“Should I ice it”?
This is one of the most common injury questions I get asked when I’m on duty in the sporting field! But this question also gets asked almost daily by patients in the clinic in regards to their everyday injuries, and after other traumatic events such as operations.
When athletes suffer a soft tissue injury, such as a sprain or strain, one of the most common first-line treatments has always been the application of ice, or what is more medically known as cryotherapy. Icing injuries is a practice that has been widely recommended by physiotherapists and sports medicine physicians to reduce pain and inflammation, with the ultimate goal of promoting recovery. However, while icing injuries has been a staple in sports injury management for decades, questions have been creeping in for some years as to how much benefit ice actually has, and new research recently published in the British Journal of Sports Medicine, raises important questions about the efficacy of using ice after injury!
In this article I will explore the science behind cryotherapy, explain how it works, its historical use, and what the latest research says about its role in recovery, helping you all make informed decisions about your future injury treatment.
The Basics of Using Cold Therapy
Cryotherapy involves the application of cold to injured soft tissue, most often through ice packs. The goal is to reduce tissue temperature, which helps alleviate pain, limit swelling, and potentially minimize the spread of secondary injury to surrounding tissues. The mechanism behind cryotherapy is based on the idea that reducing tissue temperature slows down cellular metabolism. In theory, this helps limit the inflammatory response and tissue damage caused by secondary injury (the spreading of damage to healthy tissue after the initial injury, often due to bleeding). Moreover, cold therapy is thought to reduce blood flow to the area, which helps control swelling. Many of these thoughts are now being challenged.
The Evolution of Ice Therapy: From RICE to POLICE to PEACE & LOVE
The modern use of cryotherapy in sports medicine can be traced back to 1978, when Dr. Gabe Mirkin first introduced the RICE protocol that we are most familiar with—Rest, Ice, Compression, and Elevation. Over the years, this protocol evolved as more research on injury management emerged. “Refer” was added to give us RICER; “Protect” the injury was added to create the PRICER acronym, and later “Optimal Loading” replaced Rest, forming the POLICE principle (Protect, Optimal Loading, Ice, Compression, Elevation).
We can then go even further and add more acronyms – PEACE & LOVE!
Peace stands for:
- Protection – from further injury
- Elevation
- Avoid Anti-Inflammatories – taking anti – inflammatories is a common mistake!
- Compression
- Educate – on appropriate management until seeking further advice
Love stands for:
- Load – starting to add the important load that stimulates healing
- Optimism – a positive attitude goes a long way!
- Vascularisation (or blood flow) – which comes from mobilising, not immobilising for too long.
- Exercise
Despite these changes, ice has remained a core component in treating soft tissue injuries, and it is interesting to hear that RICE is still being taught in many courses, and I would say 95% + of the people I talk to are only aware of the RICE protocol.
There are not many medical interventions that have remained unchanged over 46 years, but RICE seems to be one that has resisted the trend of change (or modernisation)!
The Pain-Relieving Benefits of Cryotherapy
One thing that remains clear is cryotherapy’s effectiveness in reducing pain. The cold numbs the area, providing short-term relief, which can be particularly helpful in the initial stages of injury when pain is most intense. For many athletes, this immediate analgesic effect allows them to manage discomfort while they plan the next steps in their recovery process.
However, beyond pain relief, there are growing concerns about whether cryotherapy truly supports tissue healing in the way it was once thought.
Does Cryotherapy Help or Hinder Recovery?
While ice has been a go-to treatment for decades, the latest research we have available sheds light on some of the limitations of using ice therapy, particularly when it comes to tissue repair and regeneration. This research highlights a key issue: much of the existing understanding of cryotherapy’s effectiveness comes from animal studies, not human trials.
Animal studies suggest that cryotherapy may reduce inflammation, but it might also delay muscle regeneration. This is significant because while inflammation is often seen as a negative aspect of injury, it’s also a critical part of the healing process. Inflammation helps the body clear out damaged tissue and initiates the repair process, laying the groundwork for new tissue to form. We actually don’t want to inhibit inflammation in this early injury period because it is helpful to tissue healing.
