Today we’re going to get into some health mythbusting, and we are going to be busting the stubborn myth of icing an injury. This is such an important one to raise awareness about, as it’s so entrenched in the mainstream medical field – and it’s often the first thing that many of us will think to do when we injure ourselves, or if we’re recovering from certain surgeries. But despite it being so prevalent, unfortunately icing an injury not only lacks any evidence of benefit, but we are also seeing clear evidence of harm, in its delay and slowing of healing. Icing is directly contradicting our understanding of how the body heals, from both an Eastern and a Western perspective. It’s really important to bust this myth apart, so let’s get into it.
When did the idea of icing become so common in the first place? Well, the widespread idea of icing an injury dates back to the 1970s ,and it was bedded down in the acronym (many of us who are a little older might remember) RICE, which was the standard first aid treatment for injuries. RICE stands for Rest, Ice, Compression, Elevation, and itwas established as best practice back in the seventies and eighties. The term RICE was coined by the sports doctor and fitness guru, Dr. Gabe Mirkin, and the idea of RICE as the first-line treatment was further spread in his bestselling title Sportsmedicine. Now since then, Dr. Mirkin has realised that icing an injury is actually harmful – not helpful – and I really admire his openmindedness and ability to admit that he was wrong. This is the scientific method and a spirit of inquiry in action, which unfortunately doesn’t always inform the advice and practice guidelines out there. So it’s really awesome to see Dr. Mirkin being openminded and continually updating his knowledge and approach. As Dr. Mirkin says “RICE is something that just stuck and it’s wrong”.
Meanwhile, in many traditional medicines, for thousands of years the standard treatment for injury is the opposite of icing. We use varying treatments that will promote circulation and the growth of new tissue, and we do this with modalities such as acupuncture, cupping therapy (which had its moment in the limelight a couple of years ago with a lot of the Olympic athletes sporting the big dark spots on their backs, and it’s also been seen gracing the red carpet!), heat therapy – whether in the form of infrared heat lamp (which feels amazing!) or moxa. Moxa is also known as moxibustion: this is an ancient practice that involves the burning of mugwort and certain other herbs which release volatile oils – these are burnt near the skin and provide a gentle, warm feeling. It feels amazing and it speeds up recovery of topical injuries, even things like insect bites, and certainly feels really lovely for arthritis and pain conditions as well. So with all of these modalities, we’re looking at improving circulation and promoting new tissue growth. We also do that with both topical and internal herbal medicines that promote recovery. Some of these herbal liniments in particular have been fine-tuned by Kung Fu fighting Shaolin monks in China. These guys have had ample opportunities over the centuries to observe the effects of herbal medicine for a vast array of training injuries, so these liniments have been tried and tested over millennia.
So where did we get the idea in the West that ice could be helpful in injuries? Well, first let’s have a look at what happens when we do injure ourselves. When that happens, whether it’s a cut, a sprain, a bruise, a fracture, a herniated disc and so on, the body mobilizes its innate healing defense system, which is characterized by inflammation. And I touched on this in some early episodes, but the process of inflammation is commonly characterized by four qualities that many of us (who have had perhaps a sprained ankle or a pulled muscle or cut ourselves) would be well familiar with. These are redness, heat, pain and swelling, and these qualities are uncomfortable and undesirable in some ways, but they’re side effects of the healing work that the body is taking care of behind the scenes. They’re an essential part of healing!
The redness that we see is a result of the dilation (or the opening up) of the smaller blood vessels near the injury, and increased blood flow to the area: this allows the flushing out of debris, allows us to deal with any bacteria or immunological threats and allows for tissue healing. The heat that is characteristic of inflammation is similarly due to increased blood flow in the area, as well as arising from some chemicals that the body releases in order to start healing the injured space. The swelling arises from additional fluid that rushes to the area, and this fluid contains white blood cells (amongst other biochemicals that the body needs to heal and protect the injured area). Together with other chemicals released by the body’s defense system, these fluids also contribute to the fourth quality, which is pain. So this understanding of why the side effects of pain, redness, heat, and swelling are occurring, helps us to see that even though it’s uncomfortable and a nuisance and it slows us down, inflammation is a fundamental and necessary step to healing. Therefore any interventions that we can apply to support this process will speed healing and allow more complete recovery, while anything that we do to hinder this can delay, or even permanently affect, healing.
