269 comments on “Why Ice and Anti-inflammatory Medication is NOT the Answer

  1. I will admit I haven’t read the comments, but I believe the way you presented this topic is flawed.

    The inflammatory response is an immediate response that CAN NOT be prevented with ice and NSAIDs(well mostly considering this exact thing is being used to treat spinal cord injuries with great success). The whole purpose of this treatment protocol is to prevent second cell death syndrome. The process of preventing healthy cells from dying due to the influx of macrophages and other phagocytes. The idea is not to stop the inflammatory response, because it can’t be stopped, but to prevent any other secondary injury caused by the “swelling” during this injury.

    ALSO this treatment is to help stop the pain spasm cycle. Because there is pain you get an inflammatory response. Because there is an inflammatory response you get pain. By eliminating one of these the cycle is broken, thus preventing a potential chronic injury status.

    In closing. You should use ice. Every time. It helps stop the pain and thus the limits the second cell death syndrome. NSAIDs can be used at your discretion, but as with the ice, if you want to stop the cycle then use the drugs. Or take acetaminophen, which would block the pain receptor.

    • Hi Tim,

      What you say seems to make sense. For me, notwithstanding the theoretical scientific understanding of the healing process, which I understand is, as yet, still incomplete, it’s the underlying philosophy of our approach to expediting recovery that I am most interested in. There are two broad approaches to the issue:
      1. Assisting the body in doing what it’s done for millennia, and got very good at.
      2. Opposing these processes, assuming that somehow, despite our incomplete understanding of the whole picture as yet, we know a way that is cleverer than the one that has been designed by evolutionary and adaptive processes.

      Which approach does the whole ‘ice’ thing fall under, in your opinion?

      Whilst I may be a statistical outlier, in over 30 years of multiple traumatic injury from martial arts activities, I have never iced and have no untoward repercussions from that. One or two of the more serious ones affected me for a prolonged period of time but probably no longer than one would have expected of the severity of the injury, My approach has always been to use the injured area gently and gradually build up its use until there are no remaining symptoms. Whilst the theory says I should have iced, the reality is that I didn’t and recovered just fine.
      So, do I write myself off as a statistical outlier or do I assume that I must have been doing something right?
      I guess one of the questions that an RCT doesn’t answer is the following:
      We know that we live in a society of people with suboptimal health. A huge majority don’t exercise enough and their diets are unhealthy. So, both treatment group and control subjects are selected from broadly unhealthy populations. Is it possible that the more realistic conclusion from trials is: if you lead an unhealthy lifestyle, suppressive modes of treatment may help. If you lead a healthy lifestyle, your body is quite capable of recovery with the facilities it’s already endowed with?

      • I am now 45. So, no spring chicken. My worst soft tissue injuries have been joint sprains and contusions. My most memorable one was on my right hand when I chose a board a little too thick to punch through. Was probably more injurious to my ego, although my fist swelled up like a balloon.

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    • Let me be the first to plead ignorance Dr. Kruse. I am not familiar with Dr. Becker’s work that shows cold and cold alone (“cold alone” being key) stimulates tissue regeneration. I would love to see this work as it may influence my thoughts. To date there are very few human studies to show efficacy that cold and cold alone stimulate tissue healing.

      As the father of electrochemical and electromagnetic medicine I am familiar with his work in these areas and have utmost respect with the work he has done from the late 60’s through early 80’s to shaped the future of rehabilitative medicine. So, please if you a link to the work that talks of cold and tissue regeneration, please send it along.

      If I am not mistaken he also introduced the world to iontophoresis. Again, with this he changed the landscape of rehabilitation. The beauty of science is that we have continually evolved.

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  5. All great thoughts, wondering if anyone has available some of the details that are needed for this discussion. At what depth does cryotherapy applied to the skin penetrate. Can an ice pack on the skin limit blood flow/inflammation to target tissue ie tendon. Is there a different between sitting in a tub of ice vs an ice pack over a joint vs ice pack over a muscle. I would say yes and I wonder if target tissue is being effected. Like everything in rehab, need to more specific, tendinitis vs osis, depth penetration of modality, target tissue, good pain vs bad pain, why did they hurt. Personally ice is just a small part of process good or bad. Can ice 2-3x/day 15minutes really make that big of a difference in the real world, not in a nfl locker room. Thanks

    • Take a look at the Father of Cyotherapy Dr Ken Knight’s work. He is research expert on the use of ice in its various formats.

    • Med Sci Sports Exerc. 2002 Jan;34(1):45-50.
      Soft tissue thermodynamics before, during, and after cold pack therapy.
      Enwemeka CS, Allen C, Avila P, Bina J, Konrade J, Munns S.

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  8. I went to see a reputable Osteopathic Physician yesterday for knee pain. I was diagnosed with Osgood-Schlatter disease and Patellofemoral pain. Although the doctor did not recommend icing, he did prescribe NSAIDs (in addition to anti-inflammatory foods and avoiding stairs, squatting, etc.). In response to my comment that inflammation is the natural way for the body to heal itself, he said that in my case the inflammation, although not painful until very recently, must have endured for quite some time because the body’s response to the inflammation was the build up of calcification on the tibia tuberosity. And without the aid of anti-inflammatory drugs/foods, eventually my knee may stiffen due to increased calcification. I have decided to treat it with turmeric, Omega-3 oils, and anti-inflammatory foods such as onions and garlic, and less vigorous exercise on the knee joints.

  9. Glm; I have treated many cases of arthritis of the CMC joint of the thumb. Responds very well to Graston Technique, cold infrared laser and adjusting/mobilization. Sometimes we have to add in topical natural antiinflammtory supplements. I am a chiropractor/rehab specialist in Central Connecticut.

      • Both Graston technique and Gua sha use similar tools, knife-like shaped.
        The different is in the philosophy of the technique

        Gua sha, traditional medicine technique, is used to take Chi away from the body on a specific spot (on an energy meridian). Their tool are usually make up of organic material (rock, ivory…).
        Graston technique is a western medicine technique. Through the use of metal tools (very expensive) they scrapped the surface of the skin in order to break of adhesions/scar tissue in muscles/tendon (very usefull around joints).

        The differences resides in the treatment philosophy of the practitioner, what he believe in.

        Just like a lumber jack and a clock worker both use hammers, but for different purposes, gua sha and graston technique are very similar but truly different..

        I am not an expert on the subject, but i have a good grasp on the subject. If anybody feels like i forgot information, correct me, or add information, please do.

      • Sounds like Mr Graston saw some potential in something that had already been in existence for a thousand years, repackaged it, used different words and claimed it was something new that he had discovered. I’ve experience it and it appears to offer no more than Gua Sha. As far as the patient is concerned, the underpinning philosophy is irrelevant; does it make them feel better?

  10. Our inflammatory response evolved to mobilize our immune cells to attack and kill invading bacteria and viruses. The release of histamines by mast cells enlarges the pores of local capillaries, allowing activated plasma proteins to leak out of the capillaries into the inflamed tissue, swelling it up. The plasma proteins then punch holes in the membrane envelopes of bacterial cells, causing them to swell and burst.

    Why does this inflammatory action occur in response to blunt-force trauma such as knee or ankle sprains, with no break in the skin and thus no danger of bacterial invasion? In a 2010 study, scientists found that multiple trauma busts cells apart in injured tissue, releasing mitochondria — the tiny organelles within our cells that generate energy — into the bloodstream. Since these footloose mitochondria resemble invasive bacteria, a person’s immune system mounts an aggressive attack against them, often leading to Systemic Inflammatory Response Syndrome (SIRS). See “How Trauma Leads to Inflammatory Response”: http://www.sciencedaily.com/releases/2010/03/100303131525.htm

    To Dr. DiNubile’s provocative question, “…Do you honestly believe that your body’s natural inflammatory response is a mistake?”, I would answer: “Yes! — when it comes to blunt-force trauma.” I think Joshua, while arguing persuasively against ice and anti-inflammatory drugs, goes overboard when he insists: “You cannot have tissue repair or remodeling without inflammation.” He overlooks the toxic aspects of inflammation, such as the massive release of radical oxygen species (including free radicals) that disrupt our enzymes and cell membranes and lead to formation of scar tissue, including fibrous and fatty plaques that stick to the walls of blood vessels.

