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Sock Doc WorkshopsOkay, you’re injured. Now what? Do you apply ice, heat, or “RICE” for injury treatment? In Part I of the Sock Doc First Aid For Injuries you learned WHY injuries occur. Injuries don’t just come of of nowhere; they’re there for a reason and typically they are from too much lifestyle stress. Now here in Part II you’ll learn what to do and what not to do if you’re unfortunate enough to sustain an injury.
Ice That Injury!?
The general idea and recommendation is to ice any acute injury, (that’s one that recently occurred). But do you really want or need to? If your body is trying to promote some natural and normal inflammation in the injured area won’t ice screw this process up and delay healing? Ice very well may do just that especially if it’s used excessively. Remember, you won’t heal without inflammation – it’s the first step of healing followed by repair and remodeling of the tissue. If you screw up step one you will screw up healing. Yeah, you will screw it up with ice.
Ice treatments (cryotherapy) are overused in regards to injuries. Using ice is much like stretching – there’s no evidence that it works to promote healing and it “helps” unhealthy people. Really it dampens the pain, providing temporary relief, (again, just like stretching), – not actual benefits. Ice will increase lymphatic congestion as well as dampen the connection between your nerves and muscles, thus delaying normal healing.
You have to make a decision regarding just how much you want to calm down inflammation. Clearly if inflammation is out of control and your body is creating more inflammation than what is needed, then ice may help out in the short term. But when the body becomes more inflamed than what is “normal” it’s often because that same body is already dealing with inflammation day in, day out and that has a lot to do with antioxidant depletion and stress, as discussed in Part I. There are of course exceptions such as heavy trauma to a joint, but in general this is true for the typical injuries athletes sustain that put them on the sidelines (or couch). A healthy person will not have excess or unnecessary inflammation to the point that they will need to ice an injury at all. I’ll discuss more about inflammation in Parts III and IV.
Ice, Ice, Baby
Ice is the typical conventional medicine go-to when it comes to an acute injury, especially in the first 24-48 hours after an injury occurs. After several days it might be a good idea to back off, or discontinue and let your body take over its own healing if you’ve decided that you just have to ice because the paradigm has been burned into your brain that it’s so important, (hey just like stretching again – okay, enough of that). Again, the healthier you are, the less ice you’ll need and want to use because you’re only going to make mattes worse. If your swelling and pain progress to the point that you’re unable to keep the inflammation down without ice then it may be time to consider other therapies or the advice of a professional.
If you’re going to use ice because your inflammation is out of control, here are some general guidelines:
1) Never apply ice directly to the skin – a moist towel or cloth helps transfer the cooling and protects your skin from burning. Frozen veges work well too.
2) Keep the ice on until you get a deep ache – slightly painful. This occurs just before the area goes completely numb. You’ll get the most “benefit” from the ice if you hit the point of the ache but not past that; typically this is 15-20 minutes. Again, this benefit may not be the one you think (healing), but pain control and perhaps dampening excess inflammation.
3) If you ice too much or too often you can increase muscle damage. Remember you’re going to delay healing using ice!
Ice for When There Isn’t an Injury
Though ice isn’t ideal for an injury there are still times when it can help an athlete out.
Ice and Endurance
Drinking ice water can lower your core temperature enough during training or racing on hot days to boost endurance. And putting ice on highly vascular areas during a race can be very beneficial too. I, as well as other endurance athletes, have seen the benefits of dumping an ice cold cup of water down the front of the shorts while passing through an aid station. After the initial shock it’s a good feeling!
Ice or Cold Baths for Recovery
Cryotherapy in the form of ice baths isn’t recommended for recovery and icing an area of soreness has not been linked to reducing delayed onset muscle soreness (DOMS), but cold baths may be beneficial. Cold baths or showers can help speed recovery – but don’t sit in a bucket of ice – you’re not trying to numb your body. If you have an area of your body that is tight or sore, say your calves, then you may help the healing and recovery by standing in a cold bucket of water. Again, you’re not trying to numb your legs/feet – but just provide a cool, relaxing sensation. Make it cold enough so the ice slowly melts in the water.
How About Heat for That Injury – or Mixing Ice & Heat?
