By Ernest Lo – B.Kin, MPT – Physiotherapist
As someone who grew up around organized sports and athletics, one of the most common phrases that I’ve heard, regardless of the sport is this: “put some ice or heat on it.” Whether you’re a dedicated athlete or simply passionate about staying active, understanding when to use these two treatments can greatly impact your recovery process. The longstanding debate between using ice and heat remains an important aspect of sports injury treatment. But what truly happens when you use these different modalities to an injured area?
Cryotherapy & RICE, PRICE, POLICE
Ice and heat can be categorized within a broader treatment modality known as thermotherapy, which involves the use of temperature for treatment effects. Starting with the former, ice can be further categorized into another treatment modality known as cryotherapy. Literally meaning “cold therapy”, cryotherapy refers to a procedure where cold packs are applied on a body part following injury for immediate pain relief and inflammation reduction. How does this work? Simply put, the cold sensation sends signals up to the brain, “blocking” the painful stimuli from reaching the brain, allowing for pain relief – this is known as pain-gating. With inflammation reduction, however, the exact physiological mechanisms leading to this effect are yet to be determined.
With the latter, warm packs are applied on an injured body part for the purpose of pain relief and promotion of tissue healing. Pain relief can be explained with the concept of pain-gating, similar to above. Heat helps with muscle relaxation as well, which could play an additional role in pain relief. In turn, the increase in temperature promotes blood flow to the area, accelerating the rate of tissue healing.
RICE, PRICE, POLICE: Decoding the Acronyms
Despite the debate between the two modalities, ice seems to be the go-to treatment immediately following sports injuries. Personally, I cannot remember a time where someone applied a heat pack at courtside immediately after injuring their ankle or pulling a muscle. Therefore, let’s start by discussing some of the popular treatment guidelines that depict what to do during the initial minutes-hours of recovery. It should be noted that other treatments are also included in these guidelines.
Starting with RICE, this acronym stands for rest, ice, compression, and elevation. Compression refers to wrapping the injured area tightly, and elevation refers to keeping the injured area above heart level (i.e. putting your foot on an elevated pillow when lying down in bed). The theory here is that immediately following injury, rest would be important to prevent further damage. In turn, ice, compression, and elevation would help to reduce inflammation, and ice would also decrease pain levels. PRICE is an extension of RICE, adding the element of protection into the picture – this refers to taking additional measures to prevent further injury, such as using crutches to walk following an ankle sprain.
However, more recent research has found that while rest is important immediately following injury, longer periods of rest could hinder the recovery process. Hence, the acronym POLICE was created, where protection is still indicated, but the concept of rest is replaced with optimal loading. This means that individuals should be using their injured body parts as much as they can, as their pain levels allow. With POLICE, the concept of ice, compression, and elevation are still indicated. If we were to compare PRICE and POLICE in the context of an ankle sprain, it could look something like this:
The individual uses crutches while walking, and places minimal weight on their injured foot to allow the structures to heal.
The individual uses crutches while walking, and places as much weight on their injured foot as they can tolerate (amount of weight would vary depending on pain levels). With time, the individual will likely be able to tolerate more weight.
What does the research say?
You might be thinking – if the popular treatment guidelines all recommend ice following sports injuries, does that mean ice should be crowned as the best treatment? That is a fair question; however, we first need to take a look at what the research says about the two modalities.
Countless studies have investigated the effects of ice on soft tissue injuries. From these, there is actually insufficient evidence that fully supports their benefits – in particular, it is currently unclear whether cold therapy has a positive influence on swelling or patient function. As well, Singh and colleagues in 2017 suggested that ice could potentially delay soft tissue recovery following injury due to a reduction in inflammation. For context, inflammation following injury is the human body’s natural response in order to repair itself. However, too much inflammation could indicate, or lead to, further damage. That being said, these effects in the study were not significant enough to prevent overall tissue healing, and other studies with similar methodologies had conflicting findings.
