Sunday, February 3, 2013

Icing, does it really help? (Pain/Injury Management)

Have you ever been out for a run or playing a little soccer with the kids when all of a sudden you tweak a muscle in your leg or roll your ankle?  Your first thought may be, “I need to go ice this!”  Icing an injury is after all what you have always been told to help get the swelling down and to dull the pain.  In fact, the oft-disseminated acronym in the sports medicine world is R.I.C.E., which stands for rest, ice, compression and elevation.

When an idea has seemingly been in circulation forever it endured the test of time and survived the scrutiny or it just may be due for a re-evaluation.  Dogma is never an effective argument to continue with a treatment such as icing an injury especially when you consider what actually happens when you do apply ice.

I think we can all agree that the human body has an amazing ability to heal it’s self if we allow it to.  Inflammation and swelling are the body’s natural response to an injury.

I think there is some merit to icing acute injuries (it just happened as a result of a specific action) and cold-water full or partial submersion for the purposes of recovery after training, but constant use of icing to dull pain is counterproductive. It essentially numbs the area, but also limits blood flow, which is the mechanism through which healing agents are delivered to the site of the injury.

Pain can be our friend.  It is a signal to our brain that something is not right.  If we ignore this call by numbing the pain with drugs or ice it’s similar to covering up the warning light on your dash that alerts you to a potential problem with your engine.

If you continue to drive the car you will eventually damage the engine and possibly even blow it out beyond repair.  If you ignore the pain in your body and continue to push your way through an injury eventually you will develop compensatory patterns to work around the pain and discomfort.  These altered body mechanics will overload areas that pick up the slack for the weak/injured area and a bigger problem usually ensues.  You can always get a new engine for your car, this is the only body you’ve got so don’t bury your head in the sand by ignoring the pain!

I am not a rehab and pain management specialist but I do have plenty of in the trenches experience dealing with my own bumps and bruises.  Cold showers particularly after a rough workout has always worked for me in managing soreness.  I tried snowboarding a few years ago and I fell down and crashed, often!  I knew I was going to be hobbled the next day unless I took aggressive precautions.  As soon as I got back to the house I jumped in a cold shower for 5 minutes.  I focused on more vulnerable areas around the knee, hips and lower back.  The only area I neglected was around my wrist joint (from breaking the falls with my hands) and guess what hurt the next day?  My forearms were on fire but the rest of my body was fine.

Another key ingredient in my recovery in this instance; I did not sit around and allow my body to get stiff.  I continued to move around for the rest of the afternoon and did some very mild mobility exercises.  Muscle activation helps drive blood in and out of the system.  The muscles serve as a pump, they bring groceries in (nourishment) and flush the garbage (waste) out.

There is basically a three-step process that must occur for an injury to heal.  The first step in the healing process is the inflammatory response followed by repair of the tissue and finally remodeling of the tissue.  Ice sends the nourishment in the wrong direction so it prevents or delays step one from occurring.  And if the inflammatory response is delayed the other two can’t happen and recovery takes longer or is never completed.  This is why rushing back to soon before an injury has had the opportunity to heal usually leads to a re-injury.

So what do the pain experts say?

I contacted two rehab specialists in the area and asked for their opinion:

When it comes to acute injury, then there is a possibility of inflammation and that is why it is very important that the player rest that joint and ice it to prevent further damage and to reduce the swelling. After about 48 hrs then you can use some isometric exercises without aggressive motion thru the joint and you can use heat if there is no swelling. That is in general; of course every injury is different.

M. Fahmy, OMPT Specialists

Ice for the first 48 hours, then after that, use heat. Don't stretch the muscle. Once the acute irritation dies down, we use gentle transverse friction massage to the muscle belly with it in the shortened position. This restores tissue alignment and allows the muscle to "fatten" when it contracts. The inability of the muscle to "fatten" with contraction is usually what causes ongoing pain after an injury.

S. McLaughlin, Michigan Institute of Human Performance

The consensus is that immediately following a mild acute injury icing is advised to control excessive inflammation, swelling and pain.  Then after the injury has settled down after 48 hours don’t just sit around.  Light muscle contraction and or gentle massage will help drive the groceries in and the garbage out and allow the body to repair and ultimately remodel.

If you constantly have to ice your back, neck or other area of discomfort to manage pain you should not ignore this signal.  Chronic pain is usually the result of incomplete recovery, over-use or poor posture and muscle imbalances.  That pain won’t go away until you get to the root of the problem.  While inflammation is essential for the repair process chronic inflammation can slowly chip away at tissue and movement quality.  And poor movement in addition to weak muscles and stressed connective tissue is a recipe for serious pain down the road.

