Okay, 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 out of nowhere; they’re there for a reason, and typically from too much lifestyle stress. Here in Part II, you’ll learn what to do and what not to do if you’re unfortunate enough to sustain an injury.
Should You Ice That Sports Injury?
The common 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 up this process and delay healing? Ice 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 for injuries. Using ice is much like stretching: There’s no evidence that it works to promote healing or that it “helps” unhealthy people. Really, it provides temporary relief by dampening the pain (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 decide just how much you want to calm down the inflammation. Clearly, if inflammation is out of control and your body is creating more inflammation than needed, then ice may help out in the short term. But when the body becomes more inflamed than “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 need to ice an injury at all. I’ll discuss more about inflammation in Parts III and IV.
Ice, Ice, Baby
Ice is the conventional medicine go-to when it comes to an acute injury, especially in the first 24–48 hours after the 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 just have to ice because the paradigm has been burned into your brain that it’s so important (just like stretching again, but enough of that). Again, the healthier you are, the less ice you’ll need because you’re only going to make matters 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. Using a moist towel or cloth helps transfer the cooling and protects your skin from burning. Frozen veggies work well too.
2) Keep the ice on until you get a deep ache that’s slightly painful. This occurs just before the area goes completely numb. You’ll get the most “benefit” from the ice if you hit that point but don’t go beyond it; 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.
Using Ice for Endurance Performance
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 my shorts while passing through an aid station. After the initial shock, it’s a good feeling!
Cold Plunges and Ice Baths
Cold plunges after training generally isn’t recommended for recovery, especially after strength (resistance) training. The ice baths can hinder muscle hypertrophy because they dampen some of the inflammation necessary for muscle growth and adaptation.
Directly icing an area of soreness has not been linked to reducing delayed onset muscle soreness (DOMS), but cold baths may be beneficial, to a certain degree. This can especially help if you’re involved in a multi-day event and looking to help speed recovery. 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 and jack up your cortisol levels. If you have an area 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 or feet; you’re providing 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 and 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. If you’re still injured after several months, or even weeks, using heat as a remedy is at best only providing temporary relief. You never want to apply heat to an acute injury or an inflamed area—that often makes matters worse. When in doubt, don’t use heat!
Sometimes heat can provide benefits beyond 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 value here to some degree, such as for a person with arthritic knees 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 is typically much more effective. Aerobic exercise should always be part of a warm-up for any activity.
Contrast Therapy
Some physicians and therapists recommend alternating ice and heat (10 minutes ice, 10 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 only does just that—dampen pain. Although it’s 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 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’ll likely only delay the healing and perhaps create injuries in other areas of your body. Obviously, you don’t want to mobilize a broken bone, but lightly contracting the muscles around the area can speed up healing.
Compression is very important, which means doing just that: Compress the area, but don’t cut off circulation. You want a fair amount of pressure. This can be accomplished by wrapping the area with a bandage or even using your hands to hold pressure over the injured area; though, obviously, you can’t keep your hands there forever. Although you don’t want to treat the injured area with a deep massage (which can bring unwanted heat and more inflammation), compressing the area around the sustained injury can be very beneficial. This is similar to the trigger point therapy techniques I discuss throughout the Sock Doc site, but you don’t want 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 (pressing and releasing muscle points for a few seconds at a time), as this can help 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, look for those points in your calves and assess and treat that area. If you injured your knee, look for areas of tenderness throughout your thigh (quads), hamstrings, and calves to work on. In these “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 help the athlete 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 as actively as possible. If you’re using ice to constantly dampen the pain or reduce swelling in an injured area, 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 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!
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.
