What is an injury? A simple question? Really, let’s see. An injury occurs when? Pain, instantly, upon completion, the next day or the second day? Is the pain sharp, dull, achy, burning? Possibly electrical—pulsing or a zap?

Or maybe it’s just sore? However, how long has it been sore? Does it come and go? I understand. You will take some ibuprophen or a few aspirin and it will be fine. Or you’ll take a muscle relaxer, or some vicodin. Maybe it will just go away. No worries.

Does this sound familiar? The reality of ice therapy—no, fundamentally the most important factor in icing is: when it is appropriate, and how. Or more accurately, when is it not important.

If you are reading this article, it is safe to assume that fitness is an important part of your life. Fitness would mean, some activity, probably CrossFit, that incorporates you physically moving your body against the gravity of the earth. These physical stresses, though normal as they may seem, physiologically have incredible impact on your body. In participating in these activities, small strains and tears occur throughout the tissue of the body. These tears are injuries. Balancing activity and its physical strain, wear and tear, is a serious issue for an active person. Understand that taking an active role in maintaining your body also includes healing it. And, regardless of how idealized your life is, the breakdown of tissue, and your body’s inability to repair it optimally, can and usually is a constant reality. Icing is the simplest and one of the least invasive means to aid your body in healing.

Icing seems simple, but appearances can be deceiving. There are some key factors in regards to icing to produce great results. It is crucial to understand the area of injury and adequately covering it. Once you have located the injured area, place a finger tip on it. A radius of six inches should be calculated from the fingertip. This six inch circle is the minimal area of cold coverage. If you want optimal, then make that radius eight inches. Now when I say coverage, I mean the entire surface area of the skin is in contact with cold. Specifically, I am emphasizing the conductivity of the area. If the area is a digit, an elbow, knee, rear of the shoulder, or heal, then wrap the whole area six to eight inches from it in ice pack. If need be, an Ace or Velcro wrap should be applied to the bandages to ensure full surface coverage of the skin. Now that the area is sufficiently covered, we must be concerned with adequate temperature change.

The majority of athletes know that they should ice their little injuries, the nagging ones, the achy ones, and the new ones. But they don’t for a very good reason: They have tried and it didn’t really help. So they disregarded it. They may have covered the area well, but they got poor or inconsistent results. Why? The temperature difference between the cold object and the limb or body area was not significant enough.

Your cold pack must be adequate. It is physics. The rate of heat transfer of conduction is determined by the difference in temperatures, and the tissue thickness. So, if you do not own a medical grade cold-gel pack, you have one hope. If you said, “Use a bag of peas,” you get to go to the back of the line. Frozen food products are not cold enough. Actually, in my practice, the only thing that has gotten equal results to the cold packs is a mixture of rubbing alcohol to water, (2:1, sometimes 3:1) combined in a double lined, gallon sized, Ziploc bag. The rubbing alcohol allows the freezing point of water to decrease, thus achieving an adequately cold temperature. (If you make these, be sure to wrap them in a pillowcase, or towel, before applying to the skin.)

1. Adequate coverage;
2. Adequately cold temperature;
3. Now you need the third element: Time of exposure.

Time is a critical component to the physiological process you are attempting to induce. A minimum of twenty minutes will achieve good results. For optimum results, a 25 minute threshold must be achieved. (These are purely my subjective parameters developed over 10 yrs of rehabilitative practice.) If one can tolerate 30 minutes it would be ideal; however, the limitation is simply that the ice packs are not cold enough, thus the inability to maintain the temperature shift long enough to be beneficial. Most packs have a tendency to transfer a majority of energy after 20 minutes, leaving the pack insufficiently cold to continue the desired physiological effect after 25 minutes.