It’s okay to experience a little soreness after a tough workout, this usually occurs within the first 24-48 hours post training. This soreness should be mild in nature but can be quite severe if you dramatically increase the intensity of your training (New Year’s Resolution!).

If you do experience this soreness the protocol is similar to that of an acute injury:
  • ·      Ice/Cold Showers within the first 24-48 hours
  • ·      Light mobility exercises (think active stretching, not static holds)
  • ·      Gentle massage
  • ·      Treading water in a warm therapy pool is also good option

As a general rule prevention is the best strategy to avoid pain and soreness:
  • ·      Follow the 10 percent rule: do not increase exercise intensity, frequency, or duration more than 10 percent a week.
  • ·      Allow for weekly mobility/flexibility time in your workout schedule.
  • ·      Cool down after vigorous exercise by jogging, walking, or slow-lap swimming.
  • ·      Use Hot/Cold Contrasts in the shower finish with cold.

Also getting adequate rest /sleep is critical to not only recovery but also injury prevention as well. Adolescent athletes who don't get enough sleep at night might be placing themselves at risk for a sports injury, researchers recently revealed at a presentation at the American Academy of Pediatrics.

"Adolescent athletes may benefit from additional sleep as they get older. We'd like injury prevention programs to focus on sleep education."

Matthew Milewski, MD, of Children's Hospital Los Angeles [1]

In my 10-14 age group many of the children (particularly the girls) are experiencing knee pain.  It would be easy to dismiss this pain as nothing more than just the typical aches that accompany growth and maturation but it is very important to listen to the child and acknowledge their discomfort.  I absolutely want my kids to tell me if they have pain so I can ask leading questions to determine if it may be something more than just their “growth spurt.”  It’s incredibly important to catch potential developmental problems in their infancy when they are much easier to counter-act.  No need to go overboard and worry yourself sick about every little aches and pain but by watching how they move and listening to them you can learn a lot.

Treatment of growing pains depends on how much pain your child has. The following things may ease discomfort and help your child feel better:
  • ·      Massaging the legs.
  • ·      Stretching the leg muscles. This may be difficult/uncomfortable for younger kids.
  • ·      Place a warm cloth or heating pad on the sore leg. Be careful not to burn the skin and do not use during sleep.
  • ·      Most kids won’t respond well to ice.  But if they can tolerate it apply ice wrapped in a towel to the sore area a few times each day. This can help to relieve pain and discomfort.

When Should You Call the Doctor?

When deciding whether to call the doctor, it's important to remember that growing pains are almost always felt in both legs. Pain that is only in one leg may be a sign of a more serious condition. Call your health care provider if this happens.

It's also important to remember that growing pains affect muscles, not joints. And they do not cause limping or fever. [2]

In summary if you think icing works for you than continue to do so for mild injuries.  Earlier studies have found little benefit from icing after exercise, but also few negative side effects. [3][4] That said icing prior to exercise or sport should be avoided!  That should be apparent but cooling will negatively affect your muscle coordination, spatial awareness and dull your motor reflexes. [5]

Next week I will examine nutritional strategies that can be used to recover from injuries.


Ibuprofen (brand names Advil, Motrin) is a non-steroidal anti-inflammatory drug (NSAID) commonly used by athletes, both before and after workouts.

Taking ibuprofen before a workout in order to reduce muscle soreness has been linked to intestinal leakage and systemic inflammation; when used chronically, ibuprofen may lead to intestinal permeability, allowing bacteria and digestive enzymes to leak into your bloodstream regularly.

Using ibuprofen chronically prior to your workouts may also reduce the absorption of key nutrients, particularly after exercise, which may make it harder for your muscles to regenerate; further, this practice has not been shown to reduce muscle damage or soreness. [6]

"We've learned through our conditioning that we just ignore the pain, or we take a medication to suppress the pain, which is no more than saying to the body, 'Shut up. I don't want to hear about it,' which allows the problem to become more advanced. When you take anti-inflammatory and pain pills for a condition that you're dealing with athletically, all that you do is set the body up for more damage, because you override the protective mechanism of your body.” [7]

Dr. Craig Buhler, Advanced Muscle Integration Technique (AMIT) Practitioner

The best strategies (rest, nutrition, corrective exercise) to help reduce muscle fatigue and soreness are those that will help to address some of the underlying causes; drugs do not fall into this category.


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