression, elevation) principle” when it came to managing acute injuries. In light of new evidence, however, experts now suggest “the POLICE (protect, optimally load, ice, compress, elevate) principle”. The distinction here is where RICE promotes rest and higher doses of ice for swelling, POLICE recommends no rest and lower doses of ice for pain management. Most importantly, POLICE also suggests optimal loading, which means getting patients into a customized exercise program designed to gradually stress the injured tissues so they become better and stronger and more resistant to repeat injury. Research has shown that POLICE in fact allows for more rapid recovery and higher activity tolerance.

So what about chronic injuries? A chronic injury can be an overuse injury or an acute injury that never fully healed, but somehow got stuck in a vicious cycle of injury à inadequate repair à re-injury. Essentially, chronic injuries are ones that seem to repeat or “flare-up” from time to time. In my practice, I often see recurring sprains, tendopathies, or strains that never fully recovered the first time around. Generally, chronic injuries are more difficult to treat and take longer than an acute injury to heal. Many patients have asked if they should be icing their chronic sprains, strains, or tendonopathies. I often hear: “When is swelling no longer beneficial to my healing?” or “When is ice the answer?”

First, let’s talk about inflammation. It is important in the case of either an acute or a chronic injury, to distinguish between good swelling and bad swelling. Good swelling is that which occurs immediately after an acute injury and it is the body’s natural and perfectly healthy response to protecting and cleaning-up the injured tissues. Because it can cause some discomfort, it may be helpful to use ice topically for no more than 10 minutes, once per day during this inflammatory phase. Once the initial inflammatory cells have served their purpose, they should be scooped up by the lymphatic system and then eliminated from the body. Studies show that some of the best ways to get the lymphatic system going is movement, muscle contraction, and optimal tissue loading. If, however, the lymphatics do not adequately remove all inflammatory agents from the injury site, we can get some bad swelling.

Bad swelling is the accumulation of waste and tissue-repair byproducts that have not been removed from an injury site. Their presence only delay or inhibit tissue repair and ultimately lead to repeat or chronic injury. Eventually this not-so-healthy tissue will become reinjured and more byproducts and waste will be produced and the vicious cycle will commence.

To put it anecdotally, think about how a city functions. What would happen if garbage just started piling up everywhere? Things would back up, clog up, cease to function, and eventually break down. Well, the human body is like a city and it needs the right environment in which to function properly. Now, if we continue along this city analogy, what would happen if it snowed in the city? Would the city move any faster or function any better? Absolutely not! The city would slow down even more, be even more stagnant, and nothing would function the way it should. Ice does the same thing to bad swelling.

So what’s the answer? Not ice, you can be certain of that! Whether the swelling from an injury is good or bad, we have to get the tissues moving to promote proper blood and lymphatic flow. Some experts even suggest using a form of moist heat therapy. Ice only slows blood flow and results in the development of less healthy, more easily damaged repair tissue. I always tell my patients that the name of the game is “More Blood Flow”. We have to promote movement of our body fluids or we turn into a clogged-up, winterized city.

To help you remember what we have learned, I have composed a little poem simplifying what you should do to manage an injury:

Pain can be tackled with ice

Swelling at first can be nice

But don’t let it last

Start moving it fast

Or you will get stuck in a vice!


Raynor MC1, Pietrobon R, Guller U, Higgins LD. Cryotherapy after ACL reconstruction: a meta-analysis. J Knee Surg. 2005 Apr;18(2):123-9.

Adie S1, Naylor JM, Harris IA. Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty. 2010 Aug;25(5):709-15.

Adie S1, Kwan A, Naylor JM, Harris IA, Mittal R. Cryotherapy following total knee replacement. Cochrane Database Syst Rev. 2012 Sep 12;9

Bleakley CM et al Effect of accelerated rehabilitation on function after ankle sprain: randomized control trial. BMJ. 2010 May 10;340:c1964

Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012 Mar;46(4):220-1


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