Ice as An Aid in Athletic Rehabilitation: Dr Hal Rosenberg discusses

Dr Hal Rosenberg great discussion on the benefits of ICE over heat. Golden Rule of Foot: When in Doubt, Ice. 

Heat vs Ice: Accupuncture vs PT (Email Exchange)

The following is an exchange with Ahab following his injury to the sesamoid bone under his big toe. Ahab later finds out the sesamoid bone is broken. 

Hi Dr. Blake

I took 2 tablets of aleve twice a day

for 3 and half days

it brought down the swelling, but i was having

reactions to the meds

should i just reduce the quantity ?

is it really going to reduce inflammation for good?

or is it just while the drug is in my body?

Any thoughts?

Or thoughts on ice/heat?

Some say never ice - because it prevents blood flow?

others say ice forces blood to flow later?

Thanks,

Ahab


 Dr Blake's response:

Ahab, 

Still not sure what your diagnosis is? Rich (Ahab was able to send his MRI Report noting a fractured tibial sesamoid under the big toe joint)

Thank you very much for you responses. I know I can't look back - but I was being very conservative

for two months - then i thought 'maybe i need PT' - the podiatrist gave me a prescription over the phone

withouts seeing me - even thought I told him - 'how do i know if i'm ready for pt'? 

Dr Blake's comment: At this time no one knew the sesamoid was broken.

he told me the PT he send me too only worked on feet. She was super confident and told me

to drop the boot and cane, to wear regular shoes, and she manipulated the big toe, wrenching it

painfully to "get it moving again' - then she had me walk directly on it - saying that it would get the 

blood flowing, and that the pain was ok. I walked directly on it for a week in regular shoes - until I 

couldn't do it anymore and questioned her reasoning. I saw her one week later - and at that point 

the foot was very very swollen - that's when I asked for crutches, and that's when the podiatrist gave

me a prescription for an MRI. My question is: obviously the PT did the wrong thing, not knowing

that my sesamoids were injured - how much damage did she do? Is this going to make the recovery 

take longer? she also had me lifting marbles with my bad foot, and she said : "bend it as much as possible,

you can't hurt it by bending it" - I was trying to make it bend like the good one. 

Do you think turned back a lot of the healing which had taken place  in the first two months?

An acupuncturist recently said to me that 'ice is for dead people' - and to not ice the foot. I've stopped

icing recently, and there is a lot of swelling. I've been told that this is the body's natural way to

heal the injury. Is that correct?

Dr Blake's comments:

Ahab, You are basically getting advice that is canned (meaning protocol driven, with little to no thought behind it). A thoughtful PT does not increase pain, and understands that without MRI the diagnosis is unclear and caution must be taken. With sesamoid injuries, without a clear diagnosis of the extent of damage, you have to treat the worse case scenario (ie fracture). PT can be used to reduce inflammation, gradually start you strengthening your foot, etc. The PT did not damage you further, may have forced the issue in getting the MRI you needed, but definitely caused a setback (we don't need these physically or emotionally). I try things all the time to help problems, that cause another problem that I have to deal with, or aggravate a condition, so I do not like to cast the first stone. The accupuncturist should become a healer. No acupuncturist that I know will recommend ice. It is not in their training. But, it I practiced at the level of my training 30 years ago, I would not being doing a good job. Golden Rule of Foot: When what you are taught doesn't work on all patients, discover when to use your skills, and when to modify them.  Have them read the literature on the effectiveness of ice. Hunter's Response is proven. Ice reduces inflammation and helps healing period (end of sentence). I know when accupuncture will work for foot problems and when not. I love accupuncture to reduce swelling and relax nerves, etc, but all my patients who go to accupuncture ice pack the area when they get home. Rich

My Niece Kelley many years ago in an Ice Bucket

Rich,

You have obviously treated many sesamoids - so I am leaning towards your advice.

I have been icing continually - and the swelling was down. Ice seemed to mask the pain.

