Cryotherapy – Why “Get Some Ice on It” is Wrong

Gabe Kapler on the basepaths

Sometimes it seems as if there aren’t enough hours in the day. I found 720 that I would like to get back.

I gather I wasted 30 hours a year from the time I became a serious athlete until the day I retired as an MLB player on a single, worthless pastime – icing injuries and sore muscles. The worst part of this? I knew better.

Jason Varitek, my spectacular teammate in Boston, miserably wrapped himself in bags of ice after every game. He stood nightly by his locker draped in football pads made of cubes while Bob Ryan and Alex Speier lobbed him questions, The rest of the clubhouse figured he knew something about the healthy benefits of living in an igloo.

He didn’t.

I had minor shoulder issues as a high school baseball player and followed the lead of MLB pitchers. I wrapped my shoulder in ice and twiddled my thumbs until the pain (from the ice, not my muscles) went away. I could feel the truth intuitively. “This doesn’t make sense,” I thought to myself. “My natural body temperature is 98.6. I’m drastically altering my natural state and creating discomfort. There is no way this is good for me.” Then I did it again the following day, and again and again throughout my career. I didn’t once feel like my condition improved from this therapy. I trusted trainers, team doctors and teammates who never explained why we should freeze ourselves. The advice was crazy general. “Get some ice on it.”

The ice did numb the limb I was focused on, and I wasn’t in pain. I was uncomfortable, however, from the cold water dripping everywhere. More importantly, my desire wasn’t to not feel my ouchie. I wanted to improve my condition for good, not be able to ignore it for a while. From an NCBI study on the effectiveness of ice on soft tissue injuries:

Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.

Essentially, if you fall on your ass, the ice will numb it. You’re kidding, right? That’s the benefit of icing?! I don’t use exclamation marks often, but this moment deserves them.

I specifically tried cryotherapy while attempting to treat muscle tears in my quad and hip flexor during my pro career. Turns out, I gave away my most precious commodity, time. From the New York Times:

Last year, a small-scale randomized trial found no discernible benefits from icing leg muscle tears. The cooled muscles did not heal faster or feel less painful than the untreated tissues.

Seriously, I’m not upset about this because I wasted time or didn’t improve. I’m pissed because I didn’t challenge conventional wisdom when every pore on my body was telling me to. The outcome may have been the same. Maybe there is enough gray area in the studies that the potential upside was greater than the downside of discomfort and the sands through the hourglass. Regardless, I needed to practice what I preach. Don’t ever do something because it’s the way it’s always been done, do it because it makes sense.

It’s July and I’m feeling a little chilly. I’m going to get my robe.

Kap

  • http://gravatar.com/mb01915 Mike

    Interesting. Post arthroscopic knee surgery I spent a lot of time icing the knee. How about heat – help or hurt?

    Sorry I have to ask, how about coconut oil – the WD-40 of the body.

    Great work, keep it coming.

    • Gabe Kapler

      I’m guessing that like ice, Mike, if it feels good, it probably won’t negatively impact your general condition. If you end up doing some research, keep me posted.

      Thanks,
      Kap

  • http://twitter.com/AvsGirl2218 GoodbyeMessyJessy (@AvsGirl2218)

    Instinctively, it feels wrong to ice my knee where I tore my quadriceps tendon, even when it hurts. Of course the docs & physical therapists kept insisting. I’ve reinjured it & haven’t been back to doc, but I’m just not icing it.
    However, I have an ankle that I’ve sprained multiple times, and ice is my go-to. And it feels good whenever it hurts. I think when swelling occurs, ice is helpful. But for an actual tear in a muscle/tendon, what good can ice really do? Other than possibly numb?

    My other concern is that my child is a gymnast. Whenever they get an injury during practice, the coaches have them put ice on the muscle for a bit, then rejoin practice. I worry that this will cause the muscle to tighten up, and they don’t stretch again before rejoining practice. It seems to me if they’re going to ice the injury, they should either be done for the day, or leave the ice off for awhile and then stretch that muscle again before practicing.

    And when she missed half a season with a lumbar strain, I really didn’t see the benefit of repeated icing, over the course of 6 weeks.

