Where Did The Idea for Icing Injuries Come From?

Well, obviously it didn’t come before 1845, when Dr. John Gorrie made the first ice making machine. Icing injuries, since our control over our ability to make ice was incredibly limited, is not an innate solution to healing injuries. So, where did the idea for slapping ice on an injury, wrapping the injured site tightly, and sticking it up in the air come from?

In 1962, a 12 year old boy by the name of Everett Knowles was heading to baseball practice in Somerville, Massachusetts. To get there, he decided to hop on a freight train. Unfortunately, a jerking motion in the train caused him to fall off the train, hitting a stone abutment, severing his right arm clean off his body. He took his arm to the hospital and what happened next changed the course of the sports medicine industry forever.

At Mass General Hospital, Dr. Ronald A. Malt, having seen the boy and the arm, realized they might have a chance to reattach the arm. Up to this point, this had never been done. While gathering the necessary doctors who could perform the surgery, he told the nurses to “put the arm on ice.”

It made sense. What do you do with meat so it doesn’t rot? Put it on ice. What do you do to preserve a severed body part in the hopes of reattaching it? Put it on ice.

To prevent a bleedout, they used a tourniquet on Knowles’ shoulder and kept him upright to keep the injury above the heart.

The surgery was a success. Over time, young Everett Knowles regained full function of his arm. When he threw a baseball for the first time after the injury, it made worldwide news. Because of the success of the surgery, Dr. Malt toured all over the world, describing the scene and educating medical professionals on what to do to save a severed limb.

Over time, the process got taken by the sports medicine industry to heal injuries. “Put the arm on ice” became “Put an ice pack on the injury.” “Use a tourniquet to prevent a bleed-out,” became “Compress the injury.” “Keep the severed area above the heart,” became “Elevate the injury.” We will discuss the ‘Rest’ portion of the R.I.C.E. protocol in a moment.

This protocol became so prevalent in treating sports injuries that in 1978, after observing the phenomena, Dr. Gabe Mirkin coined the term R.I.C.E. in The Sportsmedicine Book. And so the legend became cemented as a treatment option for sports injuries.

That is the history of the R.I.C.E. protocol and why people ice injuries. It is not based in science or fact. People took a protocol used for a completely different use-case and applied it to minor injuries, believing it would have the same benefits.

If you want to know why you shouldn’t ice your injuries and also why the rest of the R.I.C.E. protocol shouldn’t be used either, make sure to check out my first blog on ice.

If I Don’t Ice, What Should I Do Instead?

Firstly, let me just say this: heat, contrast therapy, and compression garments are not solutions to optimally healing tissue. I will write about this at some point, but we cover those details in the podcast linked above.

There was a longstanding debate between physicians long ago between rest and active recovery for healing tissues. Actually, a lot of it was happening around the time the first ice-machine was made.

Some physicians, like Hugh Owen Thomas (1834-1878) believed that for a surgeon to promote healing, he should prescribe rest for their patient. Furthermore, he maintained that an overdose of rest is impossible. Many physicians agreed with him. They formed one camp in the recovery debate.

The other camp argued that the loading of tissues (active recovery) after an injury was the better solution for healing injuries. Julius Wolff, in 1892, suggested that positive changes in bone occur due to loading. He based this off of many observed mathematical principles. This became “Wolff’s Law” and has been expanded to include connective and muscular tissues.

Today, we know that muscles, bones, connective tissues, and more face positive outcomes when the appropriate loading and activity is applied. That means that active recovery can have many benefits to healing injuries. Let’s discuss some of these benefits, as outlined by Gary Reinl in his article Healed!:

Skeletal Muscle:

• More rapid decrease in bruising and inflammatory cells.
• Accelerated and optimized tissue regeneration.
• Increased strength and stiffness.

Fibrous Tissues (Connective Tissues Such as Tendons and Ligaments):

• Increased strength and size.
• Improved organization and collagen content.

Bones:

• Increased bone formation.
• Increased bone density.
• Increased bone volume.
• Increased bone strength.

Many of these benefits are a result of providing the body with the appropriate stimulus to maintain muscle, connective, and bone tissue by simply using it. Also, active recovery helps optimize the inflammatory and healing process (remember, inflammation is not bad).

If loading tissues after injury and active recovery are so great, what makes rest so bad? Well, I got another list for you. Here is what happens with too much rest for damaged tissues:

Skeletal Muscle

• Muscle atrophy (loss).
• Poor organization of cell regeneration.
• Decreased strength.
• Increased risk of reinjury.

Fibrous Tissue

• Decreased stiffness.
• Decreased strength.

Bones

• Decreased bone density.
• Decreased bone strength.
• Increased risk of fracture.

When tissues aren’t used, they shrink in size, strength, and stiffness. They also don’t repair and remodel properly. Which, if you remember from your textbooks in high school anatomy class, are major steps in the healing process.

