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Ice, Ice Baby: Why Do Physiotherapists Love Ice So Much?

As a remedial therapist for people suffering from restricted movement or injuries, I am often asked how to reduce pain and swelling. In short, it depends on the circumstances. In the acute phase of an injury, pain is an indicator that something is wrong, so the use of the injured part (and if appropriate, load-bearing activities) should be limited. The accompanied swelling is an indicator that the body is starting to heal and is an essential natural process. During the rehabilitation phase, swelling and pain may continue as scar tissue is laid down and the area regains is strength and mobility. This stage may take anything from 6 weeks up to a couple of years to fully recover. Sometimes, residual pain and swelling may continue due to various factors.

In recent years the acronym for acute soft tissue injury has changed from R.I.C.E. to P.E.A.C.E & L.O.V.E. because the former only addressed the management of the acute stage of an injury and did not include the process of rehabilitation. Furthermore, according to the British Journal of Sports Medicine, there is evidence to show that the use of anti-inflammatories negatively affects long-term tissue healing as well as the application of ice (Dubois & Esculier, 2020)

R.I.C.E versus P.E.A.C.E & L.O.V.E.

Basic first aid training still teaches you to follow Rest, Ice, Compression and Elevation immediately after a soft tissue injury.

  • Rest - pain tells your body not to use the injured area

  • Ice - slows blood flow to the injured area, to reduce bleeding and secondary damage. Torn muscles bleed more than ligaments as they have a richer blood supply.

  • Compression - helps to push the blood back to the heart, when excess amounts are pooling due to gravity.

  • Elevation - lowers the pressure in the blood vessels and increases drainage to prevent excess swelling. The injured part should be raised above the heart, where possible.

What was the purpose of icing after an injury?

Icing stops bleeding; where there has been a soft tissue injury, such as a tear to a tendon, ligament or muscle it bleeds because it has a blood supply. Icing prevents excess swelling; the natural healing response following an injury is for the area to swell, as lymph and white blood cells increase to start the healing process. Ice is an analgesic; the cold numbs the skin and confuses the pain receptors.

Why has icing a soft tissue injury fallen out of favour?

It was suggested that cold or ice therapy may be beneficial in reducing pain and swelling by numbing the skin and reducing circulation. However, icing has fallen out of favour with clinicians because it inhibits the flow of lymph and white blood cells, thus slowing down the healing process. It also desensitises the skin, reducing the pain and fooling the person into believing it is safe to use the injured area before it has had time to adequately heal, leading to further injury or other complications.

When is cryotherapy of benefit?

Cryotherapy is most commonly used to treat skin conditions such as eczema, psoriasis, and warts. It is used to treat liver, kidney and prostate cancers. Some studies have shown that cryotherapy is an effective treatment for migraines, mood disorders, dementia and nerve issues by reducing nerve activity.

New recommendations for managing soft tissue injuries

The British Journal of Sports Medicine released an article in 2019 supported by up-to-date evidence to follow the anagram of P.E.A.C.E. for initial soft tissue injury management and L.O.V.E. for subsequent management.

How to treat a soft tissue injury within the first 72 hours?

Protect - the area, reduce mobility and avoid load-bearing activities for the first 72 hours to prevent bleeding and further injury

Elevation - above the heart, if possible, to prevent excessive swelling and encourage fluids to flow back to the heart.

Avoid - anti-inflammatories, especially during the first 72 hours, as they will negatively impact soft tissue healing in the long term. Ice also reduces the inflammatory process and may also lead to impaired tissue repair Physiotherapy Matters, 2022

Compression - using taping, bandage or tubigrip helps to limit intra-articular oedema (swelling in between the joints) and tissue haemorrhage from a damaged blood vessel.

Educate - people about the benefits of an active approach to recovery. This includes providing a clear and simple explanation of the injury, the impact it has on function, what movements should be done, and expectations of recovery.

Rehabilitation of soft tissue after the first 72 hours with LOVE

Load - the injured area with gentle and progressive mechanical loads (weights/resistance) within the pain threshold. This promotes repair, and remodelling and allows the mechanical input to be converted into cellular memory for appropriate behaviour and function.

