63 comments on “RICE: The End of an Ice Age

  1. I thought i was one of the only old schoolers that used hot whirlpool and heat on injuries as soon as possible. My mentor, if you will was ATC at Oklahoma U during 60′s and he used contrast bath of two minutes hot and one minute Ice the next day on ankle injuries. Lee Doak ATC

  2. I must also add my “two cents” as a practitioner of therapeutic massage: a recent, small-sample study has proven that massage following rigorous exercise reduced the production of cytokines, the compounds in cells that are implicated in pain associated with inflammation, whilst stimulating the activity of mitochondria (of course, we all know, the ‘powerhouses’ inside of cells that convert glucose into energy). In short: massage actually accelerates muscle repair and therefore healing. The study also indicated the same oppositional effect of NSAID’s as stated in Dr. Mirkin’s reversal above, in fact, they cautioned against a “maladaptive response” if athletes and other active people continually use inflammation-suppressing drugs after injury or overuse. … I cut my teeth in a conventional physical therapy clinic where ice was king, but I’ve since backed off, suggesting something along the same lines as Dr. Mirkin (minimal use, only immediately after injury and no need to repeat the process more than once). Massage therapy is also a form of mechanical heat production, bringing fresh, oxygen-rich red blood cells into the affected area, in turn ‘adding’ to the natural inflammatory process.

    • Do you happen to have the title and author of that study…would be a great one to add to my library!

    • Also keen to see this study! Is it on PubMed? It would in fact be a revolution as no one has ever before managed to prove that massage aids in recovery.

  3. There is a possible exception here, with torn Achilles’ tendons… The ice stops the tendon from shrinking all the way up the leg therefore and saves a lot of rehab. Could you comment on this? This was made very clear to my friend who tore both…

      • You are right Josh. Ice will not facilitate drainage, however it will reduce metabolism, and when applied early will prevent the initial build up of edema. That is why we ice.

  4. This isn’t anything groundbreaking. The RICE method has for me always been a method of minimizing swelling and pain, used instantly after injury, and never as an option to healing – let’s say – a sprained ankle.

    However, nice article and it’s good to see I’m on track with proper use of RICE.

  5. This article confuses muscle injury (sTrain) and ligament injury (sPrain). Injured muscles do well with very short ice period, then some heat. This does NOT include muscle SORENESS from normal activity. Sprain involves ligaments, which do well with ICE and chiropractic care to restore functional capacity to the damage ligaments.

  6. I use ice/cold to rehab fingers with connective tissue issues caused by hanging from small grips while rock climbing. After the initial swelling has gone down, I will submerge just my single hurt finger in an ice bath for ~30-40min. The rationale (called the Lewis Reaction) is that after the body realizes only the finger is cold, it stops shunting blood and makes a large increase in blood flow to the finger and the damaged tissues, therefore increasing healing.
    I wanted to get your thoughts on this specific type of ice treatment in relation to your findings.
    http://onlineclimbingcoach.blogspot.com/2010/05/pulley-injuries-article.html under “Ice”

  7. My Chinese medicine friends say Western medicine goes against the function of the body. In other words, if I understand correctly, they say if there’s inflammation then help it along with some more heat. Ice only slows down the inflammation reaction and thereby delays or even inhibits healing.

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  9. After reading all of these articles now and at the time when Kelly Starrett started pushing this info, I still don’t see where any research is showing us that ice in unnecessary post injury. Yes, we need inflammation for healing. No, ice will not heal tissue(but i don’t recall anybody ever stating this). My understanding was always that we were icing to REDUCE inflammation, not prevent it. Why reduce inflammation? To reduce secondary hypoxic injury. Ice isn’t meant to heal anything, it is meant to reduce more damage than is necessary. I do believe that the importance of ice has been overstated, but I still believe it to be a useful tool in the initial management of acute injury. Don’t let the contrarians change your treatment protocols just because they have a stage to do so.

