People, We’ve Got to Stop Icing Injuries. We Were Wrong, Sooo Wrong | Community Video

    08/07/2012 | 84 Comments

      Hey Leopards!

      Ready to slay a sacred cow?

      Here goes. You should stop icing.  We were wrong.  I know.  I’ve even been guilty of advocated for short icing stints on this blog.  I was wrong.  For the past year, I’ve been engaged in a personal moral debate about icing that in retrospect, seems silly if not out right obvious.  We should not ice.  For the last year, I’ve advocated for no icing with every athlete  with whom I’ve helped  either  post-surgery or post-injury.   The outcomes have been nothing short of stunning.  Even  way back in Episode 204, “Donnie Thompson, Strongest Powerlifter Ever, Cares About Your Swelling,” (15 months ago) we started shifting our management of swelling chiefly to compression.  And that was before I met Gary Reinl of Marc Pro.  Every athlete worth his or her salt knows of the old RICE acronym.  And dammit if I wasn’t already hearing and experimenting with reduced icing protocols for the last few years (remember numb and done?).  My problem with NOT icing, I told myself was that I didn’t have other good tools on hand to minimize the pain of swelling (which is the real athlete problem eh?).  As it turned out, the solutions presented themselves (excellent compression apparel, Dick Hartzell’s compression protocol, and the Marc Pro) at the same time that common sense matched up with my own clinical experience and test/retest ethic.  Maybe it was because I finally felt like I had other mechanisms with which to deal with the swelling, that I could resolve the dissonance I had around this outdated modality.  Don’t get me wrong, if you need to make something numb, ice is great.  As Mr. Reinl points out, “Yes, (making something numb is good) if the short-term goal is pain control and the prevention of the body’s normal cellular and vascular response to injury.”

      Let me quote Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal (physsportsmed.com) “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?”

      Well what does the research and  literature say?

      “When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability (lymphatic vessels are ‘dead-end’ tubes which ordinarily help carry excess tissue fluids back into the cardiovascular system). As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics ‘in the wrong direction’ (into the injured area), increasing the amount of local swelling and pressure and potentially contributing to greater pain.” The use of Cryotherapy in Sports Injuries,’ Sports Medicine, Vol. 3. pp. 398-414, 1986

      Or how about this comprehensive literature review from the Journal of Emergency Medicine?

      “Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?” JEM, 2008; Feb. 25; 65–68

      Abstract: Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practiced. This review was conducted to examine the medical literature to investigate if there is evidence  to support an improvement in clinical outcome following the use of ice or cryotherapy.  Methods: A comprehensive literature search was performed and all human and animal trials or systematic reviews pertaining to soft tissue trauma, ice or cryotherapy were assessed. The clinically relevant outcome measures were: (1) a reduction in pain; (2) a reduction in swelling or edema; (3) improved function; or (4) return to participation in normal activity.Results: Six relevant trials in humans were identified, four of which lacked randomization and blinding. There were two wellconducted randomized controlled trials, one showing supportive evidence for the use of a cooling gel and the other not reaching statistical significance. Four animal studies showed that modest cooling reduced edema but excessive or prolonged cooling is damaging. There were two systematic reviews, one of which was inconclusive and the other suggested that ice may hasten return to participation.” Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.

      Look, I know you have iced your body about a billion times.  I also know that it’s hard to resolve the dissonance about potentially retarding your own healing response by doing so.  I personally had a difficult time  slaying this icing error beast until I was confronted directly with the physiology, and my own clinical experience working with surgeries, injuries, and even rhabdo–all without  ice.  It’s hard to fight the drag of orthodoxy.  Why do we do what we do?  Because we always have?  We can do better.  Our goal needs to be to improve adaptation by improving circulation, clearing congestion, and facilitating healing.  Pretty much everyone I know has stopped taking NSAIDS for the same reasoning that we should stop icing.  Let’s kick the ice habit too.

      Here is the interview with the inflammation slayer, Gary Reinl, from the recent Crossfit Games.  Be prepared to have your mind blown.

      So let’s come up with our own new acronym and replace the old, broken RICE model.

      Here is the MWod take:  MCE

      Move safely when you can, what you can. Compress lymphatics and soft tissues (use bands, muscle contraction, clothing, normatec, etc.)  Elevate when you can.  MCE.