  • Gabe Kapler

    My quick take: The decision to ice or not has much to do with feel. So, if it suits you, ice. I don’t see much downside outside of the time spend and or discomfort. I don’t see much upside related to the overall improvement of condition.

    For your young gymnast, there is some research that suggests that icing then restarting activity immediately can be detrimental. This makes some sense intuitively as a cold muscle may be less flexible.

    The NCBI study linked in the post may be of interest to you.

    Best of luck and thanks for chiming in and adding to the discussion.

    Kap

    • http://twitter.com/AvsGirl2218 GoodbyeMessyJessy (@AvsGirl2218)

      Thank you :)

  • ty

    Kap, while I typically enjoy your posts; use caution if you’re going to question common medical modalities. I recommend reading the conclusion to the study you’re referencing. Specifically the part that reads “Additionally, the LOW methodologic QUALITY of the available evidence is of CONCERN. It states MANY more HIGH QUALITY studies are REQUIRED to create evidence based guidelines on the use of cryotherapy.” For the NYT study, I wouldnt base an opinion off one small scale trial. Many medical professionals (MD’s, RN’s, PT’s, etc) still recommend cryotherapy and the RICE (rest, ice, compression, elevate) method for a variety of injuries.

  • Shaun

    So I teach a sixth grade Physical Education class. If one of those kids gets a bump, and they ask for an ice pack, there’s really no need for them to get one, because there’s no health benefit.

  • Gabe Kapler

    Thanks, Ty. I appreciate the honest feedback.

    Most of my “questioning” is based on my own personal experience which is impossible to dispute. As for the studies I bring to light, they are presented for the reader to utilize as they see fit and research further should they be inclined. If you’ve been following the blog, you know my aim is to inspire folks to challenge conventional wisdom. I fully stand by the energy of this post which is largely made up of personal anecdotes but includes some scientific research.

    Finally, and with much respect, I challenge you to bring something stronger than this:

    “Many medical professionals (MD’s, RN’s, PT’s, etc) still recommend cryotherapy and the RICE (rest, ice, compression, elevate) method for a variety of injuries.”

    Many medical professionals also push a variety of addictive narcotics and unhealthy treatments and are heavily influenced by the pharmaceutical companies partially responsible for their financial well being.

    You’re always welcome to come discuss matters with me here, but be prepared to come correct.

    Warmly,
    Kap

  • ty

    I’m confused as to how I’m wrong? Your second point is (to some extent) correct, but I”m not sure why that’s relevant to the cryotherapy discussion.

  • Gabe Kapler

    Didn’t say you are wrong, come correct is semi-slang for “bring a stronger take”. I believe your position is simple and I’m challenging you to bring more substance if your aim is “caution” me and our readers.

  • Jygriff

    Basically you are causing vasoconstriction of the blood vessels with the application of ice. Anytime you have vasoconstriction of blood vessels then obviously you have less blood flow to injured area. I think the FIRST goal for most MD, PTs or trainers is to minimize swelling in affected area which ice helps accomplish. On contrary you have less blood flow then you have less of our anti-inflammatory helper cells.(dialed down for simplicity). This is why most will only recommend ice for the first 24hrs then heat to INCREASE blood flow(vasodilation). I think most knowledgeable trainers should and will be able to explain this to you.

  • Diane Seabury

    What Jygriff said…cryotherapy will slow the metabolic rate. We use it will good sucess in cardiac arrest victims-put them in a hypothermic state for 48 hours, then warm and extubate them. The cooling of the body halts further cardiac muscle damage. Icing an extremity does the same thing for an acute inflammatory reaponse. (Physical Therapist x 25 yrs, currently specializing in cardiac ICU)

  • Jarrod

    I agree with Jygriff, because that’s precisely what my physio instructs me to do after an injury where there is a lot of swelling. Use ice (and ibuprofen) to reduce the swelling and then he can get to work repairing the injury. While the swelling is still there it is very difficult to begin rehab.

    On a slightly related note, my brother-in-law plays cricket professionally (we live in Australia) and his guy that looks after his strength and conditioning program (not sure of the exact profession) told him a while ago that research shows no benefit for muscle recovery from ice baths. He did say however that they use ice baths after a game to drop the core body temp below it’s standard level which in turn resets circadian rhythms and allows the player to sleep better and therefore recover through good rest.