Looking next at the effects of heat on soft tissue injuries, research has found benefits in pain levels, physical function, muscle strength, and mobility. These findings were in relation to individuals with acute low back pain, or in other words, sudden pain in the low back that was not present before. Also, when comparing heat and ice as treatments following muscle injury in rats, heat seemed to facilitate the recovery of muscle size and mass. It should be noted that in this study, ice was applied once immediately after the injury, while heat was not applied until two days after the injury; heat was applied every other day from then for two weeks.
PEACE & LOVE: New Guidelines for Post-Injury Care
From above, it seems like the “benefits” of ice are not well-supported by research evidence. And while the benefits of heat are better supported, this modality is not typically used immediately after an injury, but rather a couple days post. What then, should we do immediately following sports injuries? A team of researchers reached a similar conclusion in 2019, thus coming up with yet another treatment acronym known as PEACE and LOVE. You will likely recognize a lot of the concepts based on what we have already discussed in this blog.
PEACE is used immediately following injury, and it stands for protect, elevate, avoid anti-inflammatories, compress, and educate. Please note that “ice” has been excluded, and the reason for that is similar to the notion of avoiding anti-inflammatory medications – to allow the natural inflammatory processes required for tissue healing to occur. Education has also been included, outlining the importance of being well-informed during the rehabilitation process.
Moving on to the second half of this acronym, LOVE is used after the first few days of injury, and it stands for load, optimism, vascularization, and exercise. The concept of load addresses the importance of taking an active approach to recovery, similar to the concept of “optimal loading” in POLICE. As soon as one’s symptoms allow for it, research shows that early use of an injured body part promotes healing and repair. Research also shows that optimism and positive expectations regarding rehab are associated with better outcomes; and it should be noted that the opposite is also true. Finally the concept of vascularization notes the importance of aerobic exercise and fitness levels on injury recovery. And the concept of exercise outlines the strong level of evidence supporting its use in treatment of sports injuries, as well as prevention of future injury.
Looking at this, you likely noticed that neither form of thermotherapy was included. And that could be an indication that rather than debating between ice or heat as the best treatment for sport injury, there is another form of treatment that should take the crown. Hint – it was mentioned in both POLICE as well as PEACE and LOVE.
All in all, sports treatment and management of sport injury is an area that requires further exploration and research. While cold therapy lacks strong evidence to support its effects, it is still recommended and utilized in the athletic community following sports injuries. In turn, heat therapy has positive effects on rehabilitation when utilized a couple days post-injury. It is important to understand that every person is different. Hence, even if two individuals sustain the same injury, they may not have the same experience. And in the same way, they may not respond to the same treatment technique – this is what makes research so difficult! So to answer the question in the title: neither ice nor heat is the best treatment for sports injury, and choosing between the two depends on multiple factors.
Here are some key takeaways:
- Despite the difficult nature of research, there is strong evidence that early loading and exercise accelerates recovery following soft tissue injuries. Hence, as early as one’s pain allows, individuals should begin to use their injured body parts during normal activities (i.e. walking on injured leg after ankle sprain). Exercise also has a role in preventing future injury.
- Ice is still indicated during soft tissue injuries as long as the individual finds it helpful. There is not enough evidence stating that ice, or any form of cryotherapy, prevents appropriate tissue healing, therefore its benefits outweigh its risks at this point. Ice has a great ability to help relieve pain, as mentioned above.
- Heat promotes tissue healing and pain relief following injury according to the research evidence. These effects can especially be helpful in promoting early mobilization and exercise!
- Having a positive mindset during injury, being well-informed regarding what steps to take during recovery, and maintaining/improving fitness levels, are all correlated with better outcomes.
If you still have questions, or find yourself in a situation where you are not sure which one to use, book an appointment with myself by clicking here or one of our other physiotherapists at Hayer Health!
Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE?. British journal of sports medicine, 46(4), 220-221.
Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72-73.
Cryotherapy. Physiopedia. (n.d.). https://www.physio-pedia.com/Cryotherapy
Singh, D. P., Barani Lonbani, Z., Woodruff, M. A., Parker, T. J., Steck, R., & Peake, J. M. (2017). Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in physiology, 8, 93.
Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P., Dekker, R., … & Kerkhoffs, G. M. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine, 52(15), 956-956.
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