    I favor vitamins C and E to prevent the toxic consequences of inflammation. Vitamin C neutralizes free radicals in the bloodstream and inside our cells, while vitamin E neutralizes free radicals in our cell membranes. Vitamin C in large doses is a natural antihistamine, yet it promotes a vigorous immune response. Vitamin C also plays a key role in cells’ production of collagen, a structural protein that helps form our muscles, tendons, ligaments, bones, blood vessels and skin. Vitamin E is crucial to muscle growth and repair. I swallow vitamin E capsules and also apply their oil topically to relieve joint soreness and help skin cuts heal smoothly.

    I also find that hot baths with a couple cups of Epsom salt (magnesium sulfate) crystals mixed in help relieve my sore muscles and joints. Proponents of Epsom salt claim it promotes lymphatic drainage; I don’t know if this claim has been scientifically tested.

    • Hi Daniel, I admired your writing style; direct, clear and easy to understand. That said, you may want to reconsider your key position regarding whether or not Dr. DiNubile’s question (“Do you honestly believe that your body’s natural inflammatory response is a mistake?”) is right or wrong. Consider this 2010 article from the Cleveland Clinic entitled: Hold the Ice?
      Researchers headed by Lan Zhou, MD, PhD, Neuroinflammation Research Center, Depart. Of Neurosciences at the Cleveland Clinic, and colleagues, found that in response to acute muscle injury, inflammatory cells (called macrophages) within the damaged muscle itself were found to produce a protein called IGF-1, which is required for muscle regeneration.

      • Thanks, Gary! Luckily, the study you mention — which Joshua referenced in his article above under the heading, “The Stigma of Inflammation” — is available online in its full text: “Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury,” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005436/#!po=51.9231 I just read it carefully.

        This study, conducted on different strains of mice, shows that macrophages (“big eaters” in Greek, these are large and supple immune cells) play a surprisingly versatile role in muscle tissue after acute injury: Not only do macrophages gobble up dead muscle fibers and dead immune cells that have sacrificed themselves by ingesting invasive microbes — the macrophages also produce and release an insulin-like growth factor (IGF-1), which plays a key role in rebuilding muscle cells. So far, I’m following your and Joshua’s interpretation of the study: Macrophages, one type of immune cell activated during inflammation, promote fresh growth of muscle fibers to repair the damage from injury.

        However, in their Discussion, the study’s authors go on to state: “The finding supports the notion that macrophages may play multiple constructive roles in muscle regeneration, including the production of muscle trophic factors to promote regeneration, chemotactic factors to attract myogenic cells to injured areas, and anti-inflammatory cytokines to resolve inflammation.” What? These same macrophages that swarm into the muscle during the inflammatory episode release cytokines (chemical-messenger molecules) that put an end to the inflammation?!

        We can clear up this conundrum by following the ebb and flow of the physiological story line: Inflammation plays a necessary role following acute injury (although it goes too far in blunt-force trauma, as I pointed out in my earlier posting), mobilizing immune cells and initiating tissue repair. Once the acute danger has passed and repair is well under way, inflammation needs to be switched off. If not, our bodies would get saddled with chronic inflammatory diseases.

      • Hi Daniel, I guess that settles it; you believe that you need to decide when to “switch off” your body’s innate intelligence … and I believe that my body’s innate intelligence will manage the process just fine without my help (interference). I do still question your belief that it (your body’s innate intelligence) goes too far in blunt-force trauma. Consider this; collectively, trillions and trillions of bumps and bruises (big and small) have been successfully managed by the human body’s innate intelligence during the past thousand years or so … do you seriously believe that the human body’s natural inflammatory response is a mistake?

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  13. I appreciate the fact that you highlight the body’s innate ability to heal lies in inflammation, just like fever, but I feel that this article could really mislead people. Often times true “healing ” is the result of a matrix of therapies depending on the individual. Making blanket statements is what body workers need to stop doing, or if they are going to do it, get detailed….and have fun writing that article. One important function, and maybe the primary function of ice, is reduce pain by affecting the nervous system through Gate Theory, and by reducing the pressure on nerves cause by inflammation. As a massage therapist I see people all the time in pain. It greatly affects their life. Therefore I feel that pain relief can be just as important as the actual healing process. Not only psychologically but to help reduce compensatory structures from becoming dysfunctional. Ice is a great natural option for pain relief. Secondly, I disagree that one should not rest after an injury. Why? Because, key word, in the “acute” phase the joint’s stability is compromised, and tissue can become more damaged. This is just common sense. If you weren’t to rest you could injure the tissue further. Should movement be part of the rehab process, of course! Maintaining ROM and strength training should be a part of every rehab protocol at the right time.

    • Hi Jessie, Your suggestion that pain relief is ample justification to ice damaged tissue reminds me of the sympathetic bar tender that gives an alcoholic a drink. Does it matter to you that icing the damaged tissue does nothing to alleviate the reason there is pain? That your “fix” is very short lived and ultimately delays healing, increases swelling and causes damage. Here’s another basic question; how would you “ice” deep tissue without damaging surface tissue (trick question … you can’t)? If you really want to facilitate pain relief and normalize function (and I sincerely believe that you do) … move the waste (which is likely causing much or most of the pain and dysfunction) via the lymphatic system. Simply activate the muscles around the damaged tissue, your body will do the rest (simple rule: use your brain … never cause pain). By the way, the muscle activation will not only move the waste, it will lead directly to the development of new blood vessels (angiogenesis), help prevent disuse atrophy (via the release of PGC-1A) and help prevent adhesions and other scar tissue abnormalities. Simply put; absolute stillness (rest) is, generally, a bad idea and adding ice to the process is worse.

  14. Do you know where I would be able to find the first three articles you referenced from the 2013 NATA convention? I am a member of NATA but can’t seem to find them on the website

  15. Gary, you’ve misinterpreted my summary of the mice macrophage study. Clearly, our body’s inflammatory response has built-in biochemical feedback loops (in this case, mediated by macrophages) that switch off inflammation at the right moment, bringing our immune system back into balance. I agree with your and Joshua’s persuasive arguments against icing injured body parts. Yet gentle compression and massage seem appropriate to limit swelling, stimulate blood flow to the injured tissue, and promote lymphatic drainage.

    When our skin breaks out in an itchy rash a couple days after we brush against poison ivy (or poison oak) leaves, our natural inflammatory response has made a mistake: Falsely viewing the plant’s oil (urushiol) as a dangerous toxin, the immune system overreacts, launching a delayed hypersensitivity response that irritates our skin. Sometimes a common viral invader triggers a child’s natural inflammatory response to go awry and attack the child’s own pancreas, destroying the cells that produce insulin and leading to juvenile (Type 1) diabetes.

    The high rate of asthma in rich countries stems from children’s immune systems, adapted thousands of generations ago to combat parasitic worms, launching mistaken inflammatory responses in the worms’ absence: The inflammatory symptoms of asthma would help us wall off worms burrowing through our skin; cough and sneeze worms out of our lungs; and flush worms out of our guts. With the hygiene of rich countries shielding us from worm infections, many people’s anti-worm patrol, having “nothing better to do,” springs into action when it senses airborne pollen grains and dust-mite pellets, launching inflammation of the airways. Such a mistakenly trained inflammatory response leads to asthma. See “Exposure to microscopic worms may be the link to asthma and allergies”: http://tvnz.co.nz/national-news/exposure-microscopic-worms-may-link-asthma-and-allergies-5599665

    Megadoses of vitamin C can control asthma and many allergies by regulating the amount of histamine in the bloodstream and calming trigger-happy inflammatory responses. See Linus Pauling’s book, “How to Live Longer and Feel Better,” pages 197-8, 200-1, & 239-40.

    Some people’s natural inflammatory response habitually attacks the cartilage in their own joints, leading to rheumatoid arthritis. Other people’s natural inflammatory response habitually attacks the myelin sheaths insulating their own nerve fibers, leading to multiple sclerosis. Still others’ natural inflammatory response habitually attacks the DNA of their own naturally dying cells — inflaming their joints, kidneys and central nervous system and leading to lupus (SLE).

    Our bodies’ innate intelligence — in particular our immune system, which embodies a lifelong learning process — in no way guarantees flawless functioning. Even the most intelligent people often make mistakes.

