Trigger Warning: You’ve Got to Stop Icing!

Ice

We have the right to change our minds. Remember that thing called prohibition? Or that time when Doctors advertised cigarettes? Maybe you grew up not needing a seatbelt in the back seat? Remember the advice to new mothers in the 1970s that formula was better for babies than breast milk? Or the idea that drinking water during practice made you weak? Remember trans-fats? Or Olestra? Those things seemed like a good idea for a minute until they didn’t. 

See what we did there?

Olestra aside, we sometimes operate with incomplete information (okay, we always knew Olestra was probably a poor idea based on the leaking issues on warning label…). Being a human being means making the best decision with the best information at hand and making better decisions when that information becomes more complete.

When it came to the use of ice to treat injuries, it has always pretty much just been a given. I iced in high school and in PT school and we never thought to wonder if it was doing what we thought it was doing.

So what is it doing? Icing injuries that is. 

Ask yourself, “why do we ice?”

If you were part of the well indoctrinated like me, your answer probably fell into one of two responses. The first was likely “for pain” and the second was “to stop swelling.” You aren’t wrong because ice actually does both of these things well. It just turns out that we asked the wrong question. 

So how about asking these two questions instead: (1) Is the body’s healing response to injury a mistake? (2) Does icing help my body remove the congestion from the injury?

Even without a doctoral degree and a truckful pathophysiology coursework, the answer to those questions is a pretty clear “no.”

About ten years ago, I was presented with these same questions by Gary Reinl, author of the book Iced. I knew Gary worked with literally every rehab team in professional sports and that he had a technology that could maximize healing times. What I didn’t realize was that he would ultimately present me with a simple but profound question: “How does the body remove congestion and swelling?” 

As you will see in our interview, I’ve spent the last decade trying to convert people back to the idea that movement (muscle contraction) is the best way to reduce congestion in injured tissues. I’ve been working with the company HWAVE for almost a decade and their device is the best at decongesting tissues.

Do you know what doesn’t help reduce congestion in injured tissues? You guessed it, icing.

Back in 2012, I was naive enough to think that if Gary and I had an informal conversation about icing on camera, we might just move quickly past a few decades of operant conditioning and knee jerk ice that ankle-ing. Boy was I surprised when the collective reaction on the internet was short of hatred and disbelief. “What? The Earth is Round?! Ha hahahahaa…”

Fast forward another eight years and the mood may have shifted a bit. I’ll be completely transparent in that being on the correct side of outcomes, science, and logarithmic anecdotal experience helps a bit. We still thought we should take a moment and revisit the original idea.  Both Gary and I are a bit more experienced at telling the emperor he’s wearing no clothes. And, that his clothes are getting in the way of his body’s ability to heal itself.  

Before you freak out, let me leave you with a couple of ideas. If your kindergarten-aged daughter freaks out and needs an ice pack, tell her there is no science to support her need for a placebo. Just kidding, don’t do that. Give her an ice pack. But also tell her there is no easter bunny. I kid again. She isn’t going to ice that booboo for long anyway.  

And.

We all have the right to change our minds when better information comes along.  As they figured out in the prohibition experiment, Bourbon is better with some ice. Enjoy this conversation with Gary, and don’t take our word for it. Go see for yourself.

– Kelly   

35 thoughts on “Trigger Warning: You’ve Got to Stop Icing!

  1. Avatar
    Greg A Padovani says:

    Hey KStarr,

    How does this apply to cold showers after training…..?

    Your input on this is greatly appreciated.

    Warmly,
    Greg

    • Kelly Starrett
      Kelly Starrett says:

      Dropping core temp post training is fine! Heating and cooling the body is expensive and can delay the business of adaptation to the training stimulus. This different still than even an ice bath post training which may blunt adaptation as well.
      Besides, you have to stop sweating before going to work…#theshowermusttake

  2. Avatar
    Paul Cronin says:

    Excellent education for this athlete. Twelve weeks out of full knee replacement, and working to get back to winning. Over the last 12 weeks my estem has worked better then ice. Now I guess it is time to try H-Wave.
    Thank you,
    Paul

  3. Avatar
    Kim Suarez says:

    This blew my mind! I’m currently 2 weeks post op from ACL surgery based in Oakland and while I’ve been using a Compex estim device, I’ve been heavily RICE-ing as well. My flexion is really poor and I’m not recovering as quick as I was hoping. After listening to this, I’m going to blast the estim and move more. I know you’ve worked with ACL rehab previously. Is there anything else to recommend in this sense?

  4. Avatar
    Andrea Dowd says:

    Interesting subject matter, this is the elephant in the room in therapy. I feel like it is not so black and white and we must be conscious of this. If you have someone with an ACL and menicus repair- there are limitations with movement initially after the injury- and ice is to be there to decrease pain and inflammation- if we were to move the joint too early we can then cause more damage. One thing I learned in University is do your research- one person’ opinion is the lowest level of evidence. Unless there is a randomized control trial double blinded study ( highest level of evidence. We need to decide what is it we need to do.

