Ice is Nice

Peter Loescher, MD
Posted December 5th, 2010

I spend a healthy portion of my working life thinking about, talking about, and treating patients with inflammation. I see athletes of all shapes, sizes, ages, genders, and abilities in my office, and most of them come to see me because something hurts. Usually the pain they are feeling is due, at least in part, to inflammation. The inflammation may be from an acute injury, or it may be chronic and longstanding. Whatever the underlying cause, inflammation tends to cause pain and swelling, and can take much of the joy out of training, sports, recreation, and daily activities, and can even make it hard to sleep restfully.
When I ask patients what they have tried to help ease their pain, I am constantly amazed at how few have done any regular, systematic icing of their injured areas. I also find that of those who are using ice therapy, many are using ice incorrectly, and either not getting maximum benefit from it, or actually doing harm with their techniques. This, then, is a brief tutorial on when to ice, how to ice, and what to ice (and what not to ice).
Ice therapy (or cryotherapy) decreases swelling and inflammation after injury to body tissue. It is beautiful and elegant in its simplicity—it is inexpensive, safe, and effective for treating inflammatory pain. When done correctly, it is side-effect free, and it can speed recovery from injury. It should be used after acute injury to muscle, tendon, ligament, or bone. It is also effective for chronic conditions like osteoarthritis, and should be used after activity or at the end of the day when arthritic pain is high.
Ice therapy works by limiting blood flow to the area being iced. The body recognizes areas of injury through a complex array of chemical signals, and responds by increasing blood flow to the injured area. At the same time, blood vessels become dilated and more permeable, allowing inflammatory cells to exit the vessel and release chemicals to begin the healing process. This process creates both swelling and pain. The pain comes in part from the swelling, and in part from the chemicals themselves. The pain from inflammation has an important function—it tells the brain that we are injured and to rest the area until better. So why should we want to impede this important process from doing its thing? Shouldn’t we rather promote inflammation so as to expedite healing?
The truth is, after acute injury such as an ankle sprain, there is plenty of bleeding and inflammatory response to promote healing, with or without icing. Long term healing will not be compromised, and short term relief will be greatly enhanced, if ice therapy is employed quickly and frequently after injury. For chronic conditions, daily inflammation is actually unhealthy and damages tissue. In osteoarthritis, inflammation softens joint cartilage and speeds up the rate of wear and tear and joint breakdown. If a tendon is chronically inflamed, as in rotator cuff or Achilles tendinosis or tennis elbow, the injured tendon will lose elasticity, become scarred, thickened, weakened, and prone to rupture. Daily icing will not only decrease pain, but will decrease the severity of these negative effects of inflammation.
Icing should be done in 10-minute intervals. Exceeding 10 minutes of continuous icing will not only put the icer at risk for skin injury (frostbite), but it will be counterproductive. Small nerves tell blood vessels when to dilate and when to constrict. Cold therapy sends a signal to nerves which causes vasoconstriction, decreasing blood flow to the area being iced. After 10 minutes, however, the icing causes the nerves to become sluggish, and the blood vessels open up again and blood flow is actually increased. Vessel permeability is also increased, and swelling and pain will actually get worse. Ten minutes on, thirty minutes off is a good rule to follow for ice therapy.
Immersion therapy is a great technique for icing—a bucket of ice water or cold plunge will effectively cool any immersed body part. Depending on the body part in need, this technique is not always convenient. Ice massage is an easy alternative. A Styrofoam cup full of ice makes a nice tool for this. A plain ice cube or ice chunk will work in a pinch. In the winter, I like a Ziploc bag full of snow. Keep two ziplocs and an ace bandage handy, and you will always be ready for your cryotherapy. Commercial gel pacs are handy, but can get very cold (colder than ice), so beware of frostbite, especially if gel leaks out of the package. A moist cloth between the gel pack and skin is protective (a dry cloth will be insulating and will limit cold transmission to skin).
Ice therapy should be applied ASAP after an acute injury. It should be continued in 10 minute increments with 30 minutes in between several times per day for at least 72 hours. For chronic conditions, ice after activity or workout, and again before dinner or bed—two or three 10-minute ice sessions per day are ideal. Athletes should not ice before training or playing. This will increase stiffness and risk of further injury. A general rule of thumb—heat before play, and ice after.
One caveat—for chronic back and neck pain—whatever the cause, ice tends to be counterproductive. Heat is generally much more helpful and therapeutic for chronic pain and stiffness in the back and neck. Acute lifting injuries and muscular strains of the back may be helped by icing, although often the injured tissue is too deep to realize much benefit from icing the overlying skin.
So get prepared for the great winter sports season. Do your strength work, build your cardiovascular base, work on your balance and flexibility, cross train and enjoy every minute of the outdoor activity and exercise that our Green and White Mountains and snow-filled winters provide. But if injury befalls you this year, remember to utilize the oldest, safest, cheapest, and best treatment that there is—apply snow or ice to affected area twice an hour, and if still sore, call me in the morning…
Peter Loescher is a board-certified family practitioner and sports medicine physician at the Sharon Health Center in Sharon, VT, an affiliate of Gifford Medical Center. He completed a residency in family practice at Dartmouth Hitchcock Medical Center and a fellowship in sports medicine at the University of Oklahoma and Eastern Oklahoma Orthopedic Center, Tulsa. He is the sports medicine director at The Cardigan Mountain School and provides medical coverage at many local athletic events. When not at the office, he can be found running, biking, and skiing the byways and trails of northern New England. You can reach him at