Putting ice on an injury has been an almost universally accepted treatment paradigm for decades and is actually still being recommended and taught in schools to kids and in first aid courses. Do a search on Google right now and you’ll find that almost everyone seems to recommend the RICER paradigm:
Being someone who has competed in various sports for the last 30 years, however, and at a level high enough that I’m always trying to get back out there as soon as possible, I’ve kept a close eye on the best methods in addition to talking with people newly graduated in sports science and physiotherapy. The RICER paradigm is actually so outdated that the person who coined the term, Dr Gabe Mirkin, issued a retraction of his methodology.
“We thought that, the more swelling, the longer it would take for an injury to heal,” Mirkin said. “Ice reduces pain and swelling to the injured area. Cooling down decreases blood flow, so we thought that cooling would also limit the amount of cell damage.”
As Mirkin found when evaluating 21 other recent studies, icing the affected area interferes with the first part of the healing process, decreasing blood flow, delaying and reducing the amount of healing chemicals.
What actually happens when you get injured?
To be clear here, we’re talking about soft tissue injuries that occur during sport or physical activity. So you’re playing basketball, soccer, taekwondo or whatever, and you roll your ankle pretty badly. Let’s say for this example that you’ve sprained your ankle — that means you’ve done ligament damage in the form of slightly stretching the ligament/s or possibly even slightly tearing it.
The site immediately begins swelling, so you should put ice on it to prevent that, right?
Swelling has always been thought of in the past as something to prevent, or control. This is completely counter intuitive, however, because swelling is the body’s natural response to an injury. Swelling occurs because your body is sending blood and nutrients to the site to heal the injury, much like dozens of first responders converging on a disaster area.
You want that to happen.
Icing an injury, while certainly good for pain management, actually slows recovery down significantly because it’s preventing the body from doing its job. All those first responders? It’s like you’re putting up a bunch of road blocks and stopping them from getting to the scene of the disaster. Ice constricts your blood vessels and basically slows everything down in the area.
In addition to the obvious theoretical understanding above, the research shows little to no evidence that ice is helpful for soft tissue injuries and significant evidence to the contrary.
A 2013 study by Paris researchers examined the effect of cryotherapy (freezing and thawing of the cells) on the duration of recovery after participants performed strenuous biceps exercises. Certain markers among those who received the cold therapy indicated they were delayed in returning to their normal state and muscular function.
Drainage and blood flow are king
So does that mean you should just let the area swell massively and not do anything about it? Of course not. One of the problems with an injury is that the lymphatic system gets involved, and lymphatic fluid doesn’t move away from an injured site like blood does. Blood has the heart pumping to keep it moving through, but lymph fluid requires movement of the muscles as a kind of hydraulic pressure to move it on.
So if the swelling has reached its peak, you can start to hasten the healing process in a couple of ways:
- Compression bandage, wrapped not too tightly. The pressure will force some of that fluid out.
- Elevation. Let gravity do the work by elevating the body part, which will help fluid drain from the site.
- Contrast therapy. Alternating the site between hot water (not burning hot obviously) for one minute, then cold water (not ice cold) for one minute. This creates a pumping effect as the blood vessels alternate between dilating and constricting, moving the fluid through as the area expands and contracts.
Even better? Do all three. As I said above, I’ve been competing for a very long time and am always looking to recover from injury as quickly as possible. The above 3 methods are all acceptable, but alone they aren’t the quickest. There’s no reason not to use them in conjunction with each other if you can.
The initial period of swelling and maximal pain generally lasts from 24–72 hours. Following that period, moving the affected area as soon as you practically can in a way that is no more than a 3–4 out of 10 in terms of pain is a top priority. As per the above section, blood flow is king, and there is no better way to get blood flow than movement. This proves true whether it’s a ligament or tendon sprain or a muscular strain.
Additionally, you want the structures in the area moving and bearing an acceptable level of load as quickly as possible. Scar tissue is one of the main issues with the healing process, causing future lack of flexibility in the area and a potential for re-injury. Keeping the area immobile for a long period of time will exacerbate this tendency.
Movement, along with massage (if necessary) will help to minimise the amount of scar tissue and allow the injured area to return to its pre-injury level of flexibility and performance. As the pain continues to subside and movement increases, it’s important to gradually increase the load on the area until the point the injury is fully healed and you’re able to use it at 100% capacity again.
One of the mistakes people make is leaving the injury too long without movement, allowing scar tissue to build up, then moving it less than they should in the recovery stage and then putting far too much load on it because they think it’s all healed. That’s a recipe for re-injury.
When you think of movement and injury recovery, my physiotherapist has the perfect analogy:
We’re trying to build a callus. That only happens through gradual strain and your body becoming used to that strain. The alternative is a blister.
The main points I want you to take out of this is:
- Don’t try to stop or slow down the inflammation process whether with ice or ibuprofen— it’s there for a reason and will help you heal.
- Use any and all methods to get blood flow to and from the site of injury
- Get moving as soon as possible, and gradually increase the load
Disclaimer: I’m not a doctor or health professional and this should not be taken as medical advice. I’m merely someone who has a significant experience with injuries from a long athletic career with the desire to share my results for your consideration.