Does Icing an Injury Delay Healing?

to ice or not to ice
to ice or not to ice.

The physician who coined the acronym "R.I.C.E" in the late 70s has changed his stance on the importance of using ice on a sports injury. Dr. Gabe Mirkin, who wrote one of the most popular books about sports medicine, recently wrote a post updating his position on the recommendation to use "rest, ice, compression and elevation" for the immediate treatment of sports injuries, such as strains and sprains. Citing current evidence, Dr. Mirkin writes that it now "appears that both ice and complete rest may delay healing, instead of helping."

Until now there has been little evidence to actually support the role of this widely held recommendation, but recent studies that have probed into this advice have found almost no evidence that icing an injury speeds healing. The evidence has found that icing a soft tissue injury will reduce swelling and inflammation, which had been thought to delay healing, but now researchers believe that inflammation is actually a necessary component of proper healing. 

Dr. Mirkin explains the science of inflammation as being similar to the way the immune system attacks other foreign invaders such as germs, for example. He states that when there is damage to the soft tissues—such as muscle pulls, strains or general soreness—the immune system responds by sending inflammatory cells calls macrophages to the damaged tissues. Once there, these cells release IGF-1 (Insulin-like Growth Factor), and it is this hormone that plays a role in helping the damaged tissues rebuild and repair and heal. The research also indicates that applying ice to the injured area prevents the release of IGF-1 and ultimately, delays healing.

We've known for some time that ice works to reduce pain and swelling. We also know that cold will cause the blood vessels to constrict. The unwanted side effect of this constriction, however, is that the inflammatory cells and their healing hormones are prevented from getting to the injured tissues. Dr. Mirkin points out that once these blood vessels are restricted, they stay closed for hours. The lack of circulation can result in tissue death and may actually cause permanent nerve damage.

What Dr. Mirkin says next is even more surprising. He argues that anything athletes do to reduce inflammation delays injury healing. That includes taking inflammatory or cortisone-types of medicines, using ice or other cold packs, and anything else that stops or blocks the immune system's natural response to an injury.

Should You Ever Use Ice on an Injury?

The main benefit of icing an injury is to help control or reduce pain. That may seem like a good thing. However, Dr. Mirkin says that icing for any more than 5 minutes is detrimental to not only tissue repair, but it can also reduce strength, flexibility, and endurance. If you use ice for its pain management effect, the advice is to use it no more than 5 minutes, remove it for a minimum of 20 minutes before reapplying. According to Dr. Mirkin, there is no reason to, and no benefit of, applying ice to an injury more than six hours after the initial injury.

Other physical therapists agree, at least that the main benefit of ice is pain relief, and that ice should be applied immediately after an injury and for a short period of time only. There is limited research on the effectiveness of both heat and cold therapy. One small study found no difference in outcomes in patients with ankle injury who received no ice, or ice and compression, or ice without compression. Another study of ankle injuries found better results with only a brace, vs. treatment with ice, elevation, pain relief, and restricted movement of the joint.

Researchers continue to study the best way to deal with soft tissue injuries and the jury is still out on the most effective treatments. Compression and elevation of an injury may still be appropriate and helpful. Neither action completely stops the release of IGF-1, so the immune response is still able to do its job, yet compression can help manage excessive swelling, which is often one culprit in causing pain. Still, many experts advise that treatment should be tailored to the athlete and that functional rehab and balance training may be more effective than immobilization, particularly when in managing grade I and II ankle sprains

As an athlete, it's important for you to pay attention to the warning signs your body is sending, and take care to avoid injury if you can. Taking preventive measures such as being in condition for your sports, exercising within your physical limits, using protective gear, wearing the correct footwear, and following the rules of your sport are all ways you can prevent some of the most common sports injuries. But if you do sustain a sports injury, it's important to stop playing and have a medical evaluation to determine the extent of the injury and begin the rehab process quickly. 

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  1. Hubbard TJ, Denegar CR. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? J Athl Train. 2004;39(3):278-279. PMID:15496998

  2. Nemet D, Meckel Y, Bar-sela S, Zaldivar F, Cooper DM, Eliakim A. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. Eur J Appl Physiol. 2009;107(4):411-7.

  3. Williams EE, Miller SJ, Sebastianelli WJ, Vairo GL. Comparative immediate functional outcomes among cryotherapeutic interventions at the ankle. Int J Sports Phys Ther. 2013;8(6):828-37. PMID:24377069

Additional Reading
  • Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med. 2015;127(1):57-65.

  • Prado MP, Mendes AA, Amodio DT, Camanho GL, Smyth NA, Fernandes TD. A comparative, prospective, and randomized study of two conservative treatment protocols for first-episode lateral ankle ligament injuries. Foot Ankle Int. 2014;35(3):201-6.

  • Why Ice Delays Recovery, Dr. Gabe Mirkin,,  []  March 16, 2014