    • Hi Daniel, I apologize; I did not intentionally misrepresent your summary of the mice macrophage study. A final related comment, I feel that you have, perhaps inadvertently, brought a “red herring” to this discussion (something intended to divert attention from the real problem or matter at hand; a misleading clue). We are talking about the body’s success rate at healing damaged tissue (musculoskeletal injuries) … not lupus or asthma or poison ivy. That said, I believe we have reached the point where we have agreed to disagree.
      Regarding your comment “Yet gentle compression and massage seem appropriate to limit swelling, stimulate blood flow to the injured tissue, and promote lymphatic drainage.” I wholeheartedly agree with you that lymphatic drainage via muscle activation will “limit” swelling (by evacuation not suppression) and stimulate blood flow and more (see my previous response). On second thought … maybe we don’t disagree after all!

  16. I think it is dangerous to blanket a very complex issue. My family has a strong history of ankylosing spondylitis and you absolutely need to control the inflammation because if you don’t your quality of life is hell. You can do it mostly through diet and exercise but there are times where you have to treat it with anti-inflammatory drugs. I have Spondylolisthesis and when I have a flare up I need to take some drugs to get it under control and exercise is usually the cause of the flare up. So I caution people about giving such generalized information because every person is going to be different in their injury process. This article scares me.

    • Hello ABC, have you heard of writer and peace activist Norman Cousins (1915-1990)? Linus Pauling, in his book “How to Live Longer and Feel Better,” wrote that Cousins “was suffering intensely from an ailment diagnosed as ankylosing spondylitis, a progressive form of arthritis characterized by inflammation and then the fusing together of adjacent bones, especially of the spine. As described…in his book, ‘Anatomy of an Illness as Perceived by the Patient,’ Cousins decided to try the effect of vitamin C and persuaded his physician to give him intravenous infusions of 35 grams of sodium ascorbate per day. This treatment, together with the psychosomatic aid of his determination to remain cheerful…led to his recovery.” See http://www.amazon.com/Anatomy-Illness-Norman-Cousins/dp/B000KAFLHC/ref=cm_cr_pr_product_top My link here is to the original 1981 edition of “Anatomy of an Illness…” Apparently the 20th anniversary edition removed much of Cousins’ material about ankylosing spondylitis.

      • I have AS too and have staved off degeneration by a stringent exercise regime. I have seen my father (who has it too) become crippled by not exercising and relying on medication. You probably are not exercising properly.

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  18. Thank you for this insightful and thought provoking article. I would love a similar analysis of the potential benefits/harmful effects of using heat to treat injuries, such as muscle spasms or pulls. Thanks!

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  24. I dunno bout this one… While I kinda agree with the no ice I disagree that inflammation is “good” for healing. The best way to deal with inflammation, hands down, is earthing. I’ve been pain free with a tear in my labrum for three years now do to sleeping grounded. This injury is excruciating entirely due to inflammation and prior to my barefoot reconnecting with the earth overnight I was barely able to walk. I’m currently a full time professional ballet dancer.
    As I understand it swelling is the bodys way of protecting and injury but if fact can slow the actual healing process.
    No ice, no drugs, just ground.

  25. I have thoroughly enjoyed this conversation. I applaud Josh for raising the question and for examining underlying physiologic mechanisms instead of following conventional wisdom cook book approaches. But I do believe that I most closely align with Daniel’s eloquently written comments. The body is a marvelous machine with tremendous wisdom, but it is not perfect. And, its responses were evolved for a much more physical lifestyle that would probably not apply to most people’s lives today. Certainly there is value in inflammation much of the time, as there is value in having a fever, but the body can overdo it. Also, I do think that physical activity can help the healing process, but can also physically stress the local tissues and cause more damage.
    I believe the most important thing is to treat each patient according to his/her own specific needs at the particular time that s/he presents. Not to follow an always do of always do not do something.

  26. Great article Josh, glad you are contributing to this ‘off limits’ conversation. As a former ATC and current Nurse Practitioner it’s amazing how urban legend guides our actions.
    Looking forward to reading more of your blog.

  27. Dr. Muscolino, I Googled you … wow! That said, considering your level of education and experience I have a couple of friendly questions and comments that I trust you will find reasonable. Since the body is not perfect; how often would you say it responds wrongly (regarding damaged tissue in an otherwise healthy human being when that individual did not interfere with the healing process via drugs, cryotherapy or whatever but did appropriately “load” the area in question throughout the entire healing process)? What percent of the time? Please allow me to loosen up the question; of the last billion incidences worldwide, how often did it respond wrongly (what percent of the time)? During my life (I am over 60), I figure I have “damaged my tissue” (bumps, bruises, sprains, strains, pinches, cuts, breaks, burns, etc.) at least 1000 times (that’s a little more than one “incident” per month on average). Each and every time my innate intelligence responded and all was soon well. Now don’t get me wrong, if, on a rare occasion, you need to interfere … interfere. I am simply agreeing with you … but, tightening up your response.
    Two final comments; cryotherapy is simply a bad idea. It delays healing, increases swelling and causes damage. Regarding helping the healing process via physical activity … stillness is the enemy and movement is our friend (by design; muscle activation always drives the healing process). When it comes to how much activity … my advice is always the same; “use your brain … never cause pain”.
    Based on my perusal of your academic and clinical accomplishments, I believe you would enjoy reading my book; “ICED! The Illusionary Treatment Option: Learn the Fascinating Story, Scientific Breakdown, Alternative, & How To Lead Others Out Of The Ice Age” (http://www.amazon.com/ICED-The-Illusionary-Treatment-Option/dp/0989831914). If you want a copy, please contact me (Josh has my email address and telephone number) and I will gladly send you one.

    • Hello Gary, I am not a researcher so I do not feel comfortable even attempting to answer your question. I believe it more shadings of gray, than black and white. Even if a number could be agreed upon, the degree of the excessive swelling would vary each time and would also vary based on many other factors.
      I am a strong advocate of movement, to the degree it is possible. BUT, first, the movement must do less harm than good (there is a risk when there is unstable tissue due to injury) and second the patient must be willing to do it. Patient compliance is a huge factor here. Many people are not kinesthetically aware to be able to use their brain to judge such situations and also many people are adverse to any pain, even what might be considered “good pain”. All in all, it is my belief that the body’s approaches to injury healing developed when people, by necessity had to lead physical lives and therefore movement pretty much had to occur to dissipate swelling (as well as do other things). But that now, most people’s lives are sedentary and getting them to move sufficiently is difficult or unfeasible. Given the vasoconstriction activity of ice on the arterial system that decreases fluid into the area (before the reverse vasodilation effect takes place) and that decreasing pain can also be valuable, I see valid applications for icing.
      I do not have time right now to read another book, but you are more than welcome to summarize your points.
      I will add that one of my favorite sayings is: “Follow the man who seeks the truth; beware of the man who has found it.”

  28. I am no medical expert but have suffered many chronic and acute injuries in my years playing all sorts of sports. On my own evidence, icing an acute injury in the first 1-2 hours has helped prevent many chronic injuries. I have one chronic injury – a rotator cuff injury – which if I don’t ice it, will cause the tendon/muscle to be impinged by the joint. My other injuries are less chronic either because of the way I went about the recovery or because of the type of injury.

    What I certainly agree with and should have been presented is that ice and NSAIDs are not the miracle cure – that is the main misconception amongst the general population. But the RICE principle certainly helps in the first stage of recovery. I do agree that mild exercise will speed up the recovery at a later stage. The RICE principle was designed for the first 2-3 days after an acute injury as far as I know.

  29. I agree that ICE is not always the answer. but all my patients had complained of pain more than the swelling such in px with arthritis, fracture, contusion etc. and i had to get rid of the pain first. ive used therapeutic modalities as options but ive used manual therapy too. its important to know that we can actually treat clients and or px without any modalities or drugs. still it comes down to the clinicians decision when and what are we going to use. we all want our px to receive the SAFEST and QUALITY medical service. eitherway i opt to use cold and manual therapy for treating acute and chronic Musculoskel conditions.

    • btw, if ALL px knows that ICE/drugs are sufficient enough to meet their goal, they may never seek us. they may end up resting. they end up chronically injured. regarding inflammation, yes the body does it as first line of defense (acute) but not with chronic. but why do i PRICEMEM the acute injury? because i need to respect the pain, need to stabilize and protect it (in open and closed fx, sprain and strain), need to move it gently with the aid of gravity in assisting circulation, but when everything fails, px tend to resort to drugs. i cant prescribe since im. not a doc. ive just graduated and currently reviewing for boards and i would be pleased to receive feedback.