    • Jeff,
      Thanks for the comment. You have said similar before. Point is I see more evidence that says it is unnecessary than necessary, yet it is by far the most widely used form of treatment, for both acute and chronic injury. Western Medicine is the only group that uses ice to this degree. If you applied and took a job working for Brazil Futbal club, Chinese Gymnastics, Indian Cricket, Japanese Baseball, Australian Football, or Hungarian Waterpolo and began wrapping ice to the degree that it is used here in the states they will look at you with three eyes. We are the only form of medical / practitioner care that uses ice to this degree. Are we that ignorant and omnipotent to think we are that much better than everyone else, when they have the studies to back it up and have been around much longer than Western Medicine.
      Yes, swelling and edema can result in secondary hypoxic injury. However, it takes significant swelling to have secondary hypoxic tissue death and is rare. It needs significant and prolonged swelling. That said to combat swelling and edema we prevent it with ice. Unfortunately, when we prevent it with ice we are also reducing inflammation and subsequently tissue healing. On top of that the only time ice can prevent swelling is in less than 6 hrs post injury. After that it is too late. So, why do we continue to ice hours later or in to the next day? Ice does not remove swelling or edema.
      So if your #1 goal is to prevent secondary hypoxic death (which it should not be), why use ice to do so when you have other tools at your arsenal? Instead of reducing necessary healing properties to prevent swelling, why not use other tools (compression, massage, muscle pump, etc) to remove swelling. We can allow for normal tissue healing and remove swelling! How novel!
      In response to your last statement: “Don’t let the contrarians change your treatment protocols just because they have a stage to do so.” Don’t let anecdotal evidence and old habits prevent you from thinking outside the box. There might be a better way. We might be wrong.

      • Josh, late getting back to this. Everything you said is true. We do “over ice”. No question. I have always felt strongly that compression was a far superior modality. I guess my beef is that when folks (and I do not mean you) use an enormous platform to create controversy, that the general public takes it as gospel. The message being distributed is that ice is now a wrong choice post injury. This is not what the research is telling us. Yes, you are right. It takes significant swelling to create hypoxia, and this is exactly why we ice. To prevent that significant swelling, this has ALWAYS been why we iced, but I think out of simplicity we started telling our patients that we are doing it to reduce inflammation/swelling (because to the lay person they are the same thing)which is where the message maybe got lost. I do not believe that icing, and I am more than open to changing my mind on is, is anywhere near powerful enough to completely eliminate necessary inflammation. It is simply a methos of controlling it for the reason listed above. That is where clinical judgement comes in and is what separates the great clinicians from the “protocol” oriented clinicians.
        I really do believe we are closer in agreement in this than you believe, but I feel compelled to use my little voice whenever this topic comes up as I believe a faulty message is being spread on a large scale and want to avoid future clients from questioning my judgement when and if I choose to use ice as a modality.

  10. Thank you for both this and your first piece on the subject of ice and injury recovery. I appreciate what it takes to share information that conflicts with common thought and education. I face this in both if my fields (biomechanics and Pilates/exercise ). As the squeaky wheel, we must hold to our convictions, research more than our peers and work to share new information. We may make seeming-enemies in that people do not like to question their methods…and themselves. They will fight hard against us. However. we must charge ahead! It is the only way!
    With that please keep posting information about this. I, too, will research more and seek more evidence-based data to share. We have to help people understand by brining proof to them.
    Let’s see where this goes!

  11. My understanding that ice was utilized to create a temporary hypoxic state. This hypoxic state would then decrease (again temporary) the metabolic rate of the injuried cells thus decreasing swelling. The swelling would then be decreased and thus prevent increased pressure on healthy cells and thus decrease or prevent secondary cell death. Am I mistaken?

  12. Reblogged this on Slow Mo Mother Runner and commented:
    Wow! I was just suggesting that a friend of mine be sure to ice her shins after going out on her first run in years. Maybe it’s not the best idea anymore? This is a very interesting read on the standard of using RICE for sports injuries. I don’t know about you, but that and NSAIDS were my go to fix for sore shins and tired and achy muscles. In retrospect, I haven’t been so diligent on icing this past year and haven’t faced any serious injury. Hmmmm. A lot to ponder about how we treat our bodies and how they can recover on their own.