Back in the seventies, when people realized that putting ice on an injury could cut down pain and swelling, icing was implemented to get injured athletes back on the field immediately after an injury. From there, the idea became more and more widespread. To the point where the idea of ice bathing or cold water bathing after training is now incorrectly and widely believed to be helpful. Pain and swelling are the body’s way of immobilizing an area, so that we can’t do any further damage to it, so therefore icing an injury will certainly stop the pain signal (allowing a sports person to get back out on the court, or allow them a few more minutes on the field), but by slowing that pain signal, it’s going to take away the body’s innate warning mechanism to prevent further loading and damage to the area. So it’s absolutely going to slow down healing in the long run! And this understanding has been backed up by a whole spate of studies that I’ve listed in the show notes. These show that there were no objective benefits to cryotherapy or icing, and in fact that it delays healing. The only noted change was that people were able to use the effected area more intensely after 24 hours of icing, but again, this is just due to inhibiting that important protective (and essential) pain signal that protects us from overusing an injured area. The same study confirmed no measurable actual benefits, or long term benefits, in healing. So we need to ask ourselves: is short term pain reduction a parameter that we want to use when we consider the best approach to healing an injury? It is literally short term gain for long term pain!
On a subconscious level, we understand that icing slows things down. It’s even in our common expression of “putting something on ice”, meaning to delay or postpone or shelve something indefinitely. And again, this is what we are literally doing to the healing and optimal function of the injured area. This extends also to the use of nonsteroidal antiinflammatory drugs (NSAIDs) like Voltaren and ibuprofen – whether they’re used orally or topically as a gel. The name of the drug says it all: they are anti-inflammatories, so they deal with pain and swelling by shutting down inflammation – but at the cost of long term recovery. Likewise, cortisone, which is another popular intervention, both orally and injected into joints, similarly stops healing. There is ample evidence regarding how cortisone and other steroidal anti-inflammatories inhibit the production of healing tissue. In fact, tendon surgeon, Professor Hakan Alfredson described in a British Medical Journal (BMJ) podcast recently, how multiple cortisone shots into an area can lead to dead tissue, reduced healing and wound breakdown. Two other studies, published in Radiology and Skeletal Radiology, just last year discuss observing accelerated progression of osteoarthritis, complications with joint and bone destruction and death, bone loss, stress fratctues, and also collapse of the femoral head (which is the head of the hipbone). So all these interventions are providing potential short term pain reduction, but with a long term loss of function and degradation of the tissue.
Chinese Medicine is the original functional medicine. It has always been focused on addressing the root cause of a presenting complaint. As we see it, healthy function stems from healthy flow and circulation, and the communication of all the body systems. As one of my teachers very memorably pointed out: the difference between a live body and a dead one is heat. It’s the spark of life! And when we die, the first thing that stops is movement, so let’s not shut down that vital movement – or “spark of life” – with cold. Let’s preserve it and support it, with supportive therapies. Our bodies are sending out this message too; often when I mention to my patients the difference between heat and ice therapy, they tell me already how unpleasant icing an area feels, and how when they switch to putting a heat pack on something (or we put the infrared heat lamp over an area) their bodies literally breathe a sigh of relief because it feels good! The body has been sending a message – our bodies are wise, and they’re constantly in communication with us, we just need to listen.
So how do we go about healing injuries in Chinese Medicine? Well, firstly we protect the area from further injury. By resting it, this means giving the body essential time that it needs to heal from the root up. And it means we need to be patient, and we may need to introduce changes in how we go about our daily lives: certainly we’ll have to look at how we exercise as well. There are no lasting quick fixes! So for something like a herniated disc, for example, avoiding loadbearing may be necessary for months. But the benefit is that it offers the body the space that it needs to heal comprehensively, and from the ground up. Secondly, in Chinese Medicine, we will use technologies and interventions that support the flow and circulation of essential biochemicals, fluid and blood to the area to support the healing process. In Chinese Medicine, we work with the inflammatory process, rather than directly heading-off against it – as with ice or nonsteroidal anti-inflammatories (the ibuprofens and Voltarens of the world). Depending on the injury, we will use acupuncture – and in areas that are really swollen or aggravated, the acupuncture doesn’t even need to be local to the injury to create change; often we use the body’s innately holistic structure by choosing points away from the inflamed area. In addition to acupuncture, we can also look at cupping therapy to gently move blocked or congested areas. W,e’ll look at the application of heat, as I mentioned, via infrared heat lamp and moxa. We’ll look at the application of herbal liniments and plasters. And internal herbal medicines. There’s lots of research out there on the beneficial effects of herbs, which are innately warming and circulation-promoting: in Chinese Medicine, these herbs are referred to as “warming” and “moving”. and these are things like cinnamon and ginger. There’s a lot of evidence out there looking at the beneficial effects of these kinds of herbs for delayed onset muscle soreness (DOMS), muscle fatigue, etc. These are herbs that we’ve been using in millennia in our herbal formulas for a whole range of pain and inflammatory presentations, from arthritis to muscular fatigue.