It may well be that cold therapy could inadvertently delay the body’s natural healing mechanisms, potentially prolonging recovery.
Translating Animal Research to Human Injury Treatment
It’s important to note that while these findings from animal studies raise concerns, they don’t necessarily translate directly to human injuries. Humans and animals have different injury patterns, muscle characteristics, and responses to treatment. As a result, the conclusions drawn from laboratory studies may not reflect what happens in real practice with human patients.
For now, the effects of cryotherapy on human tissue regeneration remain unclear. In reality, there’s little evidence from human studies that cryotherapy limits secondary injury or promotes faster tissue regeneration (and these two points have basically formed the whole premise behind why we apply ice in the first place)!
Despite this, cryotherapy continues to be recommended in the short term for its pain-relieving benefits and the potential to reduce immediate swelling and hematoma (bruising) formation. I think it is very important for people who are advising the application of cryotherapy to be aware of the “Why”! Why are you advising the application of ice? If you are advising it in the hope of reducing further injury, limiting swelling, and promoting tissue healing, then you may need to rethink your “why”! We just don’t have this evidence.
If your “why” is to reduce pain, then we have the evidence to back this up!
Striking a Balance: Pain Relief vs. Healing
Given the current lack of evidence regarding cryotherapy’s impact on tissue regeneration, how should we approach its use? The key seems to lie in balancing pain relief with a focus on long-term healing.
Certainly in the first 24 hours after an injury, using ice can be helpful to manage pain and potentially reduce some swelling (however I feel that compression and elevation are the two more critical factors in reducing excessive swelling). It is crucial that we do not rely solely on cryotherapy as a treatment to the exclusion of these other interventions.
Many physiotherapists now emphasize the importance of early active recovery—such as gentle, controlled movement—during the healing process. The PEACE & LOVE protocol strikes the best balance, with the PEACE component being the ideal way to manage an acute injury – and note that this acronym does not mention Ice! I strongly recommend that the “E” or educate component of this stage involves education to your athlete on whether the application of ice therapy is necessary.
After this initial 24 hours post injury, continued use of cryotherapy should be re-evaluated, especially as more research suggests that reducing inflammation too much could hinder the body’s natural healing processes.
What Do I Advise?
Firstly, my belief is that the RICE regime is a little outdated and does not highlight the critical points of immediate injury management, nor emphasise in a sequential order the importance of each intervention. The POLICE acronym does not quite have the right order, so PEACE & LOVE is the way to go for me!
Whilst I don’t think you can go wrong using the RICE principles in the immediate aftermath of an injury (provided you realise the greatest benefit of Ice is pain relief) the PEACE regime gives a much better approach to the optimal immediate management after an injury, especially in that 24-hour period after the injury. RICE (and especially Ice) should not just be continued after this first application without knowledge and thought as to “why continue”?
I still feel it is essential to consider cryotherapy as a component of a comprehensive treatment plan, and that if ice is to be applied then it is essentially for the purposes of early pain relief. I still apply ice regularly in my role as physio on the sporting field, but it is usually applied straight after an acute, painful injury, and perhaps continued intermittently for the rest of that day if pain remains a factor. From here the whole management aspect gets a bit gray – every person is unique, and every injury is different. Determining when to transition from cold therapy to more active forms of rehabilitation that promote tissue regeneration, (such as controlled movement, strength and flexibility) may require the guidance of your physiotherapist!.
Conclusion
Cryotherapy remains a popular treatment for acute soft tissue injuries, but its role in tissue regeneration is still not fully understood. While it offers immediate pain relief and can help reduce swelling in the early stages of an injury, there is no strong evidence that it promotes faster healing (and there’s some emerging evidence in animal studies that it may delay healing). Patients should work with their physiotherapist to determine the best approach to their recovery, using cryotherapy in combination with other proven rehabilitation techniques. As our understanding of the effect of cryotherapy on tissue healing evolves, there may be changes in how—and when—cryotherapy is used in the future.
As a parent or Sports First Aider, remembering the PEACE protocol is the way to go!
Anthony Lance
SSPC Physiotherapist
References available on request
