Wait, I’m not meant to ice?
“Wait, I’m not meant to ice?”
This has been people’s response lately when I tell them not to bother icing soft-tissue injuries suffered on the sporting field.
And that is totally fair.
It’s been forty-five years since Dr Gabe Mirkin taught us the R.I.C.E (rest, ice, compression, elevation) protocol for injury and only seven since he retracted part of that advice (which doesn’t make him wrong, but a good scientist).
In 2012, before Mirkin changed his view on icing, the P.O.L.I.C.E acronym began doing the rounds. This stands for protection, optimal loading, ice, compression and elevation. It introduced a key idea that more rest does not equate to better healing, and that a lack of early loading may impair recovery.
Optimal loading means applying early mechanical stress, and when possible, to resume normal activities such that injured limb receives normal blood flow, innervation and sensory feedback. All this whilst respecting any pain. It keeps the system running whilst your body goes about repairing the damage.
A simple example would be that following an ankle sprain, once weight bearing is tolerable, that you begin to introduce exercises that target balance, range of motion, and strength. In many cases now we will have people doing this from day one. You will likely need professional advice on what optimal loading means for your injury.
Until 2019 icing largely remained part of the advice given for acute injury management. That’s when Blaise Dubois and Jean-Francois Esculier published their article in the British Journal of Sports Medicine, introducing us to TWO new acronyms which separate the management of soft tissue injuries into two early-stage phases:
PEACE: Protect, elevate, avoid anti-inflammatory modalities, compress and educate.
LOVE: Load, optimism, vascularisation and exercise.
You’ll notice here the addition of ‘avoid anti-inflammatory modalities.’ This is in relation to both oral AI’s such as nurofen, and the topical application of ice. It may be a surprise to some given the extent to which we talk about getting rid of it, that inflammation is a helpful immune response. It ushers in our body’s tools for tissue repair to the site of injury.
Anti-inflammatories work by blocking a particular protein (enzyme) involved in the “inflammatory cascade”, thereby stunting its response. This will subdue the accumulation of inflammatory cells in an area thereby minimizing activation of our local pain-sensors.
This can be helpful when there is inflammation without injury- which does occur. However, this is unhelpful if the goal is to repair a torn muscle fibre or sprained ligament.
This finally leads us to the topic of icing. Icing is a helpful analgesic (pain-numbing agent) when applied topically. The downside with icing is that it causes constriction of blood vessels beneath the skins surface and will shut off the blood supply bringing in the healing cells of inflammation.
There can be nuance in how these guidelines are used. Depending on the context in which an injury takes place, and your knowledge of anatomy, there will be occasions where it is completely justifiable to apply ice to a painful injury.
You can read Dr. Mirkins own comments on the consequences of icing acute injuries here.