    Certified Athletic Therapist

    • Kelly Starrett
      Kelly Starrett says:

      Hi Andrea! You are right about protecting ranges after surgery. Please remember that I’m a physiotherapist as well as a coach. Our experience across sport and surgeries is that we have superior outcomes with no icing but with focus on decongestion. I appreciate that there are indeed nuances, but physiology is physiology. Did you have a chance to watch the whole video? Kel

      • Kelly Starrett
        Kelly Starrett says:

        I’d add, that if we are brave enough to take on flexion and spinal pain, opiates, and debunking pseudo science, we can look at current practice with them same eyes.
        In my own home/family alone:
        Two breast cancer surgeries
        Three hip replacements
        1 ACL injury
        1 shoulder scope
        Terrible spiral fracture
        Sprained knee….
        Two things:
        Give it a try and see what you think
        Flip this on its head and show the clear RCT’s supporting icing which is the active intervention. So the burden is on the icer to prove what they are doing is better at healing and return to play.

        Kelly

  5. Avatar
    Fred says:

    Kelly,

    What would be the recommended number of times per day to put on the electrical stimulation device and for how long each time?

    Thx,

    Fred

    • Kelly Starrett
      Kelly Starrett says:

      Hey Fred,
      We can walk and move as much as we are able. The same is true of these technologies like h-wave when they are available. We have our athletes pumping 24/7 when they are recovering.
      Intermittent compression like voodoo flossing
      NMES
      Normatec
      Compression socks.
      Etc.
      Kel

  6. Avatar
    Steven says:

    Would it be possible to have a basic list of possible activation options, for more common injuries, when an H-Wave is not available?

    • Avatar
      Trey says:

      Agree. I watched the whole video and have been preaching the “don’t ice” recommendation for some time now. This video puts things into good perspective. But if H-Wave isn’t an option, a list of next-best options/modalities would be useful. You noted Normatec and compression socks above, some more specifics about frequency and duration and other best practices would be super. Thanks KelStar!

      • Avatar
        Todd says:

        Tough to go wrong sticking to TRS principles. My summarized spin on them: Move as often and as completely as you can. Use the best tools you have access to and most accessible activation option will always be a combo of gravity and movement.. Find a pool and you add a wonderful compressive force. If ever it feels sketchy, it’s sketchy, back off.

  7. Avatar
    David khalfin says:

    Very interesting! So I see all these crossfit giants deep into the ice bath after each competition. The idea behind it, I am guessing, is to num the body and decrease the damage to the tissue…
    So, now given this interview, does this mean that the athletes are better off to keep activating their muscles rather than icing. It is hard to comprehend. I simply cannot imagine crossfitters to keep activating their muscles when all they want is rest before the next event…

    • Avatar
      Todd says:

      David, the device mentioned in the video generally offers a non fatiguing muscle contraction getting at the small red fibers. You can pump away without risk of further breakdown but also use your discretion.

  8. Avatar
    Yi Lan says:

    Thank you for the video, it was a very interesting watch.
    One thing came to my mind while watching the video. I remember recently seeing a few videos discussing NBA teams’ training crews, and it talked about how many teams have started using this cryochamber thing that was basically the opposite of a sauna. I don’t remember the exact mechanism of the therapy but it essentially boiled down to drastically lowering the surrounding temperature around a player who just finished playing a game.
    Does the consepts discussed in your video say that the cryochamber therapy is wrong? Or do you know if that therapy is intended for something other than recovery?

  9. Avatar
    Ryder J. Champouillon LAc MSOM says:

    Only use heat with my patients. Have Dr Mirkin’s retraction laminated and available at my practice and my box.

    Had the pleasure of a distal bicep rupture 18 months ago. Surgeon said immobilization for 8 weeks then start PT.
    7.5 weeks did 95 pullups and 10m handstand walk.

    How: I spent some time in the common sense corner, determined an outcome which was to optimize healing (not pain reduction) and did everything in my knowledge base to create that effect. Now i have a book outlining the hierarchy I used coming out soon.

    So thank you for your original post so many years ago, thank you from my patients who have remarkable results having learned that.

    #IceIsNotNice

  10. Avatar
    Beth Gilday says:

    Icing never made sense to me. It made more sense to keeping moving as much as possible. That would move the nutrients in, stimulate the removal of ware and debris and help the immune system. I love heat and dislike cold anyway, so I was looking for excuses to avoid cold.