The time span is more challenging than most realize and is the biggest factor to consistent performance results. Some of you find it a daily ritual to sink off into a deep space, and let time flow by. For most, the idea of sitting still with a cold achy thing lying on a throbbing body part after completing an activity, or sitting down to eat or sleep, maybe a fantastic idea. However, what usually happens bears a resemblance to a Freudian flight of fancy in which the feelings of anxiety, paranoia, frustration, idleness, bleakness, and behaviors of annoyance, rocking, chatter, and boredom combine to make the experience a one time only endeavor. Planning ahead or using a regular schedule for icing is a primary step to conditioning oneself for success. Those that plan ahead typically develop an activity to pass the time. Thus, they are able to complete the optimal time line of 25 minutes, every time. This allows them to achieve maximum performance results. By increasing the rate of healing, they improve recovery time, decrease pain, and build confidence. Developing the belief in the ability of the body to heal allows one to remove an underlying doubt in the psychosis of the human animal, thus freeing up the mind to exist in the moment and push levels of performance, success, and satisfaction.

So what is the point for the coverage and the duration of the ice over the injured area? The effects of cold are two fold: Initially it creates vasoconstriction, thus decreasing edema by decreasing blood flow and constricting cells, removing excess fluid or exudates. The cold also decreases the metabolism of the cell. At first this may not seem appropriate, but when a healthy person damages cellular tissue, which is what occurs with an injury, the immune system can and does overreact. A rapid chemical shift occurs when cellular material and other proteins become disrupted, and the immune-bodies begin breaking down the material. This situation can rapidly get out of control, especially when arteriole or venule tissue is also disrupted. The cold slows things down and with the vasoconstriction decreases the amount of excess fluid that accumulates.

The cold also decreases pain. Specifically, it decreases the sensitivity of the nerves by decreasing the conduction of the nerve. Nerves are also very sensitive to the chemical balance of the system. So by slowing the metabolism of injured area, the nerves are also least affected by the injury. A second fold mechanism that can be utilized is vasodilatation of the area. After prolonged exposure to cold (20-25 minutes), histamines are released that dilate the arterioles and venules (arteries and veins in a major area). This allows the area to be flooded with nutrients and immune cells to aid in healing, as well as clear away toxins and degraded proteins.

These effects are very similar to interval, or pulsed, training, and fall in line with the theories of human dynamics and the physics of our human body. By inducing a pulsed cold stress, you are stimulating the body to react and heal itself. Icing is one of the most important modalities for healing a chronic injury. Chronic injuries are most inhibited by altered cellular biochemistry. A chronically injured tissue area has altered cellular metabolic rates and blood flow. Cold returns the tissue chemistry to baseline. Decreased nerve sensitivity is also crucial in re-establishing the cellular baseline through normalizing sensitivity.

It is true that heat also aids with chronic injuries, but it is best applied prior to usage and attempted range of motion (stretching). The heat aids in increasing blood flow to the area, which, when chronically injured, is usually decreased secondary to the disrupted biochemical balance. Heat also decreases the viscosity of synovial fluids, thus improving movement and decreasing anxiety.

There are contraindications for icing. Though I may have made icing sound like a cure-all, please do not apply cryotherapy methodology if you suffer from any of the following:

1. Decreased sensation in the affected area.
2. Decreased circulation due to peripheral vascular disease, venous insufficiency, or vasculitis
3. Cardiopulmonary problems. (Consult your doctor.)
4. Open wounds
5. Hypersensitivity to cold, i.e. local histamine reaction, evidenced by decreased blood pressure, increased heart rate, and faintness.
6. Active bleeding.

Injuries are a fact of life. We are a three dimensional form, with moving limbs, a rotating trunk and a shifting center of gravity, that moves over three dimensional surfaces, or displaces masses from one surface to another. The occurrence of random strains and failures is commonplace. Ice can be a great healer. Its physiological qualities are consistent and performance enhancing. The decreased pain improves quality of life. And realizing the power and amazing abilities of the human body through the simple application of a cold pack onto an injured area is extraordinary.

Mark Smith (yes, that is his real name) has been a Registered Physical Therapist for nearly 10 years. He has a long history of athletics and was once a competitive Bodybuilder (yes, we still make fun of him about that; we recommend you do as well). Mark is available for private consultation regarding acute and chronic injuries as well as performance enhancement. Mark will be a regular contributor to the Performance Menu and will be investigating topics central to Performance, Health and Longevity. Mark is the CEO of In Home Rehabilitation and Wellness.

This article was originally published in the Performance Menu Journal.  

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