    I thought that was a pretty interesting insight into a very common practice.

  • Ed H

    Oh, but there is one benefit…. It’s called the placebo :) .

  • Sarah

    I just came home from my physical therapy appointment and my PT calls me ” the ice queen” , I love ice! So after reading your post i question all my icing habits, I’ve been dealing with a ” huge herniated disc” in my lower back for about 7 months I’m on my second round of PT and 2 failed injections , but when all else fails I turn to ice cause it makes my back, leg and bum feel better ( for short term) I don’t know if I can give up my trusty little ice pack ! I

    • Gabe Kapler

      Good thing you don’t need to. Enjoy it, Sarah.

  • http://www.lobaktrax.com Roland F. Berthiaume, DC

    “Ice or Heat…they both work so do whatever you prefer”
    I hear almost daily from patients who have been to an ER before coming to see me.
    Although I emphatically agree with the advice to challenge conventional wisdom and dogma (in fact it’s how I live my life) I really cannot understand why the Ice vs Heat debate is so complicated??
    Anyone with medical training beyond a 6 month 1st aid course and with some basic neurological training should understand it.
    Granted, I treat musculo-skeletal injuries daily so it’s more relevant to me than someone who is removing spleens and saving lives from gunshot wounds and auto accidents so maybe I pay more attention to this than suturing techniques.
    Here goes my simple explanation.
    Cryotherapy works.
    Moist heat works.
    It all depends on the injury or pain source.
    The simplistic ice for the 1st 24-48 hr’s and then heat does not work in a chronically acute situation such as your example, Mr. Varitek.
    Ice for him daily after a game makes perfect physiological and neurological sense. However a global ice bath or any icing greater than 20 minutes makes no sense.
    You see, Ice or Heat do “both work” as a pain reliever because in the nervous system, temperature receptors have a higher priority in the nervous system than pain receptors believe it or not.
    So stimulating either hot or cold receptors temporarily shuts off or over rides the pain receptors and decreases your pain..(while they are applied).
    However, what are they doing physiologically while they are being applied???
    Heat vasodialates and makes the blood vessels more porous …so not so good during inflammation.
    Cold vasoconstricts and decreases the blood flow which makes the blood vessels less porous…this is desireable during inflammation.
    What is inflammation?? Is it bad?? Is it necessary??
    Inflammation is an immune response which is designed to occur in areas of injury to allow white blood cells to the area so they can do their job of clearing the area of debris so proper healing can then ensue.
    They can only get from the blood vessels and to the damaged tissue area during vasodialation/inflammation.
    However when an injury like a tear of a muscle occurs, you also experience tearing of blood vessels which causes an exagerrated inflammatory response which is an exaggerated immune response resulting in exaggerated swelling so ice used to minimize this effect is beneficial because if you are experiencing too much immune response for debris clearing, the proper healing of the tissue cannot occur.
    So to summarize even though it needs to be applied in a case by case basis which also takes into account the occupation etc.
    Mr Varitek was chronically acute from irritating his knees and throwing shoulder almost nightly so icing packs wrapped around those areas for no longer than 20 minutes was good…. irritation/inflammation but not injury especially in a chronic situation can actually damage good healthy tissue so minimizing it is necessary.
    More than 20 minutes is not good because of the wonderful homeostasis of our body. After 20 minutes of exposure to the ice, the tissue will go into a self-preservation mode, meaning…frost bite and death to that tissue is eminent with continued exposure, so the body attempts to save that tissue by…vasodialation and inflammation to the area. Great example hear in New England, when you first go out in the dead of winter, the nose and ears turn blue because of vasoconstriction secondary to the cold…but if you stay out longer than 20 minutes those same areas become fire engine red….simple physiology.
    Ice baths will decrease the core temperature and cause the body to naturally heat itself.
    How?? shivverring are mini-muscle spasms…and is an attempt to warm the body, not good if you have irritated muscles you’re attempting to calm down.
    Now a torn muscles is different.
    You do want to ice initially and this is not clock dependent, rather, how bad is the muscle( and also blood vessel) tear?
    Is the person resting it or continuing to play/work through the injury?
    These answers will determine the proper amount of icing so that you minimize the inflammation process(some is necessary) so the body can progress to the stage of tissue repair.
    Again, this is not exact, it depends on the persons diet…pro-inflammatory diets (red meats, shellfish and dairy) will cause exagerrated inflammatory response and slower healing.
    Someone with a diet low in these things will heal quicker.
    So does ice work,,,absolutely yes!!
    Does heat work…absolutely yes…once the healing starts to occur, the irritation/inflammation response is decreased and the need for fresh oxygenated blood helps to expedite healing.
    Never use dry heat(the old heating pads)…it drys out the tissues and causes the pain fibers to actually become more sensitive and more painful.
    Again, New Englanders know of dry, cracked painful hands in the winter.
    I have not read the article, but anything being published by NBC or any of the big communication companies has to be looked at with a little skepticism. Follow the money trail and ultimately the drug companies own most of the media companies.
    A natural remedy like ice is not beneficial to them where as an anti-inflammatory such as Advil or Aleve rakes in billions for them.
    If they cannot understand the anatomy, physiology and neuro-physiology to begin with?? I don’t think their studies will be designed properly and I sincerely doubt anyone’s understanding of the whole process if they cannot understand why and how ice does work in the first place??
    Just my opinion.