  13. Mr. Stone – I slipped on ice on stairs 3 1/2 weeks ago, apparently thrusting my left foot (toes pointed down) into the deck step to prevent a complete fall. I was successful in preventing the fall but finally gave up after about 8 hours of icing (20 mins on/off) and elevation. The throbbing was too much so I went for the x-ray – broken ‘big’ toe). I have been taping the toe to it’s neighboring toe and wearing the beautiful ‘shoe’ ever sense. Honestly, I have moved away from wearing the shoe at home. I have purposely not tried to ‘baby’ the toe – walking barefoot around the house lately as long as there is not discomfort. A few days after the break, I started feeling numbness in my left foot/leg. I see an integrative med doc who put me on Curcumin (Turmeric) 2x a day stating the swelling was likely pinching a nerve. The numbness went away but has returned over the last several days. The numbness, heavy weighted feeling goes up my left leg but is not constant. Have I possibly done permanent nerve damage due to constricting with icing?

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  15. well what are the conclusions? would you use other modalities? compression is one, the use of heat and at what moment? which modality of heat? we all know that ice has been used to CONTROL swelling and prevent it but not to heal injuries, it is used to calm pain, so decreasing these pain and swelling we will be able to start movilizations and continue the rehab process, what about ice massage?? im sorry but i dont find anything new at the conclusions. Would you change the RICE method to a heat/compression method? all this needs more studies. ICE has much more to offer in his correct use.

  16. Great article Josh.
    It’s very common for outdated and entrenched medical practices to die a very slow death…Look up the Semmelweis Reflex. It’s equally true that effective unconventional therapies have a very slow uptake, typically the early adopters and innovators lead the charge (sometimes to a dead end:).
    I’ll have to reassess some of my posts on RICE and be encouraged that the evidence is mounting for newer therapies such as gradient modulated static magnetic field therapy which can produce both pain relief and tissue healing. In addition, early evidence does show a reduced inflammatory response which seems to contradict your reasoning and no doubt will require further investigation. See… http://bit.ly/10XhIbp

  17. Thanks Josh, great article! My teachers who are MD’s and Acupuncturists never told us to use ice. It was always heat. When the IGF-1 enters into the damaged cells the metabolism of that cell increases and therefore generating more heat(basic physiology). So it only makes sense that by using ice it only slows the healing process as the metabolism of the cell has to “heat up” again to start or to continue the healing process. They said to add heat to the injury, either mild heat or hotter if needed to increase and speed up the healing process. This in turn would also help to carry away any swelling/edema faster as well. There was a interesting story my martial arts teacher told us. In the days when the different martial arts schools would fight each other to see who had the best technique, it was also known that who ever had the best healing liniments could heal their students quicker and get them training again. They all used heating liniments! These techniques have been around for thousands of years!

  18. So wonderful to see that others are coming to understand this. We have long advocated against the use of ice. Use San Huang San. Visit PlumDragonHerbs, the premier manufacturer of effective herbal treatments for sports-related injuries. We have been teaching athletes for many years how to manage injuries in accordance with the body’s natural healing capabilities.

  19. Interesting. Of course ice does not make tissues heal. It does, however, reduce inflammation, prevent more inflammation and send cold signals up the fast nerve fibers to create a block in the neural gate thus reducing pain.

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  21. Reblogged this on The Touch of Soul and commented:
    Great article… While much of my training tells me to use the RICE method for treating injuries, my understanding of our immune system has always lent credit to the fact that constricting blood flow is counter intuitive. This is just another evolution of medicine.

  22. Very interesting. I wonder if this applies to most injuries and not just muscle tissue damage. I suffered two bad sprains in my ankle last fall and of course medics and later the sports med doctor all suggested RICE. Sprains dealing with connective tissue rather tan muscle damage, would RICE still apply? I ended up using ice and elevation while in a walking boot for the first 4 weeks, then slowly added resistance work until I was able to run again. I was fortunate enough to regain enough strength to run a marathon 4 months after injury, however I am still battling swelling in the joint and lack of side-to-side stabilization on uneven surfaces, such as trail and grass. Hoping RICE didn’t hamper the progress.

    • Thank you.

      This is my own personal opinion, but I believe RICE, specifically Ice, inhibits tissue healing (bone, ligament, muscle, or tendon). When there is injury the inflammatory process initiates the entire healing process. If we ice, that process is delayed or reduced, no matter where the injury is at.