Heat therapy is often recommended for more chronic types of injuries. These are injuries that are still a problem weeks, months, and even years later. Of course, if you’re still injured after several months, or even weeks, then using heat as a remedy is at best only providing temporary relief. You never want to apply heat to an acute injury or an area that is inflamed – that would often make matters worse. When in doubt, don’t use heat!
Sometimes heat can provide some benefits other than pain relief by bringing more blood and lymph flow to an area, but compression and trigger point therapy are much more effective when it comes to a chronic (as well as acute) injury. More on this in a bit. Heat is also very ineffective at penetrating deep into the body’s tissues. After about one-quarter inch into the body, heat can typically only raise the tissue temperature a mere 2 degrees Fahrenheit.
Warming-Up With Heat
Some recommend using heat during a warm-up to loosen up tight joints and muscles. I can see a value here to some degree, such as for a person with very arthritic knees, for example, who cannot walk very well without heating their knees first. However, aerobic exercise including some tissue work, (light to moderate massage), around the involved muscles are typically much more effective. Aerobic exercise should always be part of a warm-up of ANY activity.
Contrast Therapy
Some physicians and therapists recommend alternating ice and heat, (ten minutes ice, ten minutes heat), for various injuries. This is called contrast therapy. The belief here is that there will be a more powerful effect on dampening the pain pathways present during an injury, essentially altering the physiological response. Personally, I don’t recommend this type of treatment because it does only just that – dampen pain. Though better than taking pain medications, there really is no beneficial healing with contrast therapy.
RICE for Injury Treatment – Maybe Not
RICE is an acronym for Rest, Ice, Compression, and Elevation. RICE is an okay way to deal with an acute injury but it’s not the best. Remember, you’re going to delay healing with ice and the R-C-E is a not ideal either.
The ‘R’ for “rest” doesn’t necessarily mean you completely immobilize the joint. Depending on the injury sustained, active rest may be more beneficial and often is. Movement is good for an injury to a certain degree. Don’t try to push through the pain though; you’re more than likely only going to delay the healing and perhaps create injuries in other areas of your body. Obviously you don’t want to be mobilizing a broken bone but lightly contracting the muscles around the area can speed up healing.
Compression is very important which means just that – compress the area but don’t cut off circulation. You want a fair amount of pressure on the area. This can be accomplished via wrapping the area with a bandage or even using your hands to hold pressure over the injured area; obviously though you can’t keep your hands there forever. Although you don’t want to treat the area that is injured in the form of a deep massage, (which can also bring unwanted heat and more inflammation to the area), compressing the area around the sustained injury can be very beneficial. This is similar to the trigger point therapy techniques I discuss throughout the SockDoc site, but you don’t want to or need to apply too much deep pressure. There may be some slight discomfort but not pain!
Even better than just compression may be contracting/relaxing with the hands, (as in pressing and releasing muscle points for a few seconds at a time), as this can help to mobilize lymphatic tissue and remove the waste products thereby speeding up healing. Also remember that, as I mention in the many videos and posts on injuries, you want to be aware of the muscles supporting the injured area. So if you sprained your ankle, then look for those points in your calves – and assess/treat that area. If you injured your knee, then look for areas of tenderness throughout your thigh (quads), hamstrings, and calves to work on. Actually in these other “non-injured” but supporting areas you can use more aggressive trigger point therapies. Rest and elevate as necessary too! Elevation is fine but as you can see compression/contraction and (active) rest are the best for an injury; so RICE is about half right!
First Aid Overview: Think Twice Before You Apply the Ice
Using ice will delay normal healing. Though it will dampen pain, it is only going to perhaps help the athlete who is dealing with excess inflammation. If you use ice, do so wisely and make sure you’re also treating the injured area with more effective treatment therapies such as compression and trigger points, (depending on the severity of the injury), and resting as needed and actively as much as you can. If you’re using ice to constantly dampen the pain or reduce swelling in an injured area, then realize you’re not addressing the source of the injury and you’re not properly healing. Rarely should heat be used on an injury and never on an acute problem or area of inflammation. And of course have your injury checked out by a qualified physician or therapist if you’re not healing properly or if there is any question and/or concern regarding the extent of damage you sustained. Don’t be that guy (or gal) who iced and wrapped their broken foot for weeks before having it checked out!
