Injury and Workout Recovery: The Cold Hard Truth About Ice

Why athletes* should avoid using ice to recover from injuries and workouts, and what they should use instead

* “If you have a body, you are an athlete”- Bill Bowerman

Disclaimer: The Analytical Aspergian is not a medical professional and assumes no liability for following our advice

I heard the familiar bone-chilling crunch emanate from my ankle. I’d just fallen off the rock while climbing, missed my crash pad, and landed with all my weight on the outside of my ankle.

After a long hobble over rocky terrain back to the car, I looked down at my ankle. The swelling had already ballooned it to the size of … well, a balloon. From numerous (too many) almost identical past experiences, I knew very well what this injury would entail.

This was a classic grade II ankle sprain, meaning the ligaments were partially torn. Recovery time ranges but is typically 6-8 weeks. As I drove home, I thought about everything I should do to treat it according to conventional sports medicine:

• Stay off of it, and rest as much as possible.
• Elevate the ankle and compress it
• Possibly take a NSAID like ibuprofen
• For repeated 10-20 minute bouts, ice, ice, and ice some more

I took a deep breath. Based on recent research and thinking I’d done, I was about to do the exact opposite of these recommendations in hopes of reducing my recovery time. Read on to understand why I opted for a non-conventional recovery plan, and how my ankle recovered as a result!

Body Response to Injury

When you get injured or have a hard workout, your soft tissue (ligaments, tendons, muscles) gets damaged. This damage takes the form of actual micro or macro tears in the tissue. To help you recover, your body activates the immune system to do the following:

• Create blood clots to stem blood flow from damaged tissue
• Expand surrounding blood vessels and increase vessel wall permeability to promote blood flow to the damaged area
• Send white blood cells carrying supplies necessary for repair/removal of damaged tissue and rebuilding of new tissue

All of these things cause inflammation. Signs are redness, heat, swelling, and pain, as nerves get compressed and biological signals get sent to the brain.

Why we Ice

How does icing affect this process? Icing the injured area constricts the blood vessels and restricts blood flow, thereby inhibiting inflammation. This feels good in the short term because it:

• Decreases short-term pain: Reducing inflammation reduces biological pain signals sent to the brain and eases constriction of nerves. It also numbs the nerves.
• Reduces short-term swelling: Less blood flow -> less immediate swelling.
• Cools area down: Blood flow heats the area up, so cooling it off feels refreshing.

It makes sense why icing after injuries and workouts is so popular. It follows conventional wisdom, and feels good when you do it! But is inhibiting inflammation actually better for recovery? What are the implications of icing on long-term healing?

The Darkside of Ice

Despite conventional wisdom, ice actually delays healing from injuries and workouts for the following reasons.

1. Reduces Inflammation

As discussed above, inflammation is actually your body’s way of healing the tissue. Without inflammation, healing does not occur. By icing to inhibit inflammation, we are hamstringing our body’s natural response to the trauma. We are inhibiting healing.

2. Decreases Pain

Even though it feels good, this is actually not beneficial for long-term healing. Pain exists as a feedback loop for your body to tell your brain which movements and activities are causing further damage. This allows you to consciously avoid those activities.

3. Increases Swelling

Even though icing reduces inflammation, it may still increase swelling! A huge contributor to swelling is the accumulation of fluid and waste yet to be evacuated from the damaged area. It is the responsibility of the lymphatic system to clear this waste.

Icing an area constricts the lymphatic vessels responsible for evacuating this swelling. The cold also increases the viscosity of the fluid, making the congestion harder to remove.

4. Delays the Inevitable

Another argument against ice is that it merely delays the inflammation process. Once the injured area heats back up, the blood vessels will dilate again and inflammation will persist. All you’ve done by icing is delay this process.

