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Icing is not dead

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.
Photograph of an ice cube, isolated on white, representing cryotherapy.

Maybe you’ve seen skeptics scoffing at icing for rehab. Supposedly ice interferes with natural healing, and the I-in RICE is dead — the RICE guy himself said so! Icing is foolish!

This take is making me peevish. The skepticism has gotten a little sloppy and overzealous. Mistakes have been made.

Who’s the RICE guy and what did he say?

Dr. Gabe Mirkin, the physician who first proposed the well-known “rest, ice, compression, elevation” rehab protocol in 1978, recanted the ice part in 2015, declaring on his blog that “icing delays recovery” … an opinion now cited widely.

Dr. Mirkin criticizes only the idea that ice “promotes healing,” but that is not the goal of most icing. Ice can blunt acute pain cheaply and safely, and that is not a baby I will throw out with the bathwater.

And Dr. Mirkin agrees!

Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10 minute application once or twice.

Skeptics don’t seem to have noticed that punchline.

Overzealous debunking

Dr. Mirkin’s article is constantly cited on social media to support an “icing is useless” opinion. He might be startled to know how much his article has been used discourage anyone from icing at all.

Skeptics are my own tribe, and I know them all too well. We can be so eager to bust a myth that we gloss over crucial below-the-fold details and nuances.

Does ice even impede healing?

And another thing: Dr. Mirkin's word might not be the last word on whether icing impedes healing. There are two problems with that idea:

  1. It’s speculative! It’s based on indirect evidence and the common sensical idea that we shouldn’t interfere with normal healing processes. But can ice interfere? None of the evidence Dr. Mirkin presents is empirical evidence of what actually happens. Its reasonable speculation, but only that.

    It’s also contradicted by clinical evidence, which shows that icing appears to have no effect on recovery at all, good or bad. What few studies we have of this just show no difference. (See Collins and Malanga.)

  2. If icing can interfere, does that really need to be avoided? Sometimes short term pain relief is worth it. Sure, inflammation from a fresh injury is indeed mostly biology business as usual… but not all of it, not always. Not everything “normal” in biology is wise and good and never needs to be controlled or treated. Diarrhea is natural, too, but it can get out of hand. So can fevers, and much else.

Icing may not impede healing at all, and it might even promote it. But what little evidence we have suggests it’s neither of the above: ice is just neutral with regards to healing.

But there is no doubt that ice can temporarily tame acute inflammatory pain. And sometimes that’s a precious benefit.

I go into a some more detail about this in the comprehensive PainSci icing guide.

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