Optimism - promotes better healing and long-term recovery. Recognising improvements and reaching achievable goals encourages a positive mindset toward recovery.

Vascularisation - pain-free cardiovascular activity such as swimming or hydrotherapy should be started 72 hours after injury to increase blood flow to the injured area. Being able to participate in an activity boosts motivation.

Exercise - functional movement helps to restore mobility, strength and proprioception (how you sense the position and movement of your body) early after injury, without overloading the new tissue.

Long-term care for soft tissue injuries

Soft tissue injuries can take 6 weeks to a few months to heal, and longer to regain mobility, and strength and be pain-free. That sounds rather daunting but there are various solutions to help long-term care for soft tissue injuries, without resorting to prescription pain medication, steroid injections or surgery (although there are instances where these methods might be appropriate).

  • Homeopathy can be taken immediately. This includes applying Arnica cream to relieve pain and reduce swelling. If taking it internally, it would be advisable to check with your pharmacist for any interactions with prescribed medications. Ruta graveolens is recommended for strained ligaments or tendons, as well as fractures.

  • Apply heat after 48-72 hours, such as a warm flannel or heating pad, for 10 minutes two or three times a day. Heat increases blood flow to the area to promote rapid healing. Alternatively, apply a warm compress with diluted apple cider vinegar to increase blood flow and help prevent clots, after the first 72 hours. Caution should be taken when using apple cider vinegar, as it could cause irritation to people who have sensitive skin. The compress may be left on the injury area for up to 2 hours. Wrap in cling film to prevent dripping. Apply a heat pad for 10 mins every 30 mins.

  • Epsom salt baths may help reduce swelling where there has been a bony injury around the joints.

  • Bromelain tincture or supplements is an enzyme found in pineapples. It is a natural anti-inflammatory but may not be used by people on blood thinners.

How much rest should I have after a soft tissue injury?

Unless you have specifically been told by a medical professional to completely immobilise and avoid loading the injured area because of the nature of your injury, it is important to make some gentle functional movements from the outset. This will help to restore mobility and strength as the tissue begins to heal without overloading the new tissue, known as scar tissue.

Scar tissue is a fibrous tissue that forms when the original tissue is damaged. It starts to form within 24-48 hours of the injury, peaks around 3 weeks and usually stops at 6 months. New scar tissue is dynamic and pliable, so it is important to train the new tissue before it becomes less pliable, as it lacks elasticity when it matures. Functional movement provides the fibres with mechanical input which is then stored as cellular memory.

Bowen and Functional Movement for soft tissue injuries

Bowen therapy helps to regulate the nervous system and, in the case of pain caused by soft tissue injuries, pain receptors. The gentle rolling-type moves are applied directly to soft tissue, releasing any restriction, and encouraging blood supply to the area and excess fluid away from it. Bowen therapy is known to promote healing after injury, reduce swelling and pain and aid in rehabilitation and function.

Functional movement is an activity in which a specific area of the body is designed to move. This may include mechanical loading, rotation, flexion, extension, balance, interoception - sensing how the body feels, and proprioception - how the body knows where it is in the space. Functional movements retrain the body after injury and improve proprioception, to prevent further injury.

Final thoughts

What about the ice, I hear you say? Well, it has its purposes but for the acute phase of soft tissue injuries, it is no longer recommended. For pain management, ice may be applied for no longer than 5 minutes at a time just 4 times a day, to provide a local analgesic effect but be aware that this may cause delayed and incomplete healing.

A soft tissue injury takes a lot longer to heal than most expect, so it is important to follow the advice given and be consistent with the gradual process of recovery. Some injuries take longer than others. Some people take longer to fully recover than others. Due to underlying conditions, some may experience longer-term restrictions or discomfort.

If you have recently suffered an injury and you would like further advice on rehabilitation please call 079687226464 or email If your injury occurred some time ago and you still have pain and restriction or you have general mobility challenges, Bowen combined with a personalised functional movement programme will help restore your well-being.

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