  30. I’ll fill in some things that build on the ideas presented by Daniel Jacobs and Dr. Muscolino. I wanted to comment on this earlier, but didn’t have the time to do so.

    This views related in this blog post are (unfortunately) indicative of a growing incidence of this line of thought. Fortunately, the prevalence of this views is still low. They represent a simplistic, fundamentally limited and flawed understanding of acute inflammation, its purpose, process & agents and it’s role in healing. That’s not an indictment of Josh Stone, but it is an indictment of what we teach clinicians… we simply are not teaching most clinicians the things we need to teach on this topic.

    The conclusions and recommendations of this blog post to avoid cryotherapy for acute injury management are misguided and I cannot agree with them. Here is why… a little cell biology and immunology goes a long way….

    Sorry that the following is so lengthy…. but if you want to understand what’s really happening here, the length can’t be avoided. I gave a talk on this topic at the NATA Annual Meeting and Clinical Symposium in 2009 as part of the CEC Specialty Session titled “Managing Musculoskeletal Inflammation: Current Understanding and Evidence Based Practice”. My portion of the talk was titled “Should We Try to Arrest Inflammation or Try to Promote It?” I’ll re-hash a few of the key points here:

    I’ll start with my favorite quote about inflammation… it’s sets the stage for the essentials…

    “Inflammation is a real life drama, traditionally interpreted as the microscopic equivalent of warfare against true or perceived invaders, with its cellular heroes, villains, casualties, suicides, and even victims of friendly fire.” – Majno G. & Joris I. Cells, Tissues, and Disease. 1996

    The “perceived” invaders and “victims of friendly fire” are the parts of most interest to this discussion.

    1.PURPOSE OF INFLAMMATION: There are several and they are important. Acute inflammation warns of us a problem, makes it harder for us to keep using something that is damaged, works to counteract or at least limit threats to our survival, works to clean up dead and damaged tissue, and is the initiator of the healing process. It is ABSOLUTELY ESSENTIAL. However, not all of the parts are essential and there are some that are actually detrimental in most (closed) athletic injuries. It is critical to understand that one of the major features of inflammation is its role in battling the early stages of infection. Infection is a serious threat to survival and the window of opportunity is most open when the infection is beginning, before the pathogen has had an opportunity to multiply exponentially. The earliest part of the inflammatory process is a (neutrophil mediated) lethal and largely non-specific attack on the invading pathogens. With closed musculoskeletal injury, we don’t have invading pathogens but we unfortunately we DO still get this lethal, non-specific response that actually causes additional tissue damage. Fortunately for us, it is VERY possible and ACTUALLY USEFUL to limit that part of inflammation in certain specific instances where there is no threat of infection.

    2. PROCESS & AGENTS OF INFLAMMATION: In a typical inflammatory response, the purpose in the first few hours differs from the purpose later on. Initially, the goal is to try to stop the pathogen invasion in its tracks before it can gain much of a foothold. The first 6 or so hours are devoted to this and largely amount to vascular and cell signalling changes aimed at bringing a large number of neutrophils into the injury site. The neutrophils show up EVEN IF there is no invading pathogen. They are the most numerous white blood cells that we have and they have several functions. One of them is the their respiratory burst… the release of very toxic reactive oxygen species into the injury site. These are the biologic equivalent of the hand grenade. They kill pathogens quite nicely… but they also kill otherwise undamaged tissues in the area as well. We call this “secondary injury” and in this case, it’s secondary immune injury… the most common type. This is one of the “victims of friendly fire” from the quote above. The problem with closed musculoskeletal injury is that there are NO INVADERS to kill … but the neutrophil is not “smart” enough to know that. Hence, the “perceived invaders” part of the quote. They still cause considerable tissue damage that was in no way needed.

    In the period between 6 – 24 hours post injury, the predominant white blood cell population at the injury site changes. The neutrophils largely die off and you have an influx of macrophages. There are different types of macrophages. The earliest arriving ones continue the “pathogen fight” and ones that arrive later are mostly there to clean up the mess and initiate the repair and regeneration response. The macrophage population is”smarter” than the neutrophil in that they adjust to the reality of the situation around them. If there are no pathogens, they get started on the clean up and repair process as Dan Jacobs points out in his comments. The more damage they find, the longer it takes to clean up and the longer it takes to repair.

    3. ROLE OF INFLAMMATION IN HEALING: We have have learned that without the action of the macrophage, we have a MUCH slower and less organized clean up and repair of the tissue damage. In a very interesting special edition of the journal Nature Immunology 6(12), 2005 there is a series of papers reviewing the research where different parts/agents of the inflammatory process were removed (via anti-sera, knockdown, and knockout models). They reveal a VERY interesting picture of how the different agents in inflammation affect healing…

    – If we remove Mast Cells (early “lookouts” for invading pathogens/tissue damage that “call” the neutrophil army to the fight) we see reduced neutrophil numbers in the wound site AND we see NO DELAY OR WEAKNESS in the healing of the wound. – Egozi et al, Wound Repair Regen, 2003

    – If we remove Neutrophils from wounds where there are no invading pathogens, we see FASTER HEALING with NO REDUCTION IN STRENGTH of the repair – Dovi et al, J Leukoc Biol, 2003

    – If we remove Macrophages, we see FAILURE TO CLEAR THE DEAD CELLS AND DEBRIS and a SERIOUS DELAY IN HEALING. – Martin et al, Curr Biol, 2003 & Hopkinson-Wooley et al, J Cell Sci, 1994

    Essentially, from these we learn that WHEN THERE IS NO INVADING PATHOGEN ARMY, the neutrophil does far more harm than good. We can target it without fear of compromising the patient’s outcome or timeline. On the other hand, we ABSOLUTELY DO NOT want to interfere with the macrophage portion of the process UNLESS we have a REALLY IMPORTANT reason to do so (such as swelling that puts pressure on your spinal cord or brain as we see with some C-spine or head trauma or in cases of severe allergic response).

    How does acute cryotherapy fit into this? It limits the vascular and cell signalling process that bring the neutrophils to the site, it limits neutrophil action, and it SIGNIFICANTLY suppresses the unnecessary damage to otherwise uninjured tissues (i.e. suppresses secondary immune injury). This is shown in my own work. – Merrick et al, Med Sci Sport Exec 1999; J Athl Training 2002; Butterfield et al, J Athl Training 2006; Merrick et al. J Sport Rehabil 2010.

    BOTTOM LINE: No we should not “stop” the inflammatory process… nor could we EVEN IF we wanted to! There are ZERO tools in our current arsenal that can stop inflammation because it is so complex. Clinically we can limit it, but not stop it. What IS useful however is to suppress the tissue damaging effect of the neutrophil response in the earliest hours following injury. We don’t need it if there is no risk of infection and it actually causes more damage that must ultimately be repaired, delaying healing. The key is in how we do it. Acute cryotherapy in the first few hours may be our best tool here (Merrick et al, Med Sci Sport Exec 1999; Merrick et al. J Sport Rehabil 2010). NSAIDS and even more so corticosteroids suppress the ESSENTIAL and BENEFICIAL role of the macrophage in cleaning up the mess and initiating inflammation. Interfering with macrophage function has been shown to delay healing. In short, keep doing acute cryotherapy, but be cautious about the cavalier use NSAIDs and corticosteroids. These drugs have their benefits in some circumstances, but their drawbacks mean that they need to used judiciously.

    • Thank you for posting this. It was a pleasure to read and did give support with science what seemed intuitively clear to me. That is that body is a wonderful machine that has limitations and is not always perfect in its responses. I strongly believe in the minimum of intervention hen possible, but to take the ideological stance that the wisdom of the body is always correct is simplistic and when carried to its natural conclusion would obviate the need for all physicians and therapists.

    • First and foremost, I thank you Dr. Merrick for your contribution. You are a leader in the field and I have developed the utmost respect for you and your published work. It goes without saying I am honored that you have read and have taken the time to provide your insight.

      You make great points regarding cell biology and immunology.
      “In the period between 6 – 24 hours post injury, the predominant white blood cell population at the injury site changes. The neutrophils largely die off and you have an influx of macrophages. There are different types of macrophages.”
      “neutrophil does far more harm than good…..On the other hand, we ABSOLUTELY DO NOT want to interfere with the macrophage portion.”