      Rest really doesn’t make sense (Don’t flex your broken bone, duh. But do figure out a way to evacuate the swelling left over from the inflammatory cycle.) Ice? No thanks.

      Kstar

      Ps.  My success and experience with the Marc Pro technology was so profound that we talked the company into donating a unit to our wounded warrior brothers and sisters for every six units our community purchased.  If you are interested in this program, please email Troy Willis, troy@crossfitcowboy.com.  During your check out at Marc Pro, use the code “Kstar” and you will receive a small discount and have your purchase counted toward our wounded warriors.

      pps.  Gary, thanks.

      Here is a free video showing how to use Voodoo Floss compression to treat injuries.

      Here is a 3-part primer series on Voodoo Floss. (must be a pro subscriber to view)

      Voodoo Floss Part I
      Voodoo Floss Part II
      Voodoo Floss Part III

      In this video: Kelly Starrett discusses injury rehab with Gary Reinl, why we should stop icing injuries and more.

    • Injury

84 thoughts on “People, We’ve Got to Stop Icing Injuries. We Were Wrong, Sooo Wrong | Community Video

  1. jbizzzle

    Any instances which you do NOT do this technique? Ie : diabetes, PVD, neuropathy, infected wound, etc. Also, would you be so bold to do this on a 24-72 hour post op RCR or ACL repair?

    Reply
  2. Clmckin

    What do you think about Prolotherapy “re-initiating the inflammatory process” for a chronic issue to aid in healing?

    Reply
    1. anthony frangos

      I have inflammation from TMJ ( a jaw misalignment causing muscle strain and inflammation ) You can see the inflammation on the side of my face. This is causing fullness and pain in my ear and throughout the day the pain radiates to my head and neck . Would massaging the area be the protocol? Please help!

      Reply
      1. karla brawley

        anthony – you need to have that tmjd looked at by a licensed massage therapist who specializes in tmj dysfunction and can address your issue safely by doing intraoral massage. not many lmts are practiced up in this technique (i only know this because i am one and i have spent many many hours studying the function of the tmj and how to relieve issues such as the one you’re having). ask around, start with dentists. don’t think the issue will go away with external massage only, but it’s a place to start. i know you posted this a while ago, and i hope you’ve gotten relief since. best of luck!

        Reply
        1. DGoodman

          Try Bowen Therapy. In the USA it is called Bowenwork. See Bowenworkusa.com to find a Practitioner. We have a specific procedure for TMJ. It works great. Bowen therapy originated in Australia and has been in the USA since 1989. It uses the ANS to aid the body in healing itself.

          Reply
  3. Cynthia Robertson

    thank you for much for the information in the video. Our son is a sprinter and after each practice and meet, he has been getting ice wraps from the High school trainer. Three weeks ago, the trainer did an ice wrap to the back left leg at he bend of the knee “backside” he started to feel tingling and numbness and told the trainer. The trainer told him to keep the ice wrap on. Well, it’s been three weeks and the numbness and tingling is still there. He has to have an EMG done to tell where the nerve and muscle damage might. I just pray it will return soon. He also runs summer track, but has not been able to train, practice or compete. Thanks again

    Reply
    1. Marcus

      That may be a mistake on the trainer’s part – not an icing issue. there are standard areas not to put ice directly over due to the superficial nerve pathways

      Reply
  4. Shiloh

    I just wish to contribute that I always sensed this. As a kid I remember instinctively not wanting to ice my wounds, and all the adults clamoring for me to do so.

    Reply
  5. Michael

    If you have swelling in the lower back, how would you flush the area of congestion? I’m assuming you don’t wrap your torso in a voodoo band?

    Reply
  6. Tobi Opunui

    Ibuprofen has an antiplatelet effect, though relatively mild and somewhat short-lived compared with aspirin or prescription antiplatelet drugs. In general, ibuprofen also acts as a vasoconstrictor.’`:^

    View all of the best and newest write-up at our personal internet site http://www.healthfitnessbook.comdt

    Reply
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  11. Salina Boyer

    I JUST stopped using ice and replaced it with the VES Edge recovery system. Wow what a difference. I can actually sit on the toilet after a wod where i focus on legs haha. I used to try and sit in ice but it was soooooo cold i couldnt get used to it. I wish you would have written this last year. Note: i have no affiliation with ves. I chose this system because i saw Camille Leblanc-Bazinet using it in a youtube vid about how she recovers. ive only had it for a couple days now.

