Ice, Ice, Maybe? A Surgeon's Perspective on Icing Injuries
⌚️ read time: 4.8 minutes
I recently received an intriguing question from one of my readers:
Is it good or bad to ice my ankle after I sprain it? I always thought yes, but I had a coach growing up who said “NEVER ice an injury!”
While most of us might assume the answer is a resounding 'yes' (after all, that's what we've always done), there's a vocal minority arguing that icing an injury is actually a damaging approach.
Sounds like it's time for a deep dive.
Why do we use ice?
Icing acute injuries entered mainstream use in the 1970s when Dr. Mirkin proposed the "RICE" (Rest, Ice, Compression, Elevation) protocol in his book "Sports Medicine." Since then, it's been a staple on NFL sidelines, in MLB locker rooms, and Saturday soccer sidelines.
But why?
Studies have shown that applying ice to an injury will, unsurprisingly, cool the underlying soft tissues. This cooling effect leads to several changes in our anatomy and physiology:
It constricts blood vessels, reducing bleeding and swelling.
It decreases enzyme activity, potentially limiting secondary tissue damage from free radicals generated during inflammation.
It slows nerve signal conduction, numbing the area and reducing pain.
These all sound great, right? So what's the big deal?
The case against ice
Let the opponents enter the ring.
Do you remember my previous article on inflammation? If so, you may recall that our body’s inflammatory process has evolved over millions of years to stop bleeding and heal just about any injury we encounter (think those pesky saber-tooth tigers chasing our ancestors).
The anti-icing camp asks, "Why on earth would you want to halt this natural process of inflammation?"
They argue that applying ice to an injury only inhibits our natural healing ability and slows down recovery. Their reasoning parallels the above list of physiology changes and goes like this:
Constricting blood flow to an injured area could cause more tissue damage as cells starve for oxygen.
Inhibiting inflammatory enzymes blocks the natural healing process we've evolved over millions of years for this very purpose.
Slowing nerve conduction could result in long-term nerve damage if cold exposure is prolonged.
This argument makes sense in principle. We know that icing can slow down these processes at each step.
But does it actually cause a cumulative detriment to healing?
What does the evidence tell us?
When a good old-fashioned medical duel like this takes shape, the best approach is to dive into the evidence (imagine that). However, we must be cautious when interpreting results, as a slight spin could tip the scales one way or the other.
It's also important to note that the quality of evidence in this realm is average at best.
This issue is similar to studying nutrition – there are numerous variables at play when healing from an injury, and the use of ice likely has only a modest effect, one way or the other. This makes it challenging to determine with certainty how effective or harmful icing might be in any given situation.
Here's what we know:
Several studies have evaluated pools of research looking at ice application after injury and surgery. They found wildly different results from study to study, ranging from improved pain scores and range of motion to completely ineffective icing.
Importantly, no evidence of harm from icing was detected across these studies.
Perhaps our best evidence comes from knee replacement surgery patients. This surgery and the post-operative rehab protocol are highly standardized, allowing us to study the effect of changing a single variable more easily.
We can ask a simple question: What happens to patients who use ice after a knee replacement compared to those who don't?
Several studies have addressed this question, and the results are intriguing:
In general, patients who used ice after knee replacement had shorter hospital stays, were able to get up and walk sooner, experienced less blood loss, and used fewer narcotic pain medications. However, there was little to no indication that those who used ice healed any faster or had better long-term outcomes.
Crucially, there was also no evidence that they healed any slower because of their ice use.
So who should we believe?
I think both sides present valid arguments. But for me, the knee replacement literature is pretty convincing.
Why?
Because if you’ve ever seen a knee replacement, you know it is one of the bloodiest, high-trauma procedures imaginable. The degree of bone and soft tissue damage is wild.
And we have the data to prove it. The inflammatory blood marker levels (C-reactive protein) after a knee replacement skyrocket, often higher than those seen when a patient develops a body-wide infection (sepsis).
I mean, we literally saw off the ends of the femur and tibia to fit the replacement parts.
This is our modern-day saber-tooth tiger attack.
And what convinces me about this literature is less about the benefits of icing (yes, faster walking rates, quicker hospital discharge, and less narcotic use are great), but more about the lack of downside of icing.
Nowhere in any of these studies did they find something like, "Well, initial recovery was better, but by two months, these patients were all much slower to heal."
So while I completely understand the logic of the anti-icing community and the desire to let the body's natural inflammation process work, if you take patients who have undergone this incredibly traumatic surgery (knee replacement), you would expect to see some serious differences in their 'slowed healing response' after icing.
And that scientific proof just isn't there.
Seriously, Dr. G, just tell me the answer.
I'm going to tell you an answer you might not want to hear. It's not sexy, exciting, or controversial.
The answer is grey. Muddy. Unclear. If I had to make my best bet, then I’ll tell you that I'm still going to recommend icing after an injury or surgery. That's the best of our current knowledge.
Like your mom always said: Everything in moderation.
Takeaways:
The use of ice for injuries has been debated, with proponents citing its ability to reduce swelling and pain, while critics argue it may interfere with natural healing processes.
Studies, particularly on knee replacement patients, show that icing can lead to shorter hospital stays and less pain medication use, without evidence of slowed healing.
While the evidence is not conclusive, I still lean towards using ice for injuries and post-surgery, but in moderation.
So there you have it. This is a perfect encapsulation of what we deal with daily in medicine. As much as we’d like to believe it’s a science with black-and-white answers, the reality is that we are left making decisions with the best available information.
These decisions are always easier if you understand the risks and benefits. Then you can choose what feels right to you.