And finally in Chinese Medicine, we’ll also incorporate some gentle passive (and eventually, active) movement to encourage blood and lymphatic flow and drainage, and this movement will be customized for each patient depending on where their body is at. I also like to link this with breath and meditation for extra benefits! When we meditate, we allow our body to switch into the parasympathetic nervous system (PNS) mode, which is also known as the rest-digest-repair-and-heal mode. So when we drop into this space, we get out of the way of the body’s essential healing work: we let it get down to business. A dietary tweak you can also incorporate for healing is eliminating inflammatory foods: I touched on this a little bit in earlier episodes. These are foods that will disrupt the body’s healing system, and add to the inflammatory load. If you eat meat, you can also add bone broth, or grass-fed gelatin powder as a daily supplement. These important foods provide the building blocks for a whole range of body tissues from tendon to bone, to cartilage and skin. Plus it has the added cosmetic benefits of beautifying skin, hair and nails, and the health benefits of adding integrity to the gut lining. So it’s such a great all round supplement! It’s so important too, because in our modern culture we’ve tended to embrace more of the muscle meats, and we turn away from gristle (which is effectively what collagen and gelatin is) – it’s that connective tissue that’s so essential to our healing. It also contains amino acids that might not be present in muscle meats, so it’s important to incorporate bone broth (or gelatin, or gristle if you’re doing slow cooks) into your diet for a balanced amino acid profile.
So that’s how we approach things from a Chinese Medicine perspective, and it’s so great to see this being picked up in the medical field. Recently, just last year, the British Medical Journal, which is one of the peak publications in Western medicine, published the following guidelines for soft tissue recovery and they’ve used the lovely acronym, PEACE and LOVE. PEACE talks about the immediate interventions: P stands for Protect; Elevate to promote more drainage; A is avoid anti-inflammatory modalities like the non-steroidals that we talked about (and ice); then we’ve got compress, and E is educate about active recovery – and in their words, and echoing our approach in Chinese Medicine, they said “setting realistic expectations with patients about recovery times instead of chasing the magic treatment approach”. True healing takes time: we can’t rush it and we’ve got to be supportive of the process for the individual.
The second acronym, LOVE, is applied after the initial phase, and it involves L for mild Load to allow the tissues to strengthen under pressure; Optimism, and this taps into the meditation aspect – when we have a positive mindset, we’re more likely to be in that parasympathetic nervous system mode, which is that rest-digest-repair-and-heal mode; V is for vascularization – promoting new blood vessel growth and vessel profusion through the area; and finally E is for targeted Exercises to strengthen the area. So that’s fantastic, and so in line with Chinese Medicine ideas about healing injuries! Ten years ago prior to these latest PEACE and LOVE recommendations, the physiologist John Paul Cantazaro started applying a similar approach with his clients. He used the acronym METH, which is a very memorable (!) and stands for Movement, Elevation, Traction, and Heat.
It’s really great to see these traditional medicine ideas coming through into the present, and informing best practice! I hope this has been helpful, and that it’s helped bust some myths. As always, I’d love to answer any questions you might have – or bust any further myths you might have burning curiosity about! So please get in touch with me with those on Insta, Facebook, or via my website. Thanks so much for listening and wishing you the very best of health.
Research & Links
Alfredson H. Treating tendinopathy with Professor Hakan Alfredson. BMJ Talk Medicine. 2013.
Hohenauer E, Taeymans J, Baeyens JP, Clarys P nad Clijsen R (2015)The Effect of Post-Exercise Cryotherapy on Recovery Characteristics: A Systematic Review and Meta-Analysis, PLoS One 10(9), published online September 28th, 2015
Kijowski R (2019) Risks and Benefits of Intra-articular Corticosteroid Injection for Treatment of Osteoarthritis: What Radiologists and Patients Need to Know. Radiology, Published Online: Oct 15 2019
Kompel, AJ, Roemer, FW, Murakami AM, Diaz LE, Crema MD and Guermazi A (2019)
Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?Radiology, Published Online: Oct 15 2019
Lorenzen I. The Effects of the Glucocorticoids On Connective Tissue. Acta Medica Scandinavica. 1969;185:17-20.
McCormack J. “Mythbuster” on NSAIDs in sports medicine, challenging nutrition dogma, and evidence-based practice. BMJ Talk Medicine, 2014.
Mirkin G. Why Ice Delays Recovery. Dr. Gabe Mirkin on Health, Fitness and Nutrition blog. Updated October 13, 2016
Paddington-Jones DJ, Quigley BM. Effect of Cryotherapy on muscle soreness and strength following eccentric exercise. International Journal of Sports Medicine, 1997. 18:588-193
Reinl, G: Iced! The Illusionary Treatment Option, 2nd edition, 2014.
Simeone FJ, Vicentini JRT, Bredella MA and Chang CY (2019) Are patients more likely to have hip osteoarthritis progression and femoral head collapse after hip steroid/anaesthetic injections? A retrospective observational study. Skeletal Radiology, 48(9)
Starrette K, MobilityWod video: http://www.mobilitywod.com/2012/08/people-weve-got-to-stop-icing-we-were-wrong-sooo-wrong/
Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. Journal of Strength and Conditioning Research. 2013 May. 27(5):1354-61.