    Reply
  12. Josh Stone

    Hey Kelly –

    I recently wrote a blog on the overuse of Ice. It sparked a lot of debate and surprisingly angered a few. One individual commented and shared this video. I have utmost respect for the vision and knowledge you share. So I was happy to hear we have the same feelings on this subject. Kudos and keep up the great work.

    Cheers

    Reply
  13. David Gruhl

    Hi guys,
    Im studying to be a podiatrist down in Australia and Gary’s comment at the end about using the MARC PRO at a treatment protocol for a (PAD) gangrenous foot i found particularly interesting. I was wondering whether there was is a article that has been produced by the surgeons involved.
    Cheers (love your stuff)
    David

    Reply
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  17. carolyn o

    You need a proper presenter. Both of you are running your words together to the point that you’re almost impossible to understand. Please put a video together that everyone can use. I (sort of) get what you’re trying to say, but the poor audio quality and lack of enunciation (on both parts) make your message lost for those of us who need the info. Tx.

    Reply
  18. Cory

    With all the information above on acute inflammation, what is your stance on the idea of an anti-inflammatory diet, and more specifically, the daily use of fish oil supplements as an anti-inflammatory aid?

    There seems to be a growing number of advocates in support of an anti-inflammatory diet to prevent chronic inflammation in the body. The idea behind the diet is that chronic inflammation contributes to the development of some diseases. It seems to me that daily use of fish oil to treat chronic inflammation would inhibit the body’s natural inflammatory response when an acute injury is suffered, therefore negatively affecting the healing/recovery process. Would one then simply stop taking the fish oil if an acute injury is suffered to promote an inflammatory response?

    Also, as it is constantly referred to as acute ‘injury’, does this include natural muscle breakdown during exercise? I noticed a few comments above in regards to icing after a workout, but I am mixed up as to if inflammation is caused from a natural break down of the muscles during a work out. How is to one to distinguish soreness due to inflammation from soreness due to lactic acid buildup?

    Best Regards,
    Cory

    Reply
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  23. Karim

    I broke my ankle in December of 2012 and it immoible for 2-3 months. I completed PT in April and have been working out since. Squatting causes swelling and tightness. My wife purchased a muscle stimulator but i have not used it and I continue icing. Should I use this muscle stimulator instead of icing?

    Thanks,

    Karim

    Reply
  24. jesper hansen

    You’re saying a lot of right things, but you’re making some wrong conclusions. The problem is that you’re too enthusiastic and just winding yourself up about the wrong things. Ice is not bad or wrong. It’s not cancelling all the other steps in the RICEM model. You just need to know how to apply things properly!

    Reply
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  30. Sam A

    I had a question if someone would mind answering.
    So I understand why icing shouldn’t be used for soft tissue injury treatment.
    However, what is the point of elevation and compression when it comes to treatment? What physiological advantages do they provide when performed?

    Thanks!

    Reply
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  34. Parker Brown

    So…I buy into what you’e saying and I’ve sent it to all the Physical Therapists I’ve ever shadowed, but I have a question. I have a mild case of Cerebral Palsy and had Osgood Schlatter’s when I played basketball baseball football and golf in high school. The only thing that helped my pain was putting ice on the knots of my knees about 20 minutes before practice. According to this, is it OK to use ice for pain? Thanks

    parker

    Reply
  35. Pingback: Why Ice and Anti-inflammatory Medication is NOT the Answer | Athletic Medicine

  36. Athletic Trainer

    Thanks for the video! Just wanted to point out that while ICE does reverse lymphatic flow, cryotherapy above 50degF does not. I personally recommend cryotherapy at 50-65degF (10-20degC) which reduces pain and secondary metabolic injury and causes vasoconstriction but preserves lymphatic drainage. In my practice I encourage cryotherapy immediately post workout then active recovery from workouts and chronic injury within 24-48h. Acute injury follows similarly (protecting the injured tissue asside) with cryokinetics in the short phase then heat after.

