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Cryotherapy for acute injuries

This is an excerpt from Sports Massage for Injury Care by Robert McAtee.

Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.


Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.


In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.


Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,


There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)


It's important to note that this review did not find evidence that ice and compression delayed healing.


Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.


The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.


In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.


A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.


As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.


Traditional Chinese Medicine  Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.


POLICE  Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,


POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)


MEAT  MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.


A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that


Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)


As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.