Dr. Gabe Merkin and RICE

“RICE” stands for “Rest, Ice, Compression, Elevation”. It is the go-to recommendation for injury and workout recovery according to conventional sports medicine. Dr. Gabe Merkin is the man who coined the term “RICE”. Astonishingly, he now believes ice delays the recovery process. He states “anything that reduces inflammation also delays healing”. This is a telling piece of evidence: the man who created the term RICE now believes icing is less than ideal for recovery!

Counterpoints

Let’s consider a few pro-ice arguments to see if they hold any merit.

With so much inflammation, it becomes difficult to evacuate swelling from the area. Thus, icing to reduce inflammation can facilitate the lymphatic system’s removal of the waste.

Answer:  The lymphatic system responsible for evacuating waste is an entirely separate system from the vascular system responsible for inflammation. Using ice to reduce inflammation would theoretically reduce the amount of waste that needs to get cleared out of the area.

However, ice is not selective. It constricts the vessels of both the vascular system and the lymphatic system. This inhibits the lymphatic system, resulting in an accumulation of swelling. Furthermore, as previously discussed, inflammation is necessary for healing, and thus should not be quelled.

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We need ice to help the body modulate its inflammatory response. The body sends too much blood to the affected area.

Answer: While it is certainly possible that the body does not ideally modulate its own response, that would be peculiar. The human body is full of feedback loops. Why would human beings have evolved such that the body’s natural response to healing is less than ideal and needs to be mitigated with ice?

Additionally, ice delays the inflammation process, it does not eliminate it. It also inhibits the lymphatic system responsible for draining swelling, thereby compounding the problem of too much blood/fluid in the damaged area.

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Icing helps prevent blood leaking out of the microtears of damaged tissue into surrounding areas.

Answer: The body actually creates blood clots to prevent this from happening naturally.

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Facilitating Recovery

If icing delays healing and recovery, what should we do instead to facilitate recovery?

An important question to ask when considering alternative recovery methods: am I helping or hurting my own body’s efforts at recovery? Bearing this in mind, we should generally be against methods that reduce inflammation. What other natural recovery mechanisms should we be aware of, and how do we promote them?

Decrease Swelling

As previously discussed, most swelling is the accrual of waste at the end of the inflammatory cycle. Stimulating the lymphatic system is the best way to reduce swelling by facilitating the removal of this waste.

However, unlike the vascular system, the lymphatic system is completely passive. It does not have a central organ like the heart to pump and activate it on its own. In other words, we need to “manually” stimulate it with activities.

Load Repaired Tissue

After inflammation, the next phase of injury or workout recovery is where the body rebuilds the tissue and connects collagen fiber. While this is occurring, it is important to apply functional load to the tissue to essentially “show it how to rebuild”.

By exposing the budding tissue to controlled torsional and functional movement similar to your sport-specific or everyday life movement, it rebuilds in such a way as to be resilient and prepared for those loads in the future. 

Break Up Scar Tissue

The body builds up scar tissue in response to injury or trauma. While scar tissue is tough, it isn’t very flexible. This can significantly reduce range of motion in an area that’s been injured.

While recovering, it’s important to break up scar tissue that is forming to maintain future flexibility and mobility. The body can still heal itself in a resilient way, but by breaking up scar tissue, you increase the robustness of the injured area for the future.

Recovery Methods

Keeping the goals above in mind, let’s investigate other recovery methods besides ice to determine if they help or hurt the recovery process.

Active Recovery/Movement

Active recovery and movement activates your muscles and provides the “pumping” effect needed to activate the lymphatic system. Thus, it helps reduce swelling and speeds recovery from workouts.

It also helps load repaired tissue and break up scar tissue. Furthermore, it’s a great way to stay in shape if you are injured, or to cross-train on off days of a workout routine.

There are also potential mental benefits. Nothing is more frustrating than being unable to do activities you love due to injury. However, doing active recovery to tolerance can give you goals to pursue and engage you mentally while you are injured. Who knows, you may even discover a passion for a new sport or activity.

Verdict: Good (mostly). Listen to the body to not overdo it.

