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The use of cold dates back to early Greece, when snow, ice and cold water were used to combat inflammation.1 While probably one of the oldest modalities, there is currently much debate about the use of cryotherapy for acute injury, to the point that some clinicians are no longer using it. Current evidence suggests that cryotherapy is best for its analgesic effect and decreasing temperature,2-4 however, there may be negative effects if applied immediately after injury.5 Inflammation is a key component to injury healing and begins when blood vessels of the injured site are ruptured. Necrotic tissues release chemoattractants to the area, bringing in leukocytes that eventually turn into macrophages and start the process of phagocytosis. Growth factors and cytokines are then released to start the repair process. Although prolonged inflammation can impact healthy tissue, the initial inflammatory process is vital to preventing secondary cell death.6 The use of cryotherapy immediately following injury could slow the initial inflammatory process.
Acute management care recommendations began in the late 1970s, with Rest, Ice, Compression, and Elevation (RICE) by Gabe Merkin,7 who has since advised caution in using ice.8 There have been various iterations since, including PRICE9 and POLICE.10 The latest recommendation is PEACE and LOVE, which not only includes immediate care without the recommendation of ice, but subsequent management of the injury to enhance recovery.11
With any modality, it is imperative to understand how it will impact the tissue, and which modality is best to address the goals and outcomes. With cryotherapy, it is important to assess subcutaneous tissue, surface area, and amount of temperature change needed before choosing the type of cryotherapy and how long to apply it. It has been documented that subcutaneous tissue, body part, division level of the athlete, and sex play a factor in temperature change following ice application.12 Instead of ice being the go-to modality for acute injury, there should be a rationale for its use, parameters for optimum usage, and knowledge of what structures are impacted. |
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"The Effects of the Game Ready® vs a Frozen Elastic Bandage on Intramuscular Temperature" (Herzog et al, 2022) S-307. When comparing intramuscular temperature within the gastrocnemius following a 30-minute cooling intervention between a frozen elastic bandage or Game Ready®, there was no difference in the amount of cooling at the end of 30 minutes. However, within the 30-minute period, the frozen elastic bandage cooled quicker between 5-20 minutes. Once the cooling intervention was removed, there was no difference in intramuscular temperature during 25 minutes of rewarming. The maximum change in intramuscular temperature averaged 9.2°C, which occurred during rewarming between 5 min (Game Ready®) and 10 min (frozen elastic bandage). With both interventions effectively cooling the gastrocnemius at 1cm depth past subcutaneous tissue, the frozen elastic bandage is considerably more cost effective. However, there is a lack of information on optimal cooling, tissue temperature thresholds, and therapeutic impact of cryotherapy on physiological responses such as edema and secondary injury.
"Current Practices in Acute Musculoskeletal Injury Care: A National Survey of Athletic Trainers" (Beauregard et al, 2021) S-156. In a survey of current certified athletic trainers, representing 45% in the high school setting and 38% in the collegiate setting, respondents were asked about the physical agents used over the course/phases of an injury. In the immediate care of the injury, 93% of athletic trainers reported using an ice bag. The percentage of athletic trainers that used an ice bag before therapeutic exercise, after therapeutic exercise, or both were 2%, 59%, and 14%, respectively. An ice bag was used by 28% of athletic trainers during the return to function phase. The main rationale for using an ice bag during all phases was to decrease pain. If an ice bag was not used, the rationale was there were more effective treatment options, such as manual therapy. The survey highlighted the high variability in physical agents used by athletic trainers, representing inefficiencies and opportunities to improve patient care. |
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"Short-Term Effects of Cold Therapy and Kinesio Taping on Pain Relief and Upper Extremity Functionality in Individuals with Rotator Cuff Tendonitis: A Randomized Study" Durgut et al, 2024. This study examined the effects of cold therapy (ice bag) and Kinesio taping on individuals with rotator cuff tendinosis on pain intensity, upper extremity function, shoulder range of motion, and grip strength over three days. Cold therapy was only beneficial at resting and night pain relief, while Kinesio taping had a positive impact to activity pain, function, range of motion, and grip strength. If pain relief is the goal, either cold therapy or Kineso taping could be used in conjunction with a rehabilitation program. However, Kinesio taping may be more effective at improving other impairments such as grip strength and range of motion.