    $0.02

    Reply
    1. Brian LAT

      Secondary metabolic injury is never addressed in this conversation. Thank you for bringing it up. The whole time I was thinking my goal with ice is to decrease further injury to adjacent cells/tissue. Ice decreases the metabolic demand and allows cells to survive despite the disruption of nutrients. (much like a heart put on ice when transported as a donated organ). Dr. Kenneth Knight has done a lot of work looking at this. I will definitely look into the range of temperature to preserve lymphatic drainage. My recommendation is also to only use ice for first 24 – 48 hrs with acute injuries. I think that is the key. I also use the term active rest. This helps athletes, especially runners, understand they can’t go run 3 miles but they do need to be working on something (ROM and muscle activation).
      Lastly, it is very annoying when people use the term trainer. PLEASE specify who exactly, is it a Licensed Athletic Trainer, personal trainer, or other.

      Reply
    2. Tim - Athletic Trainer

      As a certified and licensed athletic trainer, I use cryotherapy in my practice. I agree with a lot of things said in this video about lymphatic drainage and the inflammatory cascade being how your body naturally heals. Inflammation is how the body deals with injuries itself and shouldn’t be shut off with NSAIDS immediately post injury. However I do disagree with that fact that we shouldn’t control the amount of inflammation, more specifically, around the area that was injured. What I don’t want to have happen is more tissue damage from secondary hypoxic injury in tissue that was unaffected from the initial injury. If the swelling is choking off proper nutrition to healthy tissues in proximity to the injured area, that is a problem and will result in greater tissue damage than what was initially injured.

      Reply
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  40. Christian

    I am a rock climber and run a climbing gym. I have recently come down with a chronic case of tendinitis in both elbows — anterior side or tennis elbow. I believe I acquired this problem, not from climbing specifically, but from kipping pull-ups at cross-fit. Most likely the combo of climbing and cross-fit did me in — unfortunately. So, my question is will this philosophy work on my elbows? I have been using the smash and floss concept using a foam roller and lacrosse ball, cross friction, etc heat AND ice. This has brought some relieve enough to get me climbing again. But, not full recovery. I did take a total of 6 months off from everything! But, as soon as I started working out with minimal arms oriented exercises the main returned! Anyone have any advice?

    Reply
    1. David Russ

      Christian,
      I had nearly the same issue (due to climbing and kayaking). I dealt with it for years… it would go away if I stayed off it but as soon as I started really using it again the aching would come back. I tried all the stretching/icing etcetera I could think of in and around my elbow but nothing worked. I had pretty much resigned myself to just dealing with it but one day I brought it up with my Master Swim coach and described the issue and she suggested the following stretch/mobility work. ….To be clear I am not a PT… but she had me do the following work on my shoulder and my problem cleared right up…..Lay on my back and let the back my arms (tricepses) rest on the ground with my forarms and hands pointed at the ceiling. (upper arms 90 degree to body but still on ground) (lower arms 90 degrees to upper arm). From this start position slowly rotate your arm from the shoulder but keeping both of the 90 degree bends. Rotate both directions (palms approaching floor/back of hands approaching floor). A couple days of doing this and the aching went away. Hope this helps..

      Reply
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  43. JR

    So I understand your point is that people should stop icing after injury, but what if the injury is specifically inflammation like tendonitis. Are Nsaids and icing still not suitable?

    Reply
  44. Mike

    This video is not conclusive. If you take the time to read the articles in full that are referenced they all point to evidence that ICING IS IMPORTANT. The actual conclusions of these articles is that icing for more than 10 or 15 minutes at a time is bad. Increasing icing time above these time limits does increase lymphatic drainage and permeability as well as increase blood flow to the area from the normal circulation. The articles argue that icing immediately for 10 minutes and waiting 30 or so minutes before icing again is important and helps speed up healing of the acutely injured area. None of these articles discuss chronic pain and swelling but research out there suggests that for chronic pain and swelling, ice helps with pain control. It is not clear at this point whether or not ice helps the healing process or not of chronically inflamed tissue.
    Icing is still important. Icing for long periods of time is not helpful and research suggests can be harmful. Ice for 10 minutes at a time with at least 30 minutes between icing sessions for the first 24-48 hours after acute injury.