Total Rest

Rest is obviously a necessary component to injury or workout recovery. However, total rest inhibits healing.

Without movement, the lymphatic system is not engaged to pump swelling, tissues are not loaded, and scar tissue builds up. Total rest can also have a negative mental impact on people who are used to being active. This can increase stress and cortisol, which have a detrimental effect on healing as well.

Verdict: Bad. Do as much responsible pain-free activity and movement as possible.

Physical Therapy Exercises

The key benefits of physical therapy exercises are as follows:

• Specific strengthening for areas of the body that are underutilized due to injury
• Controlled, functional loading of tissue
• Stimulates lymphatic system
• Reduce likelihood of future injury by correcting potential root cause of injury

Verdict: Good. Follow progression and listen to the body.

Compression

Compression as a whole inhibits healing in the same way ice does. It inhibits inflammation (flow of fluid going into the area), and also restricts swelling removal (flow of fluid going out).

However, compression can be useful for doing activities and returning to sport. It provides extra support for the injured area, and keeps it warm, both of which help during exercise. 

Verdict: Bad (mostly). Can be used as aid for returning to activity.

Elevation

Elevation actually stimulates the lymphatic system due to gravity. However, it also restricts inflammation, as the heart cannot pump the blood to the injured area. Thus, it is better to reduce swelling in other ways.

Verdict: Bad (mostly). Use other methods for reducing swelling.

Massage/Rolling Out

This is a great way to stimulate the lymphatic system to reduce swelling. It also helps break up scar tissue. You can use a foam roller to self-massage. Electrical stimulation is also another way of creating the same effect.

Verdict: Good.

Anti-Inflammatory Drugs

These are bad for healing for all of the same reasons as ice but have a major additional problem. They reduce inflammation and pain throughout your entire body, not just the injured area. This inhibits healing and recovery throughout your body, and limits your ability to use pain as a feedback loop.

Verdict: Bad. Use only if necessary.

Heat

Heat has the effect of driving more blood flow to the injured area. However, this can increase swelling if the lymphatic system doesn’t remove the extra fluid faster. Additionally, we want to trust the body to heal the injury. By heating, we are overriding the body’s efforts by externally modifying the amount of inflammation.

Heat is great to loosen up areas prior to activity, but should not generally be used for recovery.

Verdict: Bad for recovery, good before activity.

Alternating Hot-Cold Therapy

Hot-cold therapy is a method whereby you apply localized ice (or cold) to an area, then immediately switch to heat, and go back and forth several times. Timing varies, but a typical progression could be 5 sets of alternating 1 minute of cold with 2 minutes of heat.

Even though ice alone or heat alone aren’t ideal for recovery, hot-cold therapy actually is beneficial! Alternating between hot and cold provides the pumping stimulus needed to activate the lymphatic system.

It is especially useful to use as an alternative to mobility and activity. If an injured area cannot be effectively moved, hot-cold therapy is a non-load-bearing way to stimulate the lymphatic system similar to active recovery.

Verdict: Good.

That should give you an overview of a few alternative recovery methods to use to help promote healing and recovery, as well as some commonly prescribed ones to avoid.

Icing Exceptions

There are a few circumstances where icing an injury makes sense. Basically, if there is a short-term need that outweighs the long-term detrimental effects on healing, ice should be used. 

For example, if you are 50 miles into a 100-mile backpacking trip and your knee flares up, you will want to ice or take NSAIDs. The pain you’re feeling will make getting out quite difficult, and since you’ll be hiking 50 miles out, if you’re limping, you’re likely to hurt other areas of the body. The short-term benefits of inhibiting inflammation outweigh the long-term delay in healing in this case.

However, cases where ice (and reducing inflammation) are actually beneficial are not very common. Icing during activity (to get an athlete back in the game, for example) can also be problematic because it prevents blood flow and reduces strength, speed, and coordination.

My Ankle Sprain

When I arrived home with my swollen ankle after the climbing incident, it took a lot of willpower to not follow the conventional RICE method of recovery. My ankle hurt badly, felt like it was on fire, and was almost three times the size of the other one.