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  25. Hi Josh,
    would be interested in whether you’ve seen any research on the secondary influence of icing. The way I was taught was that icing would mean that the blood retreats from that area taking with it the body’s inflammatory mediators (which is consistent with what your research shows) – but the secondary effect was where the main benefit came – in that when you took the ice away the blood would return to that area over the next 20 – 30 min bringing with it a surge of the body’s good stuff (including of course IGF1). So repetition of this contrast either by ice and no ice or ice and heat would cycle the blood through & improve the healing. This would work best for the peripheral joints as icing a muscle near the axial skeleton would not get the same blood retreating to core ‘hypothermic type effect’. Would this also help explain why there was improvement when icing the ankle?
    Be interested in your thoughts on all of this.
    best regards Jonathan

    • Ice delays and interrupts healing. Why do we feel our body is unable to follow its natural course. Also why should we be applying ice so it can cycle? If we want it to cycle when is the exact moment it should be turned off?

      As you said after you remove the ice blood rushed back to the site and along with it inflammatory mediators. The problem is the healing process begins immediately and the application of ice interrupts the process. Then if we continue the ice cycle over the next 2-24 hours how much interruption should we have?
      How does the interruption of the process improve healing?

      Imagine a dam breaks and water is gushing out of the dam and will flood the towns below. We send emergency crews to the dam but stop them half way there (for no reason) they just stop on the road. Meanwhile the dam is still leaking just not as much. Then after twenty minutes we allow crews to move to the dam, they begin work, but we stop them again. This process does not improve fixing of the dam or make it faster. It slows it down. We need to allow athletes to heal and get back to activity.

      Secondly, the accumulation of swelling (byproduct of inflammation) needs to be removed. Our body’s natural system does this (although its not perfect) but ice actually causes perfusion of lymphatic vessels and reversal of flow. Why would we want that? The will increase pain and further delay healing.

      So I disagree the cycle of ice is not beneficial. I also do not think icing a sprained ankle is effective. If we allow healing to occur and facilitate removal of swelling and edema will have better results.

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  27. My opinion on the mechanism of action of cryotherapy is that vasoconstriction occurs in the beginning , but later comes vasodilation and flushing . Example: when you make a snowball in winter with bare hands , then there is a strong blood flow to the hands and redness , right? And then all the nutrients from the influx of fresh blood are present . These effects are due to the effects of cold on vascular autonomic system and the somatic nervous system. Cryotherapy leads to a reduction of pain , which reduces the tonus of the muscles and spasticity . And by reducing spasticity and pain is relieved that predisposes to proceed with physiotherapy.

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  29. I am very interested in your thinking on useing ice on injuries. Treating animal (I am a veterinary physiotherist) and myself
    I have always been reluctant to use ice. I do not like it used on myself and have always used heat, gentle massage
    and compression, massaging muscles above and below an injury will help to sedate nerves and to encouraging circulation and where possible full range of movement. I find gentle stretching has far more pain relief . All people and animals are different and need different modules of care but
    I will continue to study and research and appreciate any comments and ideas.

  30. As an occasional “athlete” and someone who has very recently (this past Friday) had a scope and clean-up done on a knee that was originally injured 17 years ago, I must say that I have never been a fan of icing an injury. Some rest, yes. Elevation to gravitationally reduce swelling, sure. I always found ice contributed to stiffness if used the way it was usually prescribed. And compression was simply annoying more often than not. I’m all for gentle massage, something passed down by my mother from the time I was a child.

