:: Dr. Victor J. Runco ::

ICE vs. NO ICE  

We have all heard the old sports medicine mnemonic “RICE”.  It stands for Rest, Ice, Compression and Elevation.  These simple but sometimes effective concepts are meant to be applied following TRAUMATIC sports injuries.  Recently the sports medicine community has challenged the value of icing following injury and especially the value of icing a CHRONIC injury.  Preventing injury is a topic that is studied intensely in the sports medicine community and would have great value to a triathtlete in their quest to complete their training and ultimately their event without injury.  In this article we will examine the current research regarding ice in the treatment of sports injuries.

 I think we would all agree that icing your legs prior to training will not prevent injury.  This concept requires some clarification.  While it may not prevent injury in an UNINJURED runner it may help lessen swelling and pain in an INJURED runner. Taking Tylenol may help lesson pain in an INJURED runner but obviously would not prevent injury in an UNINJURED runner.  So when should an injured athlete utilize ice, when should one utilize heat and when should an athlete seek out medical advice?  To better understand when and what an INJURED athlete should do we need to examine the physiology of sports injuries to better understand which therapeutic interventions would be effective.

Athletic injuries present in two different ways.  Traumatic injury (falling off your bike, breaking bones, muscle tearing) and Non-Traumatic (repetitive motion injuries, swimming, running and biking).  Traumatic injuries differ from Non-Traumatic in that they result from a moment in time and the athlete knows exactly when and how the injury occurred.  This usually results in immediate pain, swelling and redness or black and blue. 

Non-traumatic injuries are usually more difficult for an athlete to pinpoint as to when the problem began.  The pain usually occurs only during specific movements like running.  These injuries rarely result in swelling, redness or black and blue which indicate that the injury is not necessarily inflamed.  The notion that injured tissues (ligaments, tendons and muscle) can be painful but are not inflamed is not a new one.  It clearly explains why some athletes take an anti-inflammatory agent like Ibuprofen and feel no relief from his/her injury.  If inflammation was present the drug would suppress it.  Since there was no relief there was no inflammation!  If there is no inflammation then therapies that are intended to reduce inflammation, like ice, would not be effective and may be detrimental to recovery and delay healing.

  In a recent study appearing in the Journal Medicine and Science In Sports and Exercise, July 2008, a group of British Physiologists reported that “As muscle damage is a normal repercussion of strenuous training, then athletes need to avoid chronically overloading muscle tissue to maintain the quality of their training and competition performance or find a way of shortening bouts of recovery between exercise.  UNDERTAKING CONTRAST BATHING PROTOCOL OR ICING IMMEDIATELY FOLLOWING A HARD TRAINING SESSION WILL ADD A SIGNIFICANT DISTURBANCE TO AN ATHLETES LIFESTYLE.  THE RESULTS OF THIS STUDY SUGGEST THAT THE BENEFITS FROM SUCH EFFORTS REMAIN MISUNDERSTOOD AND OVEREMPHASIZED”.  In the Journal of Athletic Training, September 2004, Tricia Hubbard and Craig Denegar reported on the clinical evidence for cryotherapy (ice).  They reviewed 22 eligible clinical controlled trials that utilized ice to help treat various ACUTE, TRAUMATIC injuries.  All studies reported the use of ice following only TRAUMATIC injury.  The author’s conclusion was “ice seems to be effective in reducing pain but has not been shown to improve treatment outcomes”.  This means that you CAN ice an ACUTE injury but it will not necessarily help you recover faster.  The American Journal of Sports Medicine in 2004 also reported on “The Use of Ice in the Treatment of ACUTE Soft-Tissue Injury”.  They also reported that to date (2004) there were only 22 studies that met sports medicine criteria.  The following is a summary of their findings;

1. There is marginal evidence that ice plus exercise is most effective, after ANKLE SPRAIN AND POSTSURGERY.

    

2. There was little to no evidence to suggest that the addition of ice to compression had any significant effect.

    