  • Sidney

    I find it ironic that someone who chides the writer of a well-meaning and thoughtful response (ty), saying that he needs to “come correct” and telling him that he needs to “bring a stronger take” would use an admittedly “small-scale randomized trial” as the foundation for his argument. Sorry, but I’m going to trust the guy who knew how to keep his body healthy enough to play 15 years behind the plate before I take the word of a small-scale trial that showed up on Google. Perhaps that trial has some merit (perhaps not) and I do agree that over-icing can do more harm than good in certain instances but to make the blanket statement that Jason Varitek was “wrong” based on the findings of a small-scale trial is preposterous and to use a well-respected teammate as click-bait is just icky. Whatever mathematical formula one chooses to use, 1,488 games behind the plate is definitely greater than “small-scale”.

    • Gabe Kapler

      Sidney,

      Do you know that Jason Varitek is one my favorite teammates ever? Is there any chance that you misinterpreted my tone? I wish Tek were privy to this conversation (I’ll share it with him). Do you find it strange that not a single Red Sox fan on twitter absorbed this in the same fashion as you? Perhaps read this post http://kaplifestyle.com/2014/01/mindful-breathing and then take some deep breaths.

      In any event, I’m sure glad I heard your thoughts. I learned a ton.

      Be well,
      Kap

      Oh, and have a look at this when you have a free moment. Turns out that Google thing is exceptionally useful. Thanks, Stephanie.

      http://stoneathleticmedicine.com/2014/04/rice-the-end-of-an-ice-age/

  • Duane

    Kap how did you manage to stir things up over ICE? ICE?! Funny!

    We use ice for bumps, bruises and minor swellings however our daughter feels that sometimes it doesn’t help and she may be right. she knows her body better then we do. We’re just there to guide and support her. I feel we’re all different and not everything works for everyone. Use what works for you. Kap as usual thanks for sharing your personal life…even the little thing’s. :-)

    Duane

    • Gabe Kapler

      Thanks, Duane. No question, everybody can create the practices that work best for them. No ice for me.

  • Kevin McNeil.
  • http://gravatar.com/christinehart68 christinehart68

    I believe ice has its undeniable benefits but is wayyyy overused in situations it lends no benefit. Since it isn’t harmful…who cares? I say if you like it, use it! If not, don’t! :-) be your own advocate and do what is right for YOUR body! Peace!

  • Kyle G.

    Kap,

    Great post. My dad always talks about today’s medicine like advil that blocks the pain at your brain where Native Americans had medicines that fixed the illness at the source. I’ll be doing a lot less icing this next upcoming season.

  • http://twitter.com/luv041 luv041 (@luv041)

    Kap and Roland,

    This was a very timely discussion that I’ve stumbled upon since I just had a spinal fusion 3 1/2 weeks ago and I’m now sitting attached to my cold compression machine. I suffered from sciatica for 2 years as well as the obvious back pain of a herniated disc and slipped vertebrae. Prior to this I was a slave to my heating pad! Lol. I am soo anxious for this recovery to be over and to get back to working out!!

    Kap…love your blog and loved you on the SOX!!

    All the best,

    ~ chris