    Reply
  45. Joe Ortiz

    I am a 25 year old firefighter with multiple trauma from craniotomy from a subdural hematoma to my most recent surgery (Feb 10th 2014, a Right SC(Sternoclavicular) Joint reconstruction/replacement) my Surgen is the chief of orthopedics at NYU. I’m on Diclofenac SOD 75mg Tab 2x Daily for the swelling, should I continue to take this (after watching your video and my own experience of being able to take them like tic tacks and feel little to no difference in pain level has me questioning the clinical medicine way of thinking. A short summary of my medical history is I’ve had 15 surgeries (including the latest SC Joint surgery, 2 posterior labrum tare reconstructions (done most recently by my current orthopedic Dr.), distal clavicle excision, 4 Left knee operations (ACL replacement, 2LCL replacements, and hardware removal), Bilateral elbow and wrist surgeries to fist the Senovial Sheath in the right wrist, and left wrist to fix the TFT Cartilage (the shock absorber disk separating the hand from the forearm), both elbows were arthroscopic surgeries to remove torn cartilage that was getting caught in the joint itself I believe. Minor plastic surgery to reattach he right ear the night of my injury, and bilateral TMJ Disc Replacement done by the surgeon who invented both the surgery and prosthesis he put in (Dr. David Behrman).
    I just was wondering with all my trauma if you had any suggestions to thing that can be done for me to heal faster than I have been because I unfortunately know it’s a slow lengthy process that at time feels like it’s just drawn out.

    Reply
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  49. Jacob Leivent

    Almost every single “scientific” statement that this this supposed “expert” makes is false. The connection between muscles and nerves has NOTHING to do with the inflammatory cascade at the cellular level. Macrophages??? Macrophages have nothing to do with the inflammatory response in injured tissue. Prostoglandins and leukotrienes are involved, histamine and bradykinin are involved. “Macrophages and IGF-1″…excuse me…what the FU-K are you saying? Lymph drainage into the interstitial space is dependent on hydrostatic pressure and osmotic gradients. How is it that ice causes back-up into then interstitial space?? Oh right, it doesnt. I am unsure how K-Star can bring this guy in and call him an expert? Does he have a degree in Biochemistry, Medicine…ANYTHING?? He uses a lot of big words that the general Crossfit audience will be impressed by. Unfortunately this entire video is a crock.

    Reply
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  51. Gary

    I’ve had Sciatica from herniated discs that I keep banging. After 10 months of extreme pain, this last time I banged it, I used ice, and it has been the only thing that helps. fyi.

    Reply
  52. DaMon Bowens

    I feel like this was a greatly interesting video!! How would you know where to put the stim patches?

    Reply
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  60. Paul Melis

    Anthony, your TMJ is due to a brainstem injury, the correct person to deal with this is a NUCCA Practitioner, he will measure the position of your head on your body, and correct it, Your jaw is not tracking correctly because of this, and, I can almost guarantee that you have other bodily symptoms or problems ALL thanks to ASCS Atlas Subluxation Complex Syndrome. I can attest to this because My TMJ problem was very bad, and I am healed from this ONLY because of NUCCA.org. Forget your dentist, or Massage therapist.. Go straight to this website, and source out the person closest to you practicing this.

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  66. Bryan Zevotek

    I am curious if low to moderate icing can actually enhance the initial stages of the inflammatory response / ie blood flow (due to the homeopathic desire to warm the tissue).

    Reply
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  68. joe

    I fractured my heel as a Drill Instructor in the Marine Corps. I went and still currently am going through physical therapy to get the muscles, tendon, and tissues back in shape. I had surgery where they cut the tendon a little bit too relieve pressure and some pain. It worked to an extent. However, I still feel alot if pain and soreness on the inside of my left foot and its very sore. After physical therapy..they apply ice and put some shock pads on it for 15 minutes. My question is..are they doing the right thing? What else can I do to get the tissues and tendons rebuilt and stronger?

    Reply
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  72. Martini

    The article says:

    ‘Let me quote Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal (physsportsmed.com) “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?”’

    Yet if you go to Dr. Nick DiNubile’s website, you will find that he says the following:

    Both ice and heat are very effective in the treatment of both acute and chronic orthopaedic and sports medicine problems. Both affect circulation deep in your tissues, muscles and joints. I prefer ice for any acute injury where there is swelling. I do not tell athletes or patients to switch over to heat automatically after 48 hours but rather have them continue to use ice as long as there is swelling after an acute injury.
    http://www.drnick.com/wp/faqs/ice-or-heat-after-injury/

    It seems that they are taking the words of an authority figure out of context to make it seem that he agrees with the recommendations in the article and video.

    Reply
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