This is one of the most frequent questions we get as rehabilitation professionals “Should I use heat or ice?”  While I wish the answer was a simple one, research tells us it isn’t and, in fact, may be telling us to use ice a lot less than we currently do.  One of the most common acute injuries studied are ankle injuries, so the focus of this blog will be directly relating to ankle injuries, but that doesn’t mean that the conclusions can’t be translated to other parts of the body.  

So when should we use ice? Dr. Gabe Mirkin is credited with the standard of treatment since 1978, which has been the acronym R.I.C.E. (Rest Ice Compression Elevation) immediately after an injury.  This was the tried and true method of immediate care after injury, until we began to study it. What we have now seen is that not only may this not be effective, it may be detrimental to the healing process.

A systematic review of the literature performed in 2012 by Bekerom, et al, found that there was “Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option.”  So R.I.C.E. hasn’t been found to actually do anything to help recovery.

Nemet, et al have shown that ice may actually hinder the appropriate inflammatory response that muscles have after exercise and concluded “ice therapy immediately following sprint-interval training was associated with greater decreases in both pro- and anti-inflammatory cytokines and anabolic hormones supporting some clinical evidence for possible negative effects on athletic performance.” So, ice has been shown to hinder recovery after intense exercise. 

Ramos, et al, wanted to challenge the claim that ice hinders recovery of an immediate injury. They found that “cryotherapy reduces the inflammatory process through the decrease of macrophage infiltration and the accumulation of the inflammatory key markers without influencing muscle injury area and ECM remodeling.”  In other words ice does reduce inflammatory markers, but not ones influencing muscle injury. 

So if R.I.C.E and ice itself doesn’t seem to be the key to recovery, what is? The latest research is telling us that movement, not rest, have lead to the quickest recovery.  A systematic review of 46 papers was performed in 2016 to see what the most effective treatment of ankle sprain was. They found that “For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function.” So manual therapy and exercise along with NSAIDs are the most effective.

A recent blog by Phil Page, PhD, PT, ATC seems to sum it up best: Aside from acute trauma (<48 hours after injury), ice probably does not help beyond pain reduction. Ice alone doesn’t directly reduce swelling, which has been confirmed in several studies. However, ice’s ability to reduce pain makes it an effective and safe alternative in pain management. It’s been well established that pain and swelling can inhibit muscle strength; therefore, it would be wise for practitioners to address pain with safer cryotherapy alternatives to initiate movement as soon as possible. That’s where therapeutic exercise and muscle activation comes in. “Cryokinetics,” or the use of cold to facilitate exercise, can play a key role in a rehabilitation program.

With all of this evidence, why is ice still used? Because it is still very effective at reducing acute pain and, to a lot of people, it feels good.  Clinically, I have seen only one real difference, and its seasonal. In a lot of cases, people prefer cold in the summer and heat in the winter. Given that there is no good evidence to use ice instead of heat or vice versa, all that matters is what makes you feel better. The one thing that all the recent studies do say, is movement is better than rest.  

By: Travis H. Stoner, PT, DPT, COMT, FAAOMPT

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