I almost instinctively wanted to open the freezer, grab an ice pack, wrap the ankle with a compression bandage, and lay on the couch propping my foot up on some pillows. I felt crazy not applying ice. I felt even crazier trying gradual ankle mobility drills only hours later. What I was doing went against everything I’d been taught as an athlete growing up.

I reminded myself many times over the following days and weeks about all of the research and analysis I’d done on recovering from injuries and why ice was not ideal.

Nonetheless, this was a trial by fire. I’d hoped to analyze ice and injury recovery from a theoretical perspective. Unfortunately the rock I’d fallen from had other plans.

The Outcome

Less than two days after the injury, I was hiking with my dog over uneven terrain and doing plyometric physical therapy exercises. Less than a full week after the injury, I was mountain biking technical terrain clipped into pedals. Less than two weeks after the injury, I was going for 30-minute runs.

I’ve avoided doing anything painful. Every day, I’ve been massaging the ankle, doing hot-cold therapy, and localized stretching. The recovery has not been perfect, and I’ve overdone activity more than once.

Even still, as I type this I am 2.5 weeks removed from the incident, and can happily report I’m almost fully recovered. Without a time machine, it’s impossible to objectively compare against traditional recovery methods. However, I have had very similar injuries in the past (grade II ankle sprains) and can confidently say that this form of recovery has dramatically reduced my recovery time.

Conclusion

Is it time to reconsider ice, and the RICE protocol of injury recovery, as a whole? Can we recover faster from injuries or even hard workouts by engaging in methods that promote, rather than restrict, the body’s natural efforts? Based on logical analysis and personal anecdotal experience, I certainly think so.

What do you think? Next time you have an injury, or even just a hard workout, try avoiding the ice bath or ibuprofen, and instead try hot-cold therapy, massage, active recovery, and/or movement. Let me know your experience or thoughts in the comments!

Sources 

1: Grade II ankle sprain recovery time: https://urpt.com/blog/ankle-sprains-what-is-the-recovery-time/

2: Icing Whitepaper: http://marcpro.com/wp-content/uploads/2017/04/Icing-Whitepaper.pdf

3: Lymphatic System: http://www.lymphnotes.com/article.php/id/151/

4: Dr. Gabe Mirkin’s Ice Stance: https://www.drmirkin.com/fitness/why-ice-delays-recovery.html

5: Human Body Feedback Loops: https://www.albert.io/blog/positive-negative-feedback-loops-biology/

6: Blood Clots: https://www.medicalnewstoday.com/articles/322829#differences-in-bruise-and-blood-clot-causes

7: Scar Tissue: https://www.bbc.com/future/article/20161007-why-is-scar-tissue-different-to-normal-skin

8: Foam Roller: https://triggerpoint.implus.com/product/grid-foam-roller

9: Inflammation Overview: https://www.britannica.com/science/inflammation/Chronic-inflammation

The Use of Ice For Inflammation: A Prehistoric Approach That Should Be Discontinued

10: Wellness Nerd Icing Overview: https://yourwellnessnerd.com/why-you-should-not-ice-an-injury/

11: Move Instead of RICE: https://thischangedmypractice.com/move-an-injury-not-rice/

12: Washington Post Ice Article: https://www.washingtonpost.com/national/health-science/athletes-love-icing-sore-muscles-but-that-cold-therapy-might-make-things-worse/2019/01/31/a465dd84-1f25-11e9-8e21-59a09ff1e2a1_story.html

13: Washington Post Ice Article #2: https://www.washingtonpost.com/lifestyle/wellness/why-icing-a-sprain-doesnt-help-and-could-make-the-injury-worse/2019/03/04/25a6caa0-3ae4-11e9-a2cd-307b06d0257b_story.html

14: Ice Recovery Study: https://link.springer.com/article/10.1007/s00421-009-1138-y