3. Few studies assessed the effectiveness of ice on soft-tissue injury.

    

4. There was no evidence of optimal mode or duration of treatment.

    

A careful review of their findings is necessary.  It is important to note that there is no evidence that ice is effective in the treatment of Non-Traumatic soft tissue injuries which happen to be the type typically suffered in the running and triathtlete community.  Using ice to treat a repetitive motion injury simply does not make sense unless the athlete was not going to be performing the repetitive motion again.  For example; if a runner has shin splints and ice their legs only to continue to run they are adding a “significant disturbance to their lifestyle” and are not helping themselves in the long term.  Even if the ice was helping to reduce their pain because they continue to run, they continue

re-injuring themselves.  Imagine this example; you bang your head by accident against a low door overhang.  You apply ice to the swollen bump.  It reduces the pain and maybe some of the swelling and hopefully you do not plan on banging your head on that door overhang again.  This would be an intelligent, judicious use of ice.  Now imagine that you plan on banging your head on that same door overhang for the equivalent of 30 miles per week.  In-between “banging” sessions you ice.  What is the point!  You are only going to do it again.  A better solution might be to place a pillow between your head and the wall!  This seems like common sense yet many athletes fall into the trap of icing their Non-Traumatic injury. 

So let’s say you suffer a traumatic injury and would like to apply ice.  How long should you apply it?  This is an important question that has been answered.  According to the American Journal of Sports Medicine ice may be used for Traumatic injuries in the immediate phase of injury (0-72 hours) management to reduce tissue metabolism, thereby minimizing cell injury and swelling and seems to be most effective when combined with compression.  It should not be applied directly to the skin and application should not exceed 20 minute increments.  Ice should not be used in the treatment of repetitive motion injuries resulting from excessive training, faulty biomechanics or simply poor choice of footwear.  When an athlete suffers from a repetitive motion injury they should ask “if it is a repetitive strain due to excessive training why did I only get it on my left side”?  Since you rode with both knees or ran with both legs, if the injury was due to repetitive motion only then you should have the problem on both sides.  When an injury presents on one side only and is NON-Traumatic it usually indicates abnormal biomechanics.  Rather than icing and continuing to train and worsen the condition the athlete should examine their training schedule, the terrain they trained on, their seat and handlebar height and their shoes.  If they are still unclear as to what is causing their condition they should seek out a knowledgeable DOCTOR, that is a runner/triathtlete.  They should help the athlete examine their training program, bike fit, running form and shoes and help to eliminate all the potential causative variables and only then supply a proper diagnosis and effective intervention.  A doctor who prescribes rest, ice and Ibuprofen and who is not a runner/triathtlete will typically not help the athlete but may contribute to the worsening of the condition and prevent the athlete from performing in competition.

The sports mnemonic “RICE” which stands for Rest, Ice, Compression and Elevation was intended for treatment of ACUTE, TRAUMATIC injury not CHRONIC, NON-TRAUMATIC injuries.  The use of ice in the treatment of non-traumatic injuries is of little to no value and places a burden on the athlete resulting in no benefit.  If an athlete suffers a Traumatic injury they should apply ice with compression if possible in the first 0-72 hours only and potentially seek the advice of a Doctor.  If on the other hand the athlete is suffering from a chronic, overuse condition they should examine all of the possible variables from bike fit to shoe fit to see if something has changed thus negatively impacting their biomechanics resulting in a biomechanical injury.  If the problem persists they should seek the help of a DOCTOR who is also a runner/triathtlete to receive an accurate diagnosis and solutions to their condition.

Dr. Victor J. Runco is a Certified Chiropractic Sports Kinesiologist, Certified Strength and Conditioning Specialist and Ultra-Marathon runner.  In addition he is the owner of the San Diego Running Institute.  To date he has completed 12 marathons in 9 states and 3 Ultra-Marathons.  He maintains his private practice in Mission Valley focusing on the treatment of Running, biking and swimming related injuries.