We all have those coaches who operate with an old-school mentality. Stim and ice are the cure for everything. Ankle sprain, stim and ice. Hamstring strain, stim and ice. Lumbar pain, stim and ice. As Athletic Trainers (ATs) and allied healthcare professionals, we know otherwise. We understand that not all sprains, strains and pain are the same, and therefore, they are not treated the same. We also understand that ice is a useful modality for a variety of ailments.

What we don’t fully understand is how effective ice is when it’s not being used for acute swelling or pain. In essence, is cryotherapy an effective method of treatment for chronic injuries or recovery from intense exercise? If it is, we can keep ice as a valid treatment option. However, if it isn’t, we need to investigate how to educate our patients and coaches and break the mentality of ice as a cure all.

Ice as a modality for acute injuries has been practiced for centuries.1-5 As ATs, we were taught the concept of RICE (rest, ice, compression, elevation)4 as the initial reaction to acute injury. This treatment initially reduces pain via cold-induced neuropraxia and controls swelling via vasoconstriction.1-2, 4

Controlling pain and swelling following acute injury is important and increases the opportunity to have the patient mobile as quickly as possible. Once the patient regains mobility, we can better initiate the healing process.1 Anecdotally, I have found in the case of ankle sprains initiating pain free range of motion soon after injury resulted in decreased swelling compared to strictly ice post injury.

Cryotherapy is also used following heavy training days. We know heavy lifting, or strenuous exercise leads to delayed onset muscle soreness. A common practice for coaches and athletes is to insist upon ice baths after heavy training days. However, it has been suggested this method of reducing pain and inflammation after training may instead lead to delay in recovery from muscle damage.5 In clinical practice, I’ve found a regimen of warm whirlpool and foam rolling for complaints of muscle soreness after strength or fitness training has led to better subjective outcomes from patients.

We know that after acute injury pain and swelling can last from 2 to 6 weeks depending on the patient.1 The dilemma arises as to when we should stop icing. Ice controls swelling and pain, but it also reduces tissue metabolism, blood flow and inflammation.3 Eventually, the tissue metabolism and blood flow which is slowed down by ice will be necessary to help with the healing process. Studies3 have shown an increase in tissue temperature increases local tissue metabolism. This increase in metabolism provides the necessary actions for tissue repair to begin,3 leading to the idea of heat being a key aspect of continued healing. If this is true, it builds the case for progressing from applying ice to utilizing heat during the course of a rehabilitation program after injury.

The beauty of science and healthcare is that the field is ever changing. What we did clinically 10, 20, 30 years ago is not what we will be doing 5, 10 15 years from now. To those who perform cryotherapy, or any modality research, I salute you. It must be a tough and frustrating area of research, because every summary I’ve read tells me further research is needed.

Many of the treatments we choose, we choose because they worked with patients 1 and 2, so we apply them to patients 3 and 4. Consider changing the way you do things based on the evidence available. If we are finding immobilization and ice aren’t as effective as we once thought, maybe we try range of motion and heat. Or, perhaps ice an initial acute injury but change to heat after the inflammatory response has subsided to promote healing.

Educationally, I think it is our duty to educate coaches and athletes why icing may not always be the best option. It’s hard to change an old-school mentality, but utilize the evidence and a trial period to see if the outcome is positive or negative. Giving coaches physical evidence showing ice is not always the best choice can change even the most stubborn mind.

References

1. Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2006). Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine, 700-705.

2. Malanga, G., Yan, N., & Stark, J. (2015). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine, 1-9.

3. Nadler, S., Weingand, K., & Kurse, R. (2004). The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner. Pain Physician, 395-399.

4. Snyder, J., Ambegaonkar, J., & Winchester, J. (2011). Cryotherapy for Treatment of Delayed Onset Muscle Soreness. International Journal of Athletic Therapy and Training, 28-32.

5. Tseng, C.-Y., Lee, J.-P., Tsai, Y.-S., Lee, S.-D., Kao, C.-L., Liu, T.-C., et al. (2013). Topical Cooling (Icing) Delays Recovery From Eccentric Exercise-Induced Muscle Damage. Journal of Strength and Conditioning Research, 1354-1361.

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