      Here is my take away from this. In the first 24 hours we inhibit neutrophils, but want to encourage macrophage activity following this initial 24 hour period. Consider the following scenario: Basketball players sprains and ankle at 2pm. We apply cold / compression 15 minutes every hour. The next day the athlete reports to the athletic training facility. We continue conservative management of the inflammatory process. At what point do we stop the ice / compression and encourage the inflammatory process? Fast forward 3 days… 1 week…. 2 weeks… do we ice post rehabilitation or post practice? My point is we continue to ice long after this initial 24 hour window. I understand 24 hours is not a magical endpoint, but 1-2-3 weeks post is a bit much, is it not?

      The other question I have is the liberal use of cryotherapy on chronic injuries. Why are we compelled to ice Achilles or Patellar Tendinopathy? This is not an acute inflammatory issue, heck its not even an inflammatory issue, it is a derangement of collagen tissue and the natural process of gene transcription gone awry. Is cryotherapy indicated for these injuries?

      What stimulated this blog post was the overuse of cryotherapy and the ideal that has been created where ice replaces rehabilitation. In many athletic training rooms there are countless athletes who come in daily ice. Daily, for an entire season!

      All that said, I am certainly not attempting to debate what you mentioned. I know a debate with experts like yourself would turn me to road kill. That said, I do believe there is a general mis/overuse of cryotherapy.

      • The transition point where we discontinue the I.C.E. approach (or P.R.I.C.E. or R.I.C.E.S. or whatever acronym you prefer) is elusive. There is no simple answer or magic number of hours. What I teach my students is pretty basic and intuitive… and something we seem to have gone away from. Just use your eyes and hands to help you understand what is going on.

        If the injury is still “ANGRY”… i.e. pretty hot to the touch, still making edema / effusion, and giving the patient epicritic pain with even slight movement, then continue with cold and compression (I struggle to find any evidence for usefulness for elevation). When it starts to calm down… i.e. it has edema/effusion that is not expanding and its warm but not “hot” and it’s transitioned to protopathic pain, even with movement, then you can discontinue the cold and move on.

        The timeline is on a patient by patient, injury by injury basis and relates to both the injury’s severity and the magnitude of the acute response. If you transition away from cold too soon, the thing tends to blow up with edema/effusion again and you can actually re-initiate the acute response. That just delays you. In that regard, I do advocate REST… but my definition of rest is not sitting on the couch eating Ho-Ho’s and watching NetFlix. In this context, Rest is limited and carefully planned activity with a therapeutic goal in mind. Even then, we tend to flirt with the limit of what is therapeutic v. re-triggering the inflammatory response.

        I agree FULLY that far too many people have been lazy and have inappropriately substituted inactivity, NSAIDs and cryotherapy in the place of a proper rehabilitative program. That is especially true of one-off event coverage by athletic trainers with no follow-up. We should remember that I.C.E. + pain control is ACUTE CARE and not a substitute for care that hastens recovery and return to activity. I typically transitions patients to controlled activity ASAP… usually the next day and I am a big fan of using Cryokinetics to do so.

      • Hello Mark and Josh and all. I would just like to add that apart from cellular biology and the immune system, another very valid use for cryotherapy, at least in the world of manual (and movement therapy) where my experience lies, is to suppress pain, thereby allowing a certain degree of assertive care that would otherwise to be possible.

    • Dr. Merrick,
      You end your response with the following “BOTTOM LINE: No we should not “stop” the inflammatory process… nor could we EVEN IF we wanted to! There are ZERO tools in our current arsenal that can stop inflammation because it is so complex. Clinically we can limit it, but not stop it.”
      I completely agree with the first two sentences and offer the following edit to your third sentence; replace “limit it” with “delay” it.
      Making damaged tissue cold does not limit the inflammatory process … it merely delays it. When the tissue rewarms; the process resumes (fortunately). By the way, your suggestion that neutrophils are not “smart” enough to know what to do and when is preposterous. It is even more preposterous that you feel that you are more qualified to regulate the healing process then your innate intelligence. Sure, there are rare exceptions when things go wrong but to suggest that your belief is the norm is misguided.
      I suspect that some readers will side with you and some with side with me. But, that is not my goal. Instead, I am hopeful that you will side with the facts. You have momentous influence in this field and what you say matters … please take the time to carefully peruse the facts. Neutrophils are not irresponsible freaks of nature. The inflammatory process is an extraordinarily well regulated miracle. True, sometimes there is collateral damage. But, the neutrophils also call the repair cells to damaged area, etc. Think of it this way, a police office is forced to initiate deadly force … which results in the bad guy going down. Sometimes incident people are caught in the crossfire. That said, police officers also call for help when your house is on fire or when you are injured in a car crash, etc. Neutrophils, like police, have numerous responsibilities.
      I felt that you would find the following article relevant and useful (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1748424/):
      NOTE: This is one of many related articles.
      J Athl Train. 2006 Oct-Dec; 41(4): 457–465.
      The Dual Roles of Neutrophils and Macrophages in Inflammation: A Critical Balance Between Tissue Damage and Repair
      Timothy A Butterfield, Thomas M Best, and Mark A Merrick
      Conclusions: Neutrophils infiltrate injured tissues but can also be present after noninjurious exercise. These cells have both specific and nonspecific defensive immune system functions that can cause tissue damage in isolation or as sequelae to other tissue injury. It might seem that limiting the action of neutrophils would be clinically beneficial, but these cells are also responsible for initiating the reparative process that is later managed by macrophages. Although achieving a therapeutic balance between limiting inflammation and stimulating repair is important, the duplicitous roles of neutrophils and macrophages in both the inflammation and healing processes create a physiologic paradox for clinicians whose goals are to limit inflammation and to stimulate healing after acute soft tissue injury.
      In closing, I want you to know that I appreciate and understand that many people believe (or once believed) what you believe. That however, does not change the facts. Remember, clinicians cannot limit the inflammatory process with an ice cube … they can mealy delay it (fortunately). On the other hand, muscle activation, as Josh suggests in his blog, moves the waste that accumulates at the end of the inflammatory process. The point, if you want to normalize the rate of healing … don’t delay the process; help it.
      If you want, I will gladly send you a free copy of my book “ICED! The Illusionary Treatment Option: Learn the Fascinating Story, Scientific Breakdown, Alternative, & How To Lead Others Out Of The Ice Age” (http://www.amazon.com/ICED-The-Illusionary-Treatment-Option/dp/0989831914). Josh has my contact information.

      • Gary… this is the internet. You are completely welcome to say that my (intentionally very simplistic) summary of the non-specific immunity aspects of neutrophil biology is preposterous. Anyone with access to a basic immunology textbook can draw their own conclusions readily enough. The basics of the white blood cell response during inflammation are pretty well described in hundreds of places.

        BTW, nice plug for your new book. I hope it becomes a profitable venture for you. I see in the bio that you’ve been in the “sports medicine field” for a long time. The bio does not list any degrees, credentials, nor even a specific profession however, so I couldn’t really determine the background you bring to this conversation. I noticed that you list publishers for your previous books on your bio but not for this one. Is it self-published? Amazon lists you as the publisher rather than any recognizable publishing house and I found that curious. I also found it curious that you wrote a book about cold therapy when none of your previous published work has anything to do with the topic. The previous books listed on your bio both had to do with fitness and your two journal publications that I could find were as a minor co-author on a couple muscle stimulator papers where your affiliation was with a fitness equipment company. I don’t see the connection to this topic.

        You seem to have misunderstood the paper I published with Tim Butterfield and Tom Best a decade ago. The purpose of that paper was to point out that there is a paradox with inflammation and it’s management. There, just as I did here, we suggest that Inflammation has ADVERSE consequences just as it has BENEFICIAL ones. We can’t ignore one set of consequences and pretend that the other is the only part that is real. The real world doesn’t work like that. The goal with that decade -old paper was to identify the paradox, promote discussion, and ultimately promote investigation that is athletic injury specific (we have precious little of that). If you believe that paper to be a definitive answer that we dare not interfere with inflammation, then you have grossly misinterpreted it.

      • Hi Dr. Merrick,

        Words matter. Neutrophils are not dumb. Our innate intelligence is not hopelessly blowing in the wind. The inflammatory response is not an arbitrary or chaotic event. True, there are times when things go wrong, but wrong is the exception not the rule. But, like you said in your original post:
        “BOTTOM LINE: No we should not “stop” the inflammatory process… nor could we EVEN IF we wanted to! There are ZERO tools in our current arsenal that can stop inflammation because it is so complex. Clinically we can limit it, but not stop it.”