"Cold for Centuries: A Brief History of Cryotherapies To Improve Health, Injury and Post-Exercise Recovery" Allen et al, 2022. This invited review provides a brief historical perspective of the origins of cryotherapy, which continues to be a popular recovery and treatment modality, recommendations from research, and future direction of cryotherapy use. For cold water immersion, recommended protocols of 10-15 minutes in 10-15°C are needed to promote recovery, while 11 minutes at 10°C is needed to reduce muscle temperature. Evidence for the use of ice bags is limited, with management protocols moving from RICE to PRICE, with the removal of ice altogether with PEACE and LOVE. It is important to take into account thermal gradient, temperature and duration of cooling, and surface area when cryotherapy is considered for treatment.
"Management and Treatment of Ankle Sprain According to Clinical Practice Guidelines: A PRISMA Systematic Review" Ruiz-Sánchez et al, 2022. This systematic review addressed clinical practice guidelines on ankle sprains and included levels of evidence and grades of recommendation. Regarding cryotherapy, it was highly recommended in 3 of the 4 articles that cryotherapy was part of the rehabilitation guidelines to reduce pain in the acute phase of injury over analgesic drugs. One article showed low effectiveness when using cryotherapy in the recovery phase. It was suggested to only use cryotherapy in the acute phase for pain management.
"Multiple Cryotherapy Attenuates Oxi-Inflammatory Response Following Skeletal Muscle Injury" Zembron-Lacny et al, 2020. Participants completed whole body cooling (3 minutes exposure, -120°C, 2 times a day for 7 days) or a control condition to assess circulating markers of skeletal muscle regeneration in blood samples. While whole body cooling did not impact the markers of skeletal damage, there was a significant reduction in reactive oxygen, nitrogen species, and numerous growth factors. This indicates that whole body cooling attenuates the injury-repair-regeneration cascade delaying skeletal muscle regeneration. |
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REFERENCES 1. Swenson C, Sward L, Karlsson J. Cryotherapy in sports medicine. Scand J Med Sci Sports. Aug 1996;6(4):193-200. 2. Kerkhoffs GM, van den Bekerom M, Elders LAM, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46:854–60 3. Martin RL, Davenport TE, Paulseth S, et al. Orthopaedic Section American Physical Therapy Association. Ankle stability and movement coordination impairments: ankle ligament sprains. J Orthop Sports Phys Ther. 2013;43. 4. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52:956. 5. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48:528–45. 6. Tidball JG. Mechanical signal transduction in skeletal muscle growth and adaptation. J Appl Physiol. May 2005;98(5):1900-1908. 7. Mirkin G and Hoffman M. The Sports Medicine Book.1978. Little Brown and Company. 9. Bleakley CM, O'Connor S, Tully MA, Rocke LG, Macauley DC, McDonough SM. The PRICE study (Protection Rest Ice Compression Elevation): design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain. BMC Musculoskelet Disord. 2007 Dec 19;8:125. 10. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012 Mar;46(4):220-1. 11. Dubois B and Esculier J. Soft-tissue injuries simply need PEACE and LOVE. Br Journal Sports Med. 2020;54:72-73. 12. Jutte LS, Merrick MA, Ingersoll CD, Edwards JE. The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Arch Phys Med Rehabil. Jun 2001;82(6):845-850. |
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This content was developed in part by Noelle M. Selkow, PhD, ATC; Chris Hamlyn, EdD, AT, ATC, CSCS and the NATA Foundation Educational Resources Committee. |
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