Hey – how about those anti-inflammatory drugs (NSAIDs)? Will those help heal your injury faster or help you recover faster from training or racing? That’s up next in Part III.
Dr. Stephen Gangemi "Sock Doc"
I'm a board-certified chiropractic physician and clinical nutritionist with a passion for true natural health care. I implement dietary & nutritional therapies, exercise & movement practices, and lifestyle changes along with manual therapy techniques to help the body heal and prevent illness and injuries.
Sam Hight says
More fantastic info, thanks Sock-Doc!
I’ve heard of contrast therapy used to aid recovery from regular training rather than as injury treatment. The hot and cold is alternated every minute or two as a way to contract and dilate capillaries. The theory being that this will help mobilise waste products away from and fresh nutrients toward the used muscles. I’ve tried this and it feels very refreshing, much like a sauna/cold dip therapy.
The clear benefit seems to be mental (relaxation and de-stressing), but could you comment on whether this would actually physically improve recovery?
Cheers!
Sock Doc says
Contrast therapy does not do that. The heat part may help mobilize waste products but then every time you hit it with the cold you stop the process and maybe even reverse it. Yeah, you might be a relaxing effect and pain reduction – but neither is healing.
GWBL_RMT says
Contrast Therapydoes work if used properly. 10 hot/ cold is a ludicrous suggestion. What you should be doing is more like 30-45 sec hot and then 10-15 sec cold repeat 3 times. The heat does cause vasodilation and then yes the cold does vasoconstrict, but sock dock your missing the point. When done this way it causes a reflex action in the body, stimulating increased circulation to warm you up. So even though you end with cold, your body does not continue being vasoconstricted and you’ll find your extremities quite warm and full of circulation within a few minutes.
Cynthia Silverthorn says
Soc Doc,
Your Part II refers to cryotherapy in the form of ice baths, but what is your opinion about this …
Whole Body Cryotherapy is a hyper-cooling process that lowers a person’s skin temperature to approximately 30˚ F for a period of up to three minutes. This is achieved by enveloping the body with extremely cold air at temperatures ranging from -133˚ F to -320˚ F.
I’ve completed one 3 minute session of this type of cryotherapy in an effort to get some relief for bursitis. It seemed to help. I’m a triathlete so we’re swimming, running, and biking a lot. That tends to wear down the body. This type of therapy is becoming more and more popular among triathletes and athletes of other professional sports.
Sock Doc says
Wow. I have not heard of this, thanks for sharing. So since it’s new to me I’m really not qualified to comment but I’ll say it sounds like another crazy new therapy. Sure won’t address the cause of the problem and I’m sure those who find relief from it are overtraining and over-stressed.
PhilipV says
What do you think of “kinesio-taping” for chronic joint injuries?
Sock Doc says
I don’t use kinesio-taping only because I’ve never found it necessary to correct a problem, (I have other therapies I use that I feel are more effective). Though I don’t see any problem with it, as long as it is not chronically used to support a problem that isn’t healing – in other words, you don’t want to have to always be taping to perform. So, per your question – since you ask about chronic injuries – I think that is a problem. Use it for an acute injury only or if it helps you get through a necessary competition with less/no pain or further injury to the joint or tissue.
Chris says
Hi Sock Doc
I’ve found an unexpected and surprising source of relief of the some of little niggles from running by accident. After having slightly twisting my ankle in a pothole running at night. The next day my ankle was still a little bit sore and as I was doing some gardening barefoot in the garden I accidentally brushed my ankle on some stinging nettle, which stung a little for a few minutes. After the sting had gone away I noticed that the pain in my ankle had gone and didn’t come back. Since then I’ve tried this many times on other niggles like the beginnings of shin splints to just sore and tired feet after long runs and it works every time. The effect can last anywhere from a day to removing the pain for good, I think this may depend on the severity of the injury .
It didn’t try it when I had a Piriformis muscle problem, thought it might be a bit risky putting my bare bum it the stinging nettle patch (other bits might get stung).
What would be causing the pain relief in the nettle sting or is it a dampening of the bodies inflammation responses?
Have you seen or read any science regarding this. Ive tried to find some but have only come up with stories about the Roman Army (2000 years ago) using it on long marches for pain relief.
I put it down to another “Weird but works”, but there must be some science behind it.