        Fact is, you are right, you can’t stop it. You can delay it; but you can’t stop it (fortunately). The suggestion that delaying it will somehow “limit” your innate inflammatory response is simply not true. When the tissue re-warms the process resumes. Also, again like you said in your original post “There are ZERO tools in our current arsenal that can stop inflammation because it is so complex.”
        And, there is certainly no way to just stop neutrophils from populating the damaged area (good thing … they belong there).
        Further, there is credible evidence in the literature that icing the damaged tissue not only delays the process; it actually causes harm (increased swelling & additional damage … which paradoxically, would signal the need for more — not less — neutrophils).

        Do you recognize the name Dr. Gabe Mirkin? He’s the guy that coined the acronym R.I.C.E. Did you know that even he has publicly denounced the use of ice on damaged tissue (http://www.drmirkin.com/public/ezine111410.html).

        Regarding my book and why I self-published. More than a few publishers were interested in my book. I evaluated my options and decided that since my network of connections reaches more than a million athletes, trainers, therapists and physicians … I decided that I would do it myself (welcome to the new day). By the way, I am not alone … many people with networks like me have realized that self-publishing is the best option. NOTE: my offer is still good; if you want a copy, I will gladly send one to you (http://www.amazon.com/ICED-The-Illusionary-Treatment-Option/dp/0989831914).

        My background on this topic:
        During the last half-decade, I have interviewed several hundred elite-level athletic trainers, therapists, and physicians (with a tight focus on football, basketball, hockey and baseball) regarding the topic of recovery. Cryotherapy was a dominant part of virtually every conversation. I read several hundred related articles/abstracts and a half dozen books. I personally tried nearly every cryotherapy product on the market at a national level (I have not used a cryo chamber … nor will I). I have had detailed extensive conversations with most of the national representatives of the products noted above and have read all available related information (both on their websites and in journals). I reported my findings in my book.
        Regarding the paper that you published with Tim Butterfield and Tom Best a decade ago … I don’t believe I misunderstood or misrepresented it. I merely cited it because it is an excellent resource.

        Gary Reinl

      • If you read Gabe Mirkin’s explanation on his recanting the whole R.I.C.E. thing, he attributes his change of stance to a Nov 2010 paper in FASEB. If he read it first-hand, he might have held off on his change of position. You see, there is an interesting and instructive story on that paper … the paper actually is in the Jan 2011 edition of FASEB and can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005436/. It was available ahead of publication online and was widely discussed in various media outlets, so that is probably why Dr. Mirkin cited it as Nov. 2010.

        That paper by Zhao and colleagues is an important one but it has been WIDELY misrepresented. It demonstrated that activated Macrophages produce IGF-1, a growth factor that is quite useful in stimulating the repair process. It is frequently cited as ONE of the potential explanations for why interfering with macrophages has a detrimental effect on healing. It’s a good paper with a useful finding.

        Unfortunately, several people have suggested that it says something that it does not. The Telegraph, a newspaper in the UK, got a hold of the paper and published a piece that made the leap from Zhao’s paper to the idea that ice is bad. It can be found at http://www.telegraph.co.uk/health/healthnews/8087777/Putting-ice-on-injuries-could-slow-healing.html

        There is only one little catch… Zhao’s paper NEVER LOOKED AT COLD IN ANY WAY and did not even attempt to draw any conclusions about the use of cold. The newspaper folks made the suggestion that ice interferes with healing, the actual paper did not (and could not… cold was not studied). If all someone did is read the newspaper article, they would form a very different opinion than if they read the actual research paper in FASEB.

        My guess is that Dr. Mirkin, like so many others, probably did just that and accepted the anti-ice suggestion from the newspaper article (or from any of the other various newsletters, blog posts, etc that got their info from the newspaper article) rather than actually reading the original paper which did not deal with ice at all. That is the trouble with forming opinions from secondary sources instead of original science. It makes you dependent on someone else’s INTERPRETATION of the paper instead of what the paper actually says. In some cases you can get away with that. In this one, it is problematic to do so.

        Of course, it’s hard to blame someone for using a mistaken secondary source here given the level of biological knowledge required to fully understand a knockout mouse paper in FASEB or the extremely dry task of actually reading it 🙂

        BTW, here is a fun quote from Dr. Zhao in the Telegraph newspaper article, “…Prof Zhou, said: “We hope that our findings stimulate further research to dissect different roles played by tissue inflammation in clinical settings, so we can utilise the positive effects and control the negative effects of tissue inflammation.”

        and here is another one from the newspaper article… “Gerald Weissmann, editor of the Federation of American Societies for Experimental Biology (FASEB) journal, said: “For wounds to heal we need controlled inflammation, not too much, and not too little.”

        The actual scientists in this area understand that inflammation has both beneficial and detrimental aspects and there is an opportunity to manipulate it to our patients’ advantage.

      • BTW, absolutely appreciate this back and forth. Dr. Merrick, as the perpetual learner of sports medicine, I am well aware of your work and appreciate the input.

        Dr. Merrick, you painted a compelling pro-cryotherapy case, specifically for very early and acute management of traumatic injury. You later agreed that cryotherapy is overused and the evidence does not support treatment beyond acute phase. This is where the disconnect occurs in clinical practice. Many health care providers interpret the data to believe cryotherapy is the gold standard, proven treatment option for all injury. This is clearly not the case!

        Dr. Merrick, in the most recent comment, you shed light on the INTERPRETATION of the FASEB article, because cold was not a variable in the study and thus should not be regarded as such. I fully agree with this. However, in your initial response, you cited several studies re: cellular biology and immunology. Unfortunately, the articles cited in your original response (4) never looked at cold in anyway and did not even attempt to draw any conclusions about the use of cold. Yet, you took this cellular biology and immunology data and interpreted them in fit with your published studies 1999, 2002, 2006 and 2010.

        Like I had mentioned previously, I am not the scholar you are, but I do not see overwhelming evidence to support cryotherapy expedites tissue healing. While you certainly make a strong case for the cryotherapy in acute management, this case does not support the overuse of cryotherapy in the late acute, sub-acute, nor does it support the gross misuse of cryotherapy in chronic injury.

        The purpose of the blog was to open the eyes of many and get them to look at this from another perspective. How can science be contemporary if we do not ask the right questions? How can athletic training become an evidenced based practice if we do not practice the evidence?

        Great discussion!

      • Dr. Merrick,
        It’s called deductive reasoning (thinking logically).
        If you make the damaged tissue cold … things slow down. If things slow down, it takes longer for the needed “supplies” to reach the damaged area and longer for the “waste” to leave the damaged area. If it takes longer for the needed supplies to reach the damaged area and longer for the waste to leave the damaged area; you delay healing. And that is precisely what Dr. Mirkin reported in his article:
        “Ice Delays Recovery from Injuries” (I italicized and underlined “Delays” to bring attention to what he actually claimed)
        June 21, 2013 by Gabe Mirkin, MD
        “More than 30 years ago I coined the term RICE (Rest, Ice, Compression, Elevation) for the acute treatment of athletic injuries. Now a study from the Cleveland Clinic shows that one of these recommendations, applying ice to reduce swelling, actually delays healing by preventing the body from releasing IGF-1 (Insulin-like Growth Factor-1), a hormone that helps heal damaged tissue (Federation of American Societies for Experimental Biology, November 2010).”
        For the record, I am certain that Dr. Mirkin is qualified to read and understand the journal “The Federation of American Societies for Experimental Biology” … here’s his bio:
        Who is Dr. Gabe Mirkin?
        “Sports medicine doctor, fitness guru and long-time radio host Gabe Mirkin, M.D., and his wife, nutritionist Diana Mirkin bring you news and tips for your healthful lifestyle. A practicing physician for more than 50 years and a radio talk show host for 25 years, Dr. Mirkin is a graduate of Harvard University and Baylor University College of Medicine. He is one of a very few doctors board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology.
        Dr. Mirkin hosted a popular call-in radio show on fitness and health that was syndicated in more than 120 cities. He wrote the chapter on sports injuries for the Merck Manual (both lay and physicians’ editions), the largest selling book worldwide with over one million copies in print. His daily short features on fitness have been heard on CBS Radio News stations since the 1970′s. He has written 16 books including The Sportsmedicine Book, the best-selling book on the subject that has been translated into many languages. His latest book is The Healthy Heart Miracle, published by HarperCollins.”
        Since I don’t like to rely on “guessing” when having a serious discussion (and since I have Dr. Mirkin’s cell phone number in my elite directory) … I called Dr. Mirkin and asked him if he read the actual journal article or “The Telegraph” as you suggested … guess what? He read the journal article. NOTE: Nice try … but your red herring was dead on arrival.
        In closing, since you did not comment on the content of my previous post (where I pointed out that you can’t actually limit neutrophils by making the damaged tissue cold (you can only delay their arrival — which by the way would delay recovery) and that no one on the planet is more capable of correctly regulating the inflammatory process better than their innate intelligence (not even you, Dr. Merrick). Or that icing increases swelling and causes additional damage … which in turn increases the number of neutrophils populating the area in question, etc. I figured that you now understand that icing damaged tissue is not a good idea (at least I hope so).
        Gary Reinl

