By Gavin Buehler
I always cringe inside a little when patients tell me that they have been icing their injuries. Icing injuries is one of those phenomenon things that somehow became a popular generally accepted procedure regardless of the fact that there have never been any conclusive findings to support it. Sure, there are studies that show some aspects of icing “might” be helpful in managing pain or inflammation, but we ice because we believe it is helping us heal. However, most studies conducted to prove that icing could help have ended up proving the opposite with regard to the healing process and found that icing can cause further tissue damage and delay the healing process. So how did it get so popular that we just followed suit like lemmings? Let’s go on a little adventure, shall we?
Where It All Began
The phenomenon can be traced back to Boston, Massachusetts in May of 1962 where 12-year-old Everett Knowles attempted to hop a freight train and had his arm torn off cleanly at the shoulder. Unknowing the severity of his injury, he was rushed to Massachusetts General Hospital where they found the severed limb caught in his jacket sleeve. A replantation (reattachment of a limb) surgery had never been successfully performed prior to this but Doctor Ronald Malt decided that with a perfectly healthy arm and perfectly healthy boy why not give it a shot. Since this had never been done before it took them time to plan how the procedure would be performed and source the appropriate team. The good doctor gave the orders to put the severed limb on ice to prevent it from rapidly decaying, and to compress or tourniquet the wound elevating it above the heart to prevent bleed out. Dr. Malt would lead a team of 12 doctors to carry out the first ever successful replantation surgery.
Of course, this garnered a ton of media attention, and the doctors were asked what steps should be taken if this were to happen again? Well, you must prevent bleed out with minimal activity (rest), compression and elevation of the open wound. Then get the severed limb on ice to prevent decay. This makes perfect sense for a severed limb. However, this interrupts the healing cascade for a typical injury where limbs are not severed, and along the way this procedure got applied to all injuries. In the 1970’s Dr. Gabe Mirkin coined the term RICE and popularized it in his best selling The Sports Medicine Book published in 1978. “RICE is nice,” was born and took off like wildfire!
Dr. Gabe Mirkin has since renounced RICE writing about why it is not the best way to facilitate healing and wrote one of the forwards in Gary Reinl’s anti-icing book Iced! The Illusionary Treatment Option published in 2013, where a lot of the details in this article are sourced from.
What an awesome story right?! Now let’s move on to how the body reacts to an injury, which is knowledge that any registered healthcare provider learned before and after the RICE phenomenon but seemed to negate.
The Healing Cascade
The healing cascade is an overlapping 4-phase process that occurs when we acquire an injury. The four phases are Hemostasis, Inflammation, Proliferation, and Remodelling or Maturation. I won’t get into the full complexities of each phase in this article, but you can find a detailed description here. Basically, your immune system constricts the vessels of the damaged tissue and sends the materials it needs to the injury site to begin clotting to stop the bleeding. The healthy tissues and vessels surrounding the injury site dilate flooding the area with healing properties and nutrients to begin repairs and clean out the waste from the area. Proliferation where new tissues begin to form to replace the damaged ones starts and becomes an ongoing background process and then that tissue begins to remodel back into a more functional state.
Inflammation is thought to be a bad thing that needs to be suppressed, but it is a crucial part of the healing process and needs to occur for healing to take place. IT IS GOING TO HAPPEN NO MATTER WHAT. The issue is not the inflammation but the body’s inability to deal with the congestion in the area from the rapid influx of healing fluid. The system that manages this build up of excess fluid is the passive lymphatic system. The main pumps of this system are muscular contraction and diaphragmatic breathing. We’ll come back to this in a moment.
What RICE Does
If we understand what the body is doing, we can see that RICE is essentially stifling the healing cascade. Ice triggers constriction of all vessels cutting off the good stuff from flowing in. “But it feels good.” It numbs the area for a short period of time but interrupts the healing process suffocating the tissue, creating more damage. And guess what? The inflammation comes back because it must for healing to occur. Compression and elevation of the area do much of the same, preventing the flow of good stuff in and waste out, and if you are inactive, you have no hope of creating a strong enough pump for your lymphatic system to carry out the waste and decongest the area.
What To Do Instead
This would be a good spot to insert the usual disclaimer: As always, this article is for educational purposes only. Please consult a health professional before attempting new exercises or protocols, as the content of this article may or may not be appropriate for you.
The key is not to supress the inflammation, but to manage it more effectively. The way to do that is to decongest the area. That means getting the lymphatic system to pump. Muscular contraction is the most effective way to help pump the lymphatic system, so by contracting and relaxing the healthy tissues around the injury site, the more effectively you can decongest the area. This doesn’t mean do full blown workouts that create more tissue damage. We’re looking for non-fatiguing activity for improved circulation without more damage.
We’ve been accustomed to injuries taking a certain amount of time to heal, but we’ve been blindly using a protocol that has been prolonging the process instead of expediting it. Many professional sports team organizations have adopted the no ice protocol now with a focus on decongesting the site of injury and improving circulation. The results are players recovering in less than half the time that they used to using ice. So it turns out that the old saying of “Walk it off,” might just be the best advice after all.