You probably feel like right now you have a lot more questions than answers. I can imagine you’re probably asking: “What do you mean by ‘Loading?’”, “Are you saying I should back squat on my sprained ankle?”, “Active recovery? Like, take a walk?”. All of these are valid questions, and the same questions I first had when I got onboard with the concept of not icing injuries.

What To Do, When To Do It:

In the 1999 paper “Loading of Healing Bone, Fibrous Tissue, and Muscle: Implications for Orthopedic Practice,” Buckwalter and Grodzinsky propose some general guidelines of when to implement loading to tissues after and how to appropriately do it.

According to the paper, our goal is to start implementing loading and active recovery practices once the acute inflammatory response is over and after the initial repair tissue has formed. In my interview with Gary Reinl, he stated that once the bleeding has stopped, he is ready to begin active recovery techniques.

This concept comes with a couple of caveats. One is that your physician should clear you for activity. The second is that the time that is required for the acute inflammatory response and initial repair tissue to form is dependent on: the type of tissue injured, the nature of the injury, and then your individual characteristics.

After minor injuries and certain surgical procedures where there is minimal acute inflammation and the tissues are still stable (not severed, segmented, and the blood supply isn’t compromised), loading can be implemented almost immediately. In these cases, the initial repair tissue will form within 3-10 days. If you rest, ice, compress, and elevate, this might take significantly longer.

In most cases of minor injury, the internal bleeding that occurs is usually gone within minutes. After this stage, Gary Reinl believes that the active recovery process can begin. In cases where there is severe internal bleeding, the goal is to solve the problem first (i.e. get to the hospital and have immediate surgery). However, these cases are rare. Reinl, who has overseen the treatment of thousands of athletes, rarely sees cases like this in sports.

What To Do:

Loading of tissues in the early stages after injury should be minimized. However, it can and should be done. As long as the injury fits the guidelines discussed above, active and passive movements as well as isometric muscular contractions can be used. All of this should not cause pain or fatigue to the injured area. According to Buckwalter, once the initial response phase subsides and the initial repair tissue has been formed, loading should be increased to promote further healing.

Gary Reinl discusses the MarcPro and H-Wave technologies in the podcast. These are non-fatiguing powered muscle stimulators that can activate muscle and load tissue without the need to create true motion that might harm tissue. Unfortunately, not everyone has access to these technologies. So, I will discuss some ways you can do active recovery on minor injuries without one of these devices.

I will discuss the pathway to healing using active recovery on a minor shoulder injury.

Shoulder Injuries

Remember, the goal here is to activate tissue to promote healing and decrease the process of disuse atrophy (the process of muscle tissue breakdown from lack of use). We are not trying to get stronger or improve our pitching speed. The guidelines for these exercises in the initial stages of recovery are to do them without pain or fatigue. That being said, these movements should be repeated often.

During the initial stages of recovery for shoulder injuries, one exercise that might be useful would be squeezing a stress ball. The contraction of the arm down the chain from the injured site will not fatigue or injure the muscles of the damaged site at the shoulder, but will help aid in the flow of healing supplies and clearing of waste by the lymphatic system. Doing this periodically throughout the day may be an effective way to enhance recovery.

As healing continues and the initial repair tissue has formed, increasing the motion at the shoulder itself will be the next step. Shoulder flexion (raising your arm forward), shoulder abduction (raising your arm out to the side), shoulder elevation (shrugging), and shoulder retraction (squeezing your shoulder blades together), will continue to promote the healing of tissue. At this point, you can fatigue the tissues slightly to promote muscle tissue generation and connective tissue strength. However, pain should still not occur throughout these movements, only muscular fatigue.

Moving forward, adding more complex components to your exercises will help reestablish neuromuscular control. These A, W, and T raises on a stability ball would be a nice progression to those simple movements discussed above.

From there, you can begin loading the tissues using external resistance. To ensure you are still promoting neuromuscular control and stability, two of the most important aspects to reestablish post-injury, using integrated exercises like these two drills below will be a good progression to your recovery protocol.

If you can do all of those exercises I mentioned above, you’re certainly a lot close to being fully healed! If you were to use ice without going through any of these steps, you would find yourself weeks behind the curve.

The R.I.C.E. protocol was brought to the sportsmedicine industry by mistake. Ice has now been used for nearly half a century as a healing tool for injuries that it only limits the recovery of. If you follow the advice laid out in this blog, I am confident that you will find yourself on the field more and injured less!

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References

Buckwalter, J. A., & Grodzinsky, A. J. (1999). Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice. The Journal of the American Academy of Orthopaedic Surgeons, 7(5), 291–299. https://doi.org/10.5435/00124635-199909000-00002

Petro, B. (2018, March 19). A Brief History of Ice. Retrieved August 02, 2020, from https://www.alcoholprofessor.com/blog-posts/blog/2018/03/19/a-brief-history-of-ice

Reinl, G. (2009, December). Healed! Retrieved August 02, 2020, from https://garyreinl.com/articles/Healed.pdf