      • I often feel that people have an opinion and then choose the facts that fit their opinion (it is cherry-picking, right?). For me, I don’t have a horse in this race, but I must say that I admire the manner of reasoning that Dr. Merrick presents). I will add a few possible pertinent fact(or)s.
        Ice causes vasoconstriction, which would limit the degree of fluid entering the region, which should help decrease the amount of inflammation fluid present (swelling is a factor of fluid in versus fluid out, isn’t it?). And ice can decrease pain. Given that pain can cause muscle spasming (pain-spasm-pain cycle), then decreasing could have value.
        I de believe that most of the time, the body’s innate wisdom is great and should be observed and maintained, but I find the argument that the body’s innate wisdom is always right to be too simple. If the body is always right, we would never have (hyper)allergic responses nor autoimmune diseases, nor genetic mutations, etc. Further, if my child had a fever of 105 degrees, I would not leave it alone praising the virtue of the body’s response; rather I would look to decrease the body’s excessive response. I view inflammation in the same manner. There are times when I believe the body overdoes it, even with its innate wisdom.

      • Hi Joseph,

        Maybe the rationalisation for the ‘does the body’s innate intelligence always act in the best interests of the body’ question is resolved by the statement: it does if it’s functioning correctly. Autoimmune diseases are, by definition, a state of disease. Therefore, we endeavour to re-establish balance, even if we are unsuccessful. An athlete who sustains and injury and has a perfect bill of health may not need anything more than ‘nature’s innate intelligence’.
        It all comes down to the fact that every patient is unique and requires a unique approach. Carte Blanche approaches like “always ice” or “never ice” are doomed to only ever work for the best by chance. This is where our current scientific method has a big hole in it. To know the ‘correct’ answer through deductive reasoning, the only way is to treat this specific athlete’s specific injury, at this specific moment, in this specific way. Then take the same athlete back to the identical circumstances and repeat the process with a comparator method or ‘no treatment’. Then do the same for a significant ‘n’ of other athletes. The variables are so hugely complex (most of the discussions above sound extremely comprehensive but, come next year, will be outdated as we learn more about a ‘new’ component or pathway).
        Therefore, we have to come out of the text book and into the realm of experience where the physical therapist, whatever their modality, can use their vast experience and computer brain that makes a billion deductions in a bat of an eye, taking into consideration the sound, presentation, complexion, verbal explanations, medical history etc. of the patient, make a unique diagnosis for that specific patient at that specific moment and give an appropriate treatment for that moment…which may be inappropriate the very next day. Enter holism! 😉

      • Opinion versus Fact

        Ice does cause vasoconstriction (which limits the amount of fluid entering the region, which can help decrease the amount of inflammation fluid present). KEY POINT: Temporally!

        But, the fluid is sent to area by design. When “injury” occurs the damaged vessels automatically constrict … but, the healthy vessels automatically dilate and increase profusion (bringing the needed repair and cleanup “supplies” to the area). KEY POINT: The fluid is a integral part of the healing process.

        Swelling is a factor of fluid in versus fluid out. KEY POINT: Incapacitating the lymphatic system will not move the fluid out (and ice incapacitates the system). Conversely, muscle activation will move the waste out (the lymphatic system is a passive system that works when muscles contract and relax).

        Ice does decrease pain. KEY POINT: Temporarily!

        But, it also delays healing, causes additional damage, increases swelling and shuts down the signals that alert you to harmful “movement” (which will ultimately cause more pain, not less). Using ice for “temporary” pain relief reminds me of the sympathetic bar tender that gives the alcoholic a drink to temporally “ease his pain.”

        The Body’s Innate Wisdom

        Question: Considering all known facts; what percent of the time would you say that the body’s innate intelligence fails to correctly respond to damaged tissue (in an otherwise healthy individual)?
        My opinion: significantly less than 1%. Now the big question; when it does fail, do you honestly believe that an ice cube is the solution?

      • While I love the discussion, I hope we have reached a point of enough. I believe we’ve all had our voice and opinion heard MORE THAN ONCE. I think by this point we all get it and we all get your stance, no matter which side of the fence you are on (pro-ice, anti-ice, or maybe-ice).
        This is starting to sound like right-wingers and left -wingers on the floor of the senate bickering over abortion or gay rights.

      • Ahhh…. if the whole thing were really so simple as to merely follow deductive reasoning it would be lovely. I did not attack the credibility of Dr. Mirkin, I merely suggested that his conclusion mirrored that of a newspaper article and did not match the actual findings of the study he referenced. I do not know him and even if I did and had him on my cell phone i would not make such an self-agrandizing comment as to describe it as “my elite directory”. You don’t establish credibility by name dropping or calling yourself an expert. You establish it by earning the degrees and professional credentials that give the level of knowledge and experience to understand something on a very deep level. Dr. Mirkin is an expert in that way and he has earned the professional respect due him, including my own. He’s earned that distinction in the conventional way through focused professional preparation coupled with personal experience. If Gary says that he read the article and used deductive reasoning to come up with changed stance, that’s fine. He’s welcome to make that conclusion. It is a professional opinion from someone qualified to make it. That does not make it a gospel truth however. Experts draw conclusions that are mistaken all the time (myself included). That’s part of being human. Making a leap that all cryotherapy is detrimental from an article that says activated macrophages express a potent growth factor that is important to healing but that did not examine whether cryotherapy affects it is overstepping.

        Josh correctly points out that I also provided some deductive reasoning in discussing papers about the manipulation of inflammation that used similar knock-out models but did not expressly examine cold. Kudos on picking that up… probably the most astute observation or comment in this entire thread. :-). I too make a small leap there and it may turn out in the long run that I am overstepping too. I have no qualms with admitting that there is a lot that I don’t know… that is why I am a successful scientist. We form theories, and revise, refine, or reject them as we examine their details and learn things we didn’t know. I However, I don’t think I am overstepping here and here is why.

        I do not subscribe to the “all or nothing” view of inflammation that Gary continues to paint in this thread. If I understand him correctly, I can simplify his stance as suggesting that any interference with the “innate intelligence” of inflammation at any stage is bad because the end product of inflammation is good and interference with any part of the process will harm or delay the outcome. If I have mischaracterized his view, then please accept my apologies. The trouble is that such a view is very simplistic and it just doesn’t hold up to scientific scrutiny. My leap is smaller and more carefully calculated because it involves very specific sub-processes in inflammation coupled with a somewhat more intricate understanding of the details of the process (a benefit of having earned a PhD in physiology). The intricacies of the process get lost in these types of online discussions with audiences of mixed background because I either assume the audience knows more than it does and I don’t elaborate or there is just not time or space to teach an entire course on the subject.

        In this entire thread, I’ve (almost criminally) oversimplified the inflammatory process in an attempt to show the “big picture” at the expense of the critical details. That is why I described the neutrophil as not “smart” (I don’t think I called it “dumb”). No one needs to defend the honor of the neutrophil to me… I’m one of it’s biggest fans 🙂 I wasn’t making a judgement about it’s “innate intelligence” or its value. Quite the contrary. I was describing (simply) that it fulfills a largely positive feedback type role in the process where, once activated, it causes haphazard damage to anything in range of its weapons. It does not differentiate between friend or foe (we call that non-specific immunity) and that is what I meant in calling it not “smart”. It’s akin to a “smart bomb” v. “regular bombs” where “smart” ones specifically go after a particular target and “non-smart” ones are not so carefully targeted. “Non-smartness” in the inflammatory defense system actually has an important purpose… it is FAST and lets us fight a pathogen more quickly than the other “smarter” (more discriminating) defenses that take longer (hours) to show up an get organized. In the early stages of inflammation we sacrifice careful specificity of defense in favor of all out speed because speed is more valuable at that time. It means we get friendly fire, but we’re willing to accept that in order to repel the attacking pathogen hoard that is multiplying fiendishly. This is indeed “innate intelligence”, but it would be overly simplistic to lump both the early non-specific and later more refined and discriminating phases of the response together because they do different things, for different reasons, at different times… and we don’t always need a full-blown response in both of these phases. On that, the science is pretty straight forward.