Any Ideas?
Cheers.,
Chickenlegs
Sock Doc says
That’s pretty interesting. I know that the root of stinging nettle can help with tissue repair and the leaf is supposedly helpful for prostate problems – though you’d be getting neither from skin contact. So maybe it is from something in the nettle sting. Thanks for sharing.
Greg says
Hey Sock Doc,
I just found you yesterday, as I was looking for more answers as to why cryotherapy does not work and can actually make matters worse. I wasn’t expecting to run into a gold mine of information.
I was wondering if you could elaborate on how ice dampens the nerve and muscle connection as well as how it increases lymphatic congestion? Everybody has theories about what works and what doesn’t work, I’m just trying to find the science behind what works and what doesn’t work. If that makes sense? Also, what is the importance of the lymphatic system when it comes to injury?
Thanks!
Sock Doc says
Thanks Greg. Well you can think of the “dampening” as the “numbing” effect ice has on tissues – blocking pain receptors similar as to when you rub an area vigorously that is injured – you’ll stimulate mechanical receptors that will block pain receptors. Now this may be fine in the short term (for pain management) but since it affects the muscles ability to properly contract that is a problem because it’s the muscles contracting that pumps the lymphatic system – your second question.
Your lymphatic system is very important in removing waste and excess fluid. Ice is said to increase the permeability of the lymphatic system which essentially backs up this one-way system increasing swelling and pressure while not allowing the waste to be removed. This, of course is not good.
kieren says
Great article! For years I have been advising fellow runners against icing. Many look at the professions that take an ice bath after a hard training session. It follows then that amateur runners and coaches then thing it’s a good idea – it’s not.
As you mentioned, it delays healing by reducing blood flow and inflammation. Why would someone want to delay healing? So that the can get a greater training effect by training hard sessions back to back either on the same day or consecutive days. This is stuff for the 10%, the elites. The vast majority of people don’t need to be training hard sessions back to back and can generally do a lot more effective training before they would even need to consider doubles.
Nick says
Doc, I don’t know if you are still taking questions, but I’ll give it a shot anyway.
For PF, since it could be a microscopic tear(s), or something else that needs healing, isn’t it best to stay off the foot as much as possible (or walk very lightly on the foot) and to wear an arch until the pain goes away, and then work on foot health?
Why don’t you talk about inflammation in your article and video on this? Couldn’t it be just inflammation for many people?
Thank ya.
Isn’t it best to i
Sock Doc says
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Alando says
I have a game ready icing machine which I use probably 2-3times a day after gym & rugby sessions on my knee.
Have had key hole operation to sort out the fat pad in my knee (bruising) but have also had issues with patella tendonitis in the past. That same knee my PCL is un functional & also think I have a bit of fusion in the knee now.
However, still able to partake in trainings etc but the knee can be a bit stiff at times. After warm up before gym & field training my knee starts to free up.
My game ready is great for after session treatment but now afraid if I am icing too many times a day. Thoughts?
Sock Doc says
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Dublin5girl says
Hi Sock Doc
I have an eleven year old son who just started camp and comes home in tears from sore feet, shin splints and pain up his legs.
What can I do for him? He doesn’t have any injuries but did have Severs last year but it has eased up some. He also wears custom orthotics. I feel like we are back to square one again..
Should I do ice first followed by heat and stretches afterwards? Could this be leg cramping or “growing pains” from being on his feet all day long.?
Thank you so much.
Sock Doc says
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James says
Hi Sock Doc,
I have read all of the above and think there are some really great insights and explainations. I was wondering weather you could please provide some sources for this information to back it up. I am a trainer and i like to give advice which is backed up by quality research. If you have some good sources that would be outstanding from my point of view.
p.s I’m not trying to catch anyone out here.
Thanks James
Sock Doc says
Read the Kenneth Knight book on Cryotherapy – used on Amazon. It’s a good start.
Jackemeyer says
Now at 37 yrs of age and lots of soft-tissue damages from outdoor adventures and indoor basketball and volleyball since youth, my n of 1 experiences to managing swelling with RICE are each in-line with your thoughts in these articles. RICE is a good centering technique, to bring acute awareness to the problems, but no excuse to become passive bystander! (Life’s Lessons: the relevant details that emerge with self-education & reasonable experimentation never cease to uncover increasingly useful strategies).
