Ice and Anti-Inflammatory Meds Are NOT the Answer

By Josh Stone *

The controversy surrounding the practice of using ice and anti-inflammatory medications continues! What is surprising to me is that a controversy exists at all. Why, where and when did the notion of anti-inflammation start? I’m not exactly sure, but using ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most.

Enter any athletic training room or physical therapy clinic and you’ll likely find nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). But, I can’t stop wondering: “Why do people want to get rid of inflammation and swelling related to chronic and acute injury?” If you don’t know how to answer that question, you best keep reading.

The Stigma of Inflammation

As the editor-in-chief of The Physician and Sports Medicine Journal, Dr. Nick DiNubile once posed this question: “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” Much like a fever increases body temperature to kill off foreign invaders, inflammation is the first physiological process to the repair and remodeling of tissue. Inflammation, repair and remodel. You cannot have tissue repair or remodeling without inflammation.  In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase (1).

Researchers headed by Lan Zhou, M.D., Ph.D., at the Cleveland Clinic, found that in response to acute muscle injury, inflammatory cells within the damaged muscle conduct phagocytosis, contribute to accumulation of intramuscular macrophages, and produce a high-level of Insulin-like growth factor 1, (IGF-1) which is required for muscle regeneration (3). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth and proliferation, and a potent inhibitor of programmed cell death. Similarly, in 2010, Cottrell and O’Conner stated, “Overwhelmingly, NSAIDs inhibit or delay fracture healing.” (2). And people choose to stop this critical process of healing by applying ice, because inflammation is bad?

The Anecdotal Rationale for Ice

Somewhere along the line, the concept that ice facilitates healing became conventional wisdom. Sorry, but that wisdom is wrong. I had someone tell me the other day, “We need to ice, because we need to get the swelling out.” Really? Does ice facilitate movement of fluid out of the injured area? No, it does not. The lymphatic system removes swelling. The Textbook of Medical Physiology says it best: “The lymphatic system is a ‘scavenger’ system that removes excess fluid, protein molecules, debris, and other matter from the tissue spaces. When fluid enters the terminal lymphatic capillaries, any motion in the tissues that intermittently compresses the lymphatic capillaries propels the lymph forward through the lymphatic system, eventually emptying the lymph back into the circulation.”

Lymphatic drainage is facilitated by contraction of surrounding muscle and changes in compressive forces that push the fluid back to the cardiovascular system. This is why ankle pumps works so well at removing swelling accumulation.

Besides, since when is swelling a bad thing? Swelling is a necessary first phase of the healing process. Swelling is controlled by the body’s internal systems to attain homeostasis. If swelling is accumulated it is not because there is excessive swelling, rather it is because lymphatic drainage is slowed. The thought that ice application increases lymphatic flow to remove debris makes no sense. Gary Reinl, author of Iced! The Illusionary Treatment Option gave me a good analogy: If we were to compare two tubes of toothpaste–one iced for 20 minutes, and the other warmed to 99 degrees–in which tube would the toothpaste flow fastest?  It does not take an advanced physics degree to know that answer.

What might surprise you is that ice actually reverses lymphatic drainage and pushes fluid back to interstitial space. A foundational study published in 1986 found that when ice is applied to a body part for a prolonged period of time, lymphatic vessels begin to dramatically increase permeability. As lymphatic permeability increases, fluid will pour from the lymphatics into the injured area, increasing the amount of local swelling (5). So … ice can increase swelling and retard debris removal!

Load Facilitates Repair

The acronym RICE (rest, ice, compress, elevate) is bogus in my opinion. Rest is not the answer. Rest does not stimulate tissue repair. In fact, rest causes tissue to waste. The other reason RICE is bogus is obvious: ice. Evidence has shown that tissue loading through exercise or other mechanical means stimulates gene transcription, proteogenesis, and formation of type I collagen fibers (See studies by Karim Khan, Durieux, Mick Joseph, and Craig Denegar). Ice does nothing to facilitate collagen formation.

Our body has all types of cells. When a cell is born it has no clue what type of cell it will eventually become. This infancy cell – for lack of a better term – is called a progenitor cell. Progenitor cells can be changed to a specific cell type. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte. Ever wonder why myositis ossificans (calcification or bone growth in muscle) develops? The direct, repeated trauma turns progenitor cell currently living within muscle to an osteocyte. Subsequently, we develop bone growth within muscles.

Ice will not influence progenitor cells development. Ice does not regenerate tissue. Ice does not facilitate healing. It inhibits natural healing process from occurring. Ice does not remove swelling; it increases swelling and lymphatic backflow.

Closing Thoughts

Bottom line: Ice and NSAIDs are over utilized. We have made ice in to a magical cure-all that fixes everything and is required for healing. But, it is not the gold standard everyone seems to think it is.  Please … think before immediately turning to ice and NSAIDs. Is it really the best option? My goal is to get this trend reversed–one clinician and one patient at a time. Have you seen the video, People, We’ve Got to Stop Icing, featuring Kelly Starrett, DPT, and Gary Reinl? If not, I recommend you watch it. It’s fascinating. I am glad to have expert minds like Kelly and Gary in this fight with me.

I ask health care professionals to do one thing, just try it. Pick one client with chronic musculoskeletal pain, skip the ice, skip the NSAIDs, and try to use light exercise as a repair stimulus. Then, try skipping the ice on a client with an acute mild injury. The outcomes might surprise you.

Josh Stone holds certifications as an athletic trainer, performance enhancement specialist, corrective exercise specialist, personal trainer, fitness nutrition specialist, senior fitness specialist, mixed martial arts conditioning specialist and more. He earned his master’s degree in kinesiology with an emphasis in athletic training and sports medicine from San Jose State University and an undergraduate degree in movement and exercise science from East Stroudsburg University of Pennsylvania. Throughout his career he has served as faculty member at Bryan University, a Sports Medicine Program Manager at the National Academy of Sports Medicine, and as Director of Functional Ergonomics. Currently he is the Acquisitions Editor at Human Kinetics, where he collaborates with industry leaders to develop top-notch educational products for higher education.

* This article was first published by Josh Stone in his Athletic Medicine blog, dedicated to cutting-edge research and trends in sports medicine, performance enhancement, fitness and nutrition. Visit Athletic Medicine for full references and updates made by the author.

Bryan University offers future-proof, industry-strong online degree programs in health and legal services, including an associate degree in Advanced Personal Training and Exercise Science. For more information, visit www.BryanUniversity.edu.

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