  31. Mice studies show that insulin-like growth factor (IGF-1), released by macrophages that swarm into injured tissue, helps rebuild muscle fibers while limiting scar-tissue formation (fibrosis). Along the way, IGF-1 tones down inflammation by blocking inflammatory signaling molecules and allowing macrophages to migrate out of the injured tissue. See “Local expression of IGF-1 accelerates muscle regeneration by rapidly modulating inflammatory cytokines and chemokines,” The FASEB Journal, May 2007: http://www.fasebj.org/content/21/7/1393.full.pdf+html
    What a paradox! The same hormone (IGF-1) secreted by macrophages (large inflammatory cells) winds up turning off the inflammatory response and encouraging macrophages to clear out of the injured area! Physiologists call this a “negative-feedback loop,” in which a series of biochemical reactions, once it has run its course, switches itself off to restore balance. The authors of this FASEB study explain: “The full recovery of muscle strength after injury is…hampered by the persistence of inflammatory response and the development of fibrosis” (p. 1400).
    This shows that Dr. Gabe Mirkin overstates and oversimplifies his case in his subhead, “Anything That Reduces Inflammation Also Delays Healing.” While correctly criticizing pharmaceutical drugs and ice packs, Dr. Mirkin overlooks the toxic consequences of inflammation, especially when it persists beyond the acute phase.
    Neutrophils, highly mobile immune cells, are the first to rush to the site of injured tissue. Aiming to gobble up invasive pathogens, neutrophils release a burst of reactive oxygen species — notably superoxide anions and hydrogen peroxide. These toxic radicals kill invasive bacteria and fungi, but they also wind up killing the neutrophils themselves. And hydrogen peroxide poisons the extracellular medium — the watery environment outside the neutrophils — damaging the injured tissue. Worse still, in blunt-force trauma — with no break in the skin — neutrophils may find no invading pathogens to attack and gobble up! So their “collateral damage” becomes a serious problem during the inflammatory phase.
    We need not resign ourselves to the inevitability of collateral damage following muscle injury. Vitamin E prevents neutrophils from releasing large amounts of hydrogen peroxide, thereby protecting injured tissue from free-radical damage. See “Vitamin E — a selective inhibitor of the NADPH oxidoreductase enzyme system in human granulocytes,” 1983: http://europepmc.org/articles/PMC1916385/pdf/amjpathol00192-0049.pdf Studying human volunteers who took vitamin E capsules, these authors found that vitamin E greatly reduces the amount of hydrogen peroxide released by neutrophils, yet improves neutrophils’ ability to attack and kill pathogens.
    Vitamin E, both taken internally and applied topically, might well promote recovery and healing from muscle and joint injuries. In addition to swallowing vitamin E capsules, you can rub vitamin E oil or cream into the skin and then apply gentle heat to drive the vitamin into the injured tissue. Of course, you can also combine this with massage.

  32. Thanks Daniel Jacobs for the review of the chemistry of a bruise. Judicious use of ice/cold packs mediates the inflammation but sadly is overused by the length of time it is usually applied. While studying hydrotherapy during massage college studies, ice was recommended immediately after injury but as Dr. Mirkin recommends after the first 6 hours more than 10 minutes is possibly damaging. What I have witnessed in my own injuries (3rd degree ankle sprain in 1984) and what I have recommended for my clients during 24 years of practice as a Registered Massage Therapist, is that yes after the immediate inflammatory response, the next phase of healing can still benefit from ice therapy. Particularly after exercise after injury, 3-5 minutes of ice with a linen towel or t-shirt between skin and ice pack, and then reapplied in 1 hour increments as needed due to discomfort with gentle stretching to regain full range of motion, helps to interupt the inflammatory chemical process. Icing longer than 5 minutes ( I tell clients that when they feel the chill, that is long enough but don’t exceed 5 minutes) creates a chill in the muscle and skin tissue that sets up the body to rewarm the area that is now too cold. Too much ice sets up a warming response that can recreate the inflammation and really slow healing. The 3rd degree sprain I had was treated in a college physiotherapy department and was vigorously attacked with both heat and ice and exercise and balance boards and ROM. To this day, that ankle tolerates cold better due to the ice whirlpool that was used after the exercises and ultrasound. I have no crepitous 30+ years later and no limitations of any kind. I will continue to recommend ice to those that have stalled in their healing, particularly after the massage therapy that may have included frictions.

  33. I agree with the above! I love results!!! As a licensed massage therapist for 23 years most of my clients say they finally have relief after using ice. In my own healing, nothing else worked when the pain took me to the floor…steady usage of ice 3 times a day allowed me to move and keep moving without crippling spasms. I had a client also who while waiting for a knee replacement, used ice 3 times a day and found she could walk normally even after work could go for a walk on the beach. I love it; I recommend it and of course if it doesn’t provide a good response know that that is not for that particular client/situation.

  34. Does this mean that NSAIDs should not be taken for pain relief following orthopedic surgery (I am immune to oral narcotics)???

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