Author: George Terwilliger. George is an ER physician who lives in Brattleboro and is a lifelong Vermont Resident. He is an avid backcountry skier and has skied many sections of the Catamount Trail.
On my first day of medical school at UVM, just before going upstairs for an introduction to our assigned cadavers, we met with our Dean, Dr. Tormey. His prophetic words shaped my practice of medicine: “Fifty percent of what we will teach you over the next 4 years is wrong; you’ll spend the rest of your career trying to figure out just which 50 percent that is.” I’m hoping this little vignette will soften the criticism I may sustain for questioning the dogma of ice therapy for orthopedic injuries.
The practice of using ice and NSAIDS (non-steroidal anti-inflammatory drugs) to reduce the inflammation caused by sprains and other sports injuries is the cornerstone of therapy. It seems to be seldom questioned by athletes, let alone their sports medicine practitioners. Go to any school’s training room and you will see young athletes icing a variety of injuries: ankles, feet, knees, shoulder, and elbows. They are told that ice will reduce inflammation, an alleged enemy of healing which causes swelling, warmth, redness and pain. Further, they often take prodigious quantities of NSAIDS such a ibuprofen to further attack the “enemy” inflammation.
Surely, you would think, that such a widespread practice must be backed by good evidence. Well, you’d be wrong. There are no good studies showing any benefit to icing injured body parts in sports injuries (other than brief pain reduction) and actually there are plenty of studies showing significant harm such as delayed bone fracture healing when inflammation is reduced by taking NSAIDS.
The idea that inflammation is bad is wrong. Inflammation is the body’s response to tissue injury whether it be mechanical, thermal, or infectious. This response is a programmed symphony of processes which secrete growth factors, grow new blood vessels, increase blood flow, and attract progenitor cells. This results in the grow of new tissue. All this commotion produces pain which while unpleasant, protects the injured body part from further damage. Most of the time, this inflammation is appropriate and should not be interfered with.
When the inflammation has run its course and healing is progressing, swelling and pain abate. As the injury heals the body part becomes more robust allowing progressively more exercise and stress tolerance. Doing too much will kick up more inflammation and pain signaling the need for gentler activity. Pain is usually your friend, it helps guide the safe use of injured body parts.
Excessive pain and swelling may indicate an imbalance in the body’s inflammatory mechanisms. This can be the sign of increased inflammatory activity which in the long run can lead to such disorders as coronary artery disease, arthritis, colitis, gout, hypertension, obesity, diabetes, and even Alzheimer’s disease. The treatment for excessive inflammation is primarily quitting smoking, increasing fruit and vegetable consumption and reducing or eliminating processed foods and animal products. A plant-based diet is protective due to beneficial phytochemicals and soluble fiber. One of the latest, most compelling theories of why fruit and vegetable fiber is so healthful centers on the progressive improvements in our gut microbiota, the bacteria that outnumber your human cells 10 to 1. These diminutive digestive system denizens help to maintain your health in a myriad of ways only just now being elucidated: production of vitamins, preventing harmful bacteria from causing infection and, most importantly, modulation of the immune system so that it does not attack human cells.
What then, if the pain and swelling are unbearable? Rest and protection of the injury is paramount as is elevation. You may need a splint. Gentle compression with an ACE bandage is also reasonable as long as you don’t have arterial disease. Limited icing is acceptable if the pain is unbearable and is certainly preferable to NSAIDS. However, if you notice that uninjured body parts away from the injury, as in finger or toes in forearm or lower leg injuries, are pale and painful, then you may have swelling of a muscle compartment which is shutting off the flow of blood and pinching nerves. This condition is a true medical emergency and can be limb threatening. If you have signs of this uncommon condition, do ice the injured area, remove any constrictive clothing, braces, or ACE wraps and go to the nearest emergency department immediately.
While splinting may be important to prevent further damage, there is also an opposing need to mobilize the injured parts which can hasten healing, improve blood flow, and prevent decreased mobility of joints which can be a huge problem in shoulders, especially for those older than 40. Do not hesitate to see your primary care doctor, orthopedist, or physical therapist for an injury that seems like it is going to cause more than minor problems.
You’ve heard some of this before, prevention is the most important thing: eat well and don’t smoke. When injured, take my advice: nix the ice.
Further Reading – The above information will come out more and more in the press as studies are publicized. Below you will find some additional supporting references.