Re: the last image of big swelling just above knee — I have experienced equally large (& unbelievab!y qu!ck) swelling after a cycling crash. I was shocked that I could wrap/compress and reasonably ice the area, sleep on it, and the next afternoon, “check myself in” to my self-education, hand’s-on learning environment of the local $25/mo gym. No emergency room, no swelled-ego MDs: RICE, an alert & reflective mind led to an active recovery, and within days, working toward a full deep squat again.
Best to everyone in their own experiments & education 🙂
Andrea says
What about Epsom salt water bath?
Sock Doc says
That can help. Even better some nice mineral sea salts.
Umberto Bergonzini says
Have you ever looked into far infrared therapy for quicker recovery? If so what do you think?
Sock Doc says
I have had patients use that in saunas but with no definite outcome.
lucy says
I just got hit hard by a drum on my right knee.. it has swollen and is hurting… the day aftr tomorw.. i hv an importnt work.. where ill have to walk for about 6-7 kilometers.. what to do ?
Michael says
I injured a knee yesterday and it’s swollen only put a little ice as we finished playing soccer after that went home had a shower and have not touched it now it swollen and can’t bend my knee not sure what to do elevate it or not ice or deep heat or none have to wait to see a doctor tomorrow any suggestions it’s painful I can’t walk up or down the stairs , I banged it into another person’s foot and felt it ouch as it happened.
Dr. Stephen Gangemi "Sock Doc" says
I think you should have that checked out by your physician/therapist.
Tylor says
If you do your research, doctors are now using the M.E.T.H. method. Movement, Elevation, Traction, Heat. The most important change from RICE to METH is the heat aspect. The only thing that ice does for you is numb you and make the pain go away. In reality it is counterproductive to the healing process. Your body produces pyrogens when injured to send to your brain for the specific purpose of setting your body temperature up. That is why we get fevers. This increases cell movement. When ice an area it slows cell movement. You have to let Lymphocytes do their job and they can’t if they are frozen.
Melanie says
What do I do if I hurt my big toe and it is swelled but when I apply ice to it it makes the pain increase?
Dr. Stephen Gangemi "Sock Doc" says
Look at the muscles around the foot as I show in my videos and don’t use ice!
Maggie says
It’s good to know that I should be icing an injury within the first 24-48 hours of when an injury occurs. Just this morning I tripped and hurt my ankle, and it’s really starting to hurt. When I have a chance later today, I’ll definitely grab something cold to put on it. Hopefully it’ll start to feel better soon!
Kailla says
great article Sock-Doc!
however, u said compression to the injured area is good. can that compression be from a knee guard ?(if we injured our knee) can u also provide techniques that could be done for compression?
Dr. Stephen Gangemi "Sock Doc" says
It really needs to be compression from something like tape/wrap or actually manual therapies – see the article on trigger point therapies. https://sock-doc.com/trigger-point-therapy/
Rama says
Sir, I have soft tissue injury in my right knee, actually it’s muscle tear. I am on rest past three weeks n I was doing contrast therapy n follows the rest of RICE…Now there is some improvement like I can feel some contraction there and I can lift up my leg straight…But still i m unable to walk…What I can do and how much more time it will take?
Terry says
I am very interested in your opinion about plantars fasciitis. I’m going to try your techniques because I’m truly to the point of giving up on traditional ways of trying to handle this. But everything I have read seems to deal with younger generation. Well I’m 62. Any hope for my generation?
Dr. Stephen Gangemi "Sock Doc" says
Yes you should still be able to resolve your PF, regardless of your age.
AnnettePayne says
Then what do you use for a broken ankle. I am using ice for swelling taking pain medicine
but it burns alot around the break and is really sore What can I do . I do elivare my foot and
try to stay off of it as much as I can.
Dr. Stephen Gangemi "Sock Doc" says
Breaks are a different story as you’re probably in a cast already. There are different nutritional considerations for a fracture as opposed to a sprain/strain.
Ashley Johnson says
I liked that you explained that usually, the first step after receiving an injury would be to place ice on it. I would imagine that getting an injury would be stressful, especially if you are an athlete. I would definitely use a bag of ice as a temporary solution to the problem before heading to the doctor.