The new cold, hard truth about ice therapy

While ice likely remains helpful in the first 6-12 hours post-injury to alleviate acute symptoms, it may act as a barrier to healing if used too long, potentially leading to tissue damage and even nerve injury. Consequently, ice is now considered best for short-term pain management rather than a primary strategy for ongoing recovery from musculoskeletal injuries.

Cooling Controversy: Rethinking Ice for Injury Recovery The RICE protocol (Rest, Ice, Compression, Elevation), introduced by Dr. Gabe Mirkin in 1978 in The Sports Medicine Book, was long considered the gold standard for treating acute injuries. However, Dr. Mirkin has since revised his stance, suggesting that ice should be used cautiously post-injury. Emerging data indicates that while ice therapy can reduce pain and control swelling in the immediate aftermath of an injury, prolonged cooling (beyond 6-12 hours) may actually hinder recovery by delaying tissue repair and increasing scar tissue formation.

Forget RICE, it's now PEACE & LOVE

Rather than aiming to eliminate inflammation, current recommendations focus on regulating and optimizing the inflammatory response to support recovery. Recent evidence has led practitioners to shift from RICE to the PEACE & LOVE approach, which emphasizes early protection, elevation, avoiding anti-inflammatories, compression, and education, followed by (controlled) loading, optimism, vascularization, and exercises.

When to Use Ice Therapy

• Acute Musculoskeletal Injuries- i.e., sprains, strains, contusions, etc. Cold therapy has proven to be most beneficial for controlling excessive swelling within the first 6-12 hours post-injury.

• Migraine Headaches: Using ice for migraines can provide relief. Applications include cold-gel headbands or caps placed on the forehead and wraps applied to the neck to target the carotid arteries.

• Acute Rheumatologic Flare-Ups: While there is no research consensus, ice therapy is generally considered beneficial for reducing inflammation in acute rheumatologic flare-ups, particularly in cases of gout.

• Post-Knee Arthroplasty: Studies indicate that cold compression therapy after knee replacement surgery can improve outcomes, such as better pain relief, compared to other treatment methods.

Practical Application of Ice Therapy

Types of cold therapy: Ice pack therapy, migraine ice cap, bagged ice, compressive cryotherapy devices, immersion ice bath therapy, or whole-body cryotherapy chambers.

The optimal temperature of ice therapy: Undefined and dependent on the amount of internal and external insulation. Somewhere between cool water and nearly 0ºC for a chemical instant ice pack (which carries a frostbite risk).

How long to apply ice therapy: 10-20 minutes. When using an ice pack, patients may progressively feel cold, followed by burning, aching, and finally numbness (CBAN). Remove the ice pack if numbness occurs.

Contraindications for Ice Therapy: Ice therapy should be avoided in cases of impaired circulation, Raynaud’s disease, cryoglobulinemia, hemoglobinuria, peripheral vascular disease, hypersensitivity to cold, cold urticaria, Complex Regional Pain Syndrome (CRPS), or skin anesthesia. It is also contraindicated over regenerating nerves, open wounds, or burns, as it can worsen tissue damage or lead to hypothermia. Whole-body immersion and cryotherapy chambers should be used with caution to avoid potential side effects like hypotension, tachycardia, and syncope. Proper screening and precautions are essential, especially with prolonged exposure or specific applications like ice massage or cold packs.

When to see US!

Book your appointment to see one of our therapists within 48hrs of injury. We can advise you on correct first aid and how to proceed, help with taping, loading and exercise advice, ensure you have a safe and speedy recovery - and maybe even help you not do it again!