      • Sorry, I was typing the last post and did not see the comment come through to close the thread. My apologies… didn’t intend to pile on after the thread was closed.

      • No worries, Dr. Merrick. Always appreciate the insight.

        Check out this battle of published in the Journal of Haemophilia. I think you – most of all – will appreciate it no matter which side you are on:

        The original article:
        DOI: 10.1111/j.1365-2516.2012.02918.x

        A rebuttal in a letter to the editor published:
        DOI: 10.1111/hae.12163

        Then a rebuttal to the rebuttal letter to the editor:
        DOI: 10.1111/hae.12265

        I am sure you have full-text access, but if not, I’ll send PDFs.

  31. Hi Scott,
    In the article that you referenced “Cryotherapy in ankle sprains” the results are “questionable”. The authors claim that grade four sprains reached “full recovery in 13.2 days. Grade “four”, according to the authors, meant “unable to bear weight because of pain”. Assuming that a “grade four” of yesteryear would convert to a least a grade two by today’s standards consider this; a grade two sprain can take 4 to 6 weeks to heal. If I am wrong and the “grade four” of yesteryear would convert to a grade one by today’s standards (which makes no sense when all data is reviewed) consider this; a grade one sprain usually takes 5 to 14 days to heal. Source: The National Athletic Trainers Association (NATA).
    Further, the study does not make any claim whatsoever that icing damaged tissue is better than combining active recovery with not icing … the point of Joshua’s post.
    Here are a couple of historical facts regarding the article that you referenced:
    It was published five years before “The Use of Cryotherapy in Sports Injuries,” Sports Medicine, Vol. 3, pp. 398-414, 1986 … the main take away from this article; icing damaged tissue increases the amount of local swelling and pressure and potentially contributes to greater pain.
    It was published 29 years before “Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury” FASEB J. 2011 January; 25(1): 358–369. doi: 10.1096/fj.10-171579 … the main take away from this article; icing damaged tissue delays recovery.
    It was published 32 years before “Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage” J Strength Cond Res. 2013 May;27(5):1354-61. doi: 10.1519/JSC.0b013e318267a22c … the main take away from this article; icing damaged tissue delays recovery or worse.
    It was published 32 years before the doctor that coined the term “R.I.C.E.” publicly acknowledged that he was wrong about icing damaged tissue and officially removed the “I” from his world famous treatment formula … http://www.drmirkin.com/public/ezine111410.html
    It was published nearly 33 years before “ICED! The Illusionary Treatment Option: Learn the Fascinating Story, Scientific Breakdown, Alternative, & How To Lead Others Out Of The Ice Age” … http://www.amazon.com/ICED-The-Illusionary-Treatment-Option/dp/0989831914

  32. With greatest respect to all the comments here, I see nothing that will cause me to alter the process that has worked wonders during a 35 year career as a Sports Massage Therapist. Ice numbs pain and is preferred for most if not all acute injuries for the first day or two. Period. As the body’s healing response kicks in and pain subsides, shift away from cold to contrast; mild heat followed by cold to finish. Not one comment has convinced me that this protocol is harmful or dangerous. Thank you for allowing me to share my opinion, which after all is like… a nose; everybody has one. I tell my students
    ” Heat is wonderful, Ice is magic”. Kind regards to all.

    • With regards to the pain comments by both David and Dr. Muscolino… We used to think that ice was useful in allowing exercise to begin sooner because it lessened pain. I taught this to my own students for many years and it was the basis for the rehabilitative use of cryotherapy, especially cryokinetics (as opposed to the acute injury management use of cold).

      More recently, we’ve been able to show that it’s not the pain that was entirely the issue. Instead it is also a phenomenon called Arthogenic Muscle Inhibition. We have learned that when there is a stretch on a joint capsule (i.e. through effusion), that there is a central nervous system mediated inhibition of the motor neuron pool supplying the muscles that cross that joint. Most likely, this is a protective mechanism to minimize your use of the injured extremity. We even get it in the laboratory when we create artificial joint effusion by injecting sterile saline into an uninjured joint to make it swell (the swelling is temporary and produces a feeling of “tightness” but it is not painful… I’ve been on the receiving end of this procedure before).

      Interestingly, when we apply cold (or TENS), this neuromuscular inhibition is not only corrected but we actually see a facilitation of the motor neuron pool. Even more interestingly, we see this even when we apply cold to an entirely different body part than the one injured (e.g. facilitation in the leg when we apply an ice bag to the arm pit!) Very interesting stuff. For more on this topic, see some of the work of Ingersoll CD, Palmieri RM, Hopkins JT, or the fairly recent review paper by Rice and McNair at http://www.sciencedirect.com/science/article/pii/S0049017209001218

  33. Thanks, Josh, for your courage, foresight and patience in launching and hosting such a long-running discussion of this contentious and intricate topic. Despite the rancor of the recent exchanges, I’ve learned a lot by sifting through the competing arguments and studying some of the scientific articles referenced. It might be worth revisiting this hot/cold topic every year or so.

  34. Thank you for this revealing piece. I am a licensed massage therapist and have taught classical ballet for more than 20 years. I have observed countless cases of soft tissue injuries like tendonitis, plantar fasciitis, pulls, tears, strains, sprains– you name it. I have always felt icing to be counterproductive to the healing process, much like I felt aspirin to inhibit the good that low grade fevers are trying to accomplish against infection. A healthy body will attempt, often with more effectiveness than we can outwardly give, to heal itself. This article will be posted in my studio. Thanks again.

  35. Pingback: RICE: The End of an Ice Age | Athletic Medicine

  36. A cold pack is extremely valuable for injury support and health stimulation generally as if stimulates the circulation. However the duration is what counts. 5 minutes to stimulates the removal of fluids and return of fresh fluids afterwards to do their healing work ensures there is an efficiency fluid supply in the area. If there is pain it is likely to be held still and so this supports the inflammatory process. Cold is good (ice with a tea towel is ok) or a cold flannel on shallow areas like the neck or the elderly who may be thin. ITS ALL ABOUT THE DURATION. Naturopaths that know about hydrotherapy know this already.

  37. I think people use ice and NSAIDS to stop the pain. I’ve never had a patient even think about inflammation after an injury, let alone try to make the inflammation go down. Pain control is a priority.

  38. Josh, how does your theory work with tendonitis? This is extremely painful and Ice and rest seems to be the only way to help.

      • Josh, Are you saying that tendinITIS never exists? That is always tendinOPATHY? That swelling is never part of the process and it is only the degeneration of the opathy? That ice cannot have an effect on the swelling process, if you believe that it does exist? I am not sure if the end result of your/our blog discussion was as simple as you are summarizing here for Brenden…

      • Two part question:
        1- Nope not saying that. Saying more often than not those things that we typically call itis are actually deranged collagen tissue not normal tendon that is inflammed.
        2- I think I clarified in this post and others that I do not think ice has a positive impact on the swelling or inflammation. In fact I think it has a negative impact. I’ve found nothing to change my mind on this despite conintued looking.

        Lastly you are right. It is not as simple as I made it, but if I responded to each inquiry with full detailed description then I’d never rest.

  39. Pinch of Cayenne pepper, two drops of water, make a paste, apply to surrounding affected area immediately and regularly.
    Keep arguing about ice/no ice, medication/no medication. The answer is somewhere else and no-one in the field of medicine has the guys to endorse it.

  40. I find this hard to believe I went through athletic training and people we treated healed just fine with ice for 20 minutes and doing range of motion ice is just used for pain control not to decrease swelling the body will heal its self naturally! And the process can’t be sped up! Also data has been inconclusive to whether ice decreases strength and no data supported says it decreases speed maybe if you are still numb but that’s a no brainer! People and mice are way difference we have more body heat for starters

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