  11. Avatar
    Basil Cunningham says:

    Hi Kelly,

    I love the way this debate has developed since the originally video back in 2012, thanks so much for revisiting. The problem I have with this debate is while it feels like there is more consensus around loading and utilisation of the lymphatic system especially with the introduction of ‘POLICE’ in most PT rehab programs, I feel that the issue of ice has not been properly addressed and most of what Gary Reinl says is based around the theory of how the healing process works which makes it just that a “theory” I firmly believe that you and him are right but the problem is when it comes to scientific research belief is not enough we need to test the hypothesis and prove or disprove it. Sorry if I’m missing something but where is the research, I feel like Gary Reinl and others has had 10+ years now to do some form of research but I am yet to see it. Might you be able to provide any journal articles as a reference to back up this message.

    Love your work Kelly, keep up the great content.
    Basil

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  13. Avatar
    Rolf says:

    Hey Kelly. So just like they put people post hip replacement surgery on pain killers so they can start moving again, wouldn’t It be good to ice just to get rid of pain so you can start using that joint again normally? A couple years back I partially tore my tibialis posterior, got X-rays to make sure nothing was broken and I stuck my foot in an ice bucket just to help me sleep and function through the day as needed. As soon as I could weight bear, I did and as soon as I could manage going iceless and use my foot, I did. I was off crutches in a month and was 100% in about 4. If I didn’t ice it I don’t think I would’ve been able to force myself back to normalcy as fast. Would icing provide some positive cost benefit in this case despite the fact icing delays healing? Thanks

  14. Avatar
    CJ says:

    This is very interesting, but the video is TOO long, I suggest summarizing the main points (or a shorter edited version) for most people who dont have 1 hr to watch it, especially because it is so repetitive…

  15. Avatar
    Matthew Gibble says:

    This has been mentioned to some extent in the comments above, but what is your feeling with joint replacements surgeries and ice machines that patients are prescribed to use; typically 20 mns out of every hour for weeks on end along with elevation?

    My wife went through this and this is the recommendation of the PT department with pre-surgery classes for candidates for knee replacement. She has had good recovery but now since being back to work as a teacher gets continued swelling after being on her feet all day.

  16. Avatar
    Todd says:

    Bit of a rant: Been on the no ice-wagon since you got it rolling. After a two-month stint teaching K-6 PE…imo…easier to teach kids not to ice. Harder to be present for them emotionally (with 29 other kids banging around) but easy peezy pointing out to them to do more of what they were already doing to solve the problem…shaking it and moving around. Very empowering to harness the healing superpower. I had a perfect record keeping them from the ice. They needed emotional security and I was happy to give it. Being present, I gave them options if “it” persisted. It never did. Kids got ice from other sources at other time and “it” became a whole tangle of concern.

  17. Avatar
    Ollie says:

    My question is about regular cold water exposure (non-injury related) and if this does potential harm, despite the immediate relief I experience.

    Essentially, I put my hands through a lot of abuse as a musician. After intense sessions, I regularly soak my hands & forearms in iced cold water (5-7 degrees, for approx. 10 minutes) at the end of a long day. I have been doing this proactively as a form of (I thought) body maintenance (reduced swelling/pain) and because it feels wonderful afterwards. I am also very diligent with hand/wrist/finger/elbow mobility exercises and am fortunate to say I do not have any injuries or chronic pain at all. It was simply proactive. However, listened to your talk has kinda turned what I thought upside down.

    Is what I am doing beneficial in any way (reduced inflammation / feels good) or would you advise to stop soaking in cold water all together after intense days?

  18. Avatar
    Lance Morrison says:

    (I don’t believe I saw this question answered above). I appreciated how Kelly mentioned that this wasn’t an advertisement for H-Wave. So, I hope there is some sort of less-expensive alternative? Does H-Wave serve a purpose with nagging injuries (not just post-surgery or immediately after injury)? If so, how can I not just maintain but improve lingering inflammation and discomfort around certain joints and connective tissue (which always flares up during and after my-workouts because of my movement patterns that I can’t seem to shake quick enough) without having to spend $$$$ on an H-Wave machine. I saw and heard the term “intermittent compression” above. I’ve also seen physiotherapist message tissue continuously. Does that type of stuff create a sufficient amount of “pumping” affect? Thanks for reading and hope to hear back! Please be elementary with your explanation as I’m very new to this. Thanks!

  19. Avatar
    Shakil Hafiz says:

    Kelly, is ARITA Also the best modality for overuse tendinitis, such as lateral epicondylitis? I am a family medicine physician, but every time I tried being consistent with weight lifting, my elbows start killing me. I can’t even lift up my kids. I’ve spent good money on compression devices and icing devices as treatment and prophylaxis for elbow tendinitis. Any advice?

    • Avatar
      Todd says:

      Kelly can chime in but yes ARITA IS great for overuse conditions but you first must do no further harm. Heavy lifting can irritate the condition. I recommend device mentioned in interview since it will load and decongest without irritation and also loading the tendon with eccentric work. Check out Theraband FlexBar and recommended exercises.

  20. Avatar
    Andrew says:

    Kelly,
    First and foremost great video and I love the content. I am DPT working in a physician owned clinic and want to make this a standard of care where I practice. Do you have any good links to high quality research that supports this?

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