I read something about - 'inflammation is the body's natural way to heal' - so stopped icing

on friday night. By this morning the foot was all swollen again. If you say to continue icing,

 I will do that. I'm seeing another podiatrist on Monday who has supposedly treated many 

sesamoids - this podiatrist wants to see the images with me - which I think may be a good 

sign. The podiatrist who ordered the MRI didn't even mention the word fracture to me - 

I had to order the report myself to see that word - he later told me "Patients don't like to hear

the word fracture." - If he's trying to avoid giving accurate information - I don't know. He didn't

even recall how I received the injury when I went for a follow up after the PT. He thought I just

stubbed the toe, instead of going straight up on it. 

My question is - you recommend icing for your patients with sesamoid issues with the purpose

of having new blood flow into the injury? Is that correct? Icing certainly makes the foot look

less frightening 

Is the sesamoid bone actually inflamed? If it's not displaced, then why does it seem to be 

pushing out further on the injured foot as opposed to the uninjured one? Or is it the tendon

around the bone which is inflamed and giving the appearance that the bone is pushing out?

Extremely grateful for your help,

Ahab

Dr Blake's comment:

Ahab, Here are 2 links to look at. 

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

http://www.sportsinjuryclinic.net/treatments-therapies/cryotherapy-cold-therapy/effects-cryotherapy-cold-therapy

Rich,

Thank you for these links. I put ice on my extremely swollen feet, and they were immediately feeling better.

When I don't ice the swelling can be so great that it is clear, or seem to be clear that 'something must be done' - if it's not 

ice, then it has be another method - perhaps an acupuncturist would know. I can apply ice myself. 

this was a response (not to your icing links - but to your email mentioning Hunter's  Response from an acupuncturist) - 

do they make any sense to you?

"Ice is very useful for preserving things in a static state. It slows

or halts the decay of food and dead bodies but does not help damaged

tissue repair itself. Ice does reduce the initial swelling and

inflammation of a fresh injury, and it does reduce pain, but at a

cost. Contracting local blood vessels and tissues by freezing them

inhibits the restoration of normal circulation. The static blood and

fluids congeal, contract, and harden with icing, making them harder or

impossible to disperse later. It is not uncommon to see a sprained

ankle that was iced still slightly swollen more than a year after the

original injury.

Cold causes contraction of the muscles. When you go out on a cold day,

the muscles contract automatically to produce warmth. You can feel how

the body literally draws into itself when exposed to the cold. Every

athlete knows that it is harder to stretch and easier to pull a muscle

in cold weather. Icing an injured area causes further contraction in

muscles, ligaments, and tendons that are already contracted in

reaction to being overstretched. This further slows the natural healing

process and prevents the return of normal movement.

Acupuncture has five effective alternatives to icing: emergency

acupoints to move energy, kill pain, and stimulate circulation;

cupping and bleeding the local area to actually draw out and disperse

blood and fluid that is coagulating and blocking normal circulation -

often reducing pain immediately; self-massage with liniments such as

trauma liniment that move blood, reduce inflammation, and kill pain - 

removing static fluids and blood and reducing swelling; energetically

cooling herbal poultices and plasters that reduce inflammation and

also stimulate circulation and help torn muscles and tendons heal; and

herbal pills or powders that are taken orally to promote blood

circulation and prevent blood from stagnating further.

If you ignore all of this and decide that you simply must ice, try to

apply it for only ten minutes every hour. This will help to reduce the

swelling while minimizing negative side effects as listed above."

Dr Blake's comment: I love acupuncture (even though I rarely spell it correctly), and this discussion is really not about Amir getting acupuncture, it is about when during each day during these next 6 to 12 months of healing should he use ice. 

Thanks,

Ahab

Dr Blake's response:

Ahab,


 Thanks for the fun exchange. Just remember that you should always feel better after icing or heating an area. In sports medicine, ice and heat are used a lot and in many different forms. Accupuncture is wonderful tool to help in many ways. I look at ice therapy and accupuncture as both ways to improve circulation and healing when done at the appropriate time for an injury. Since you get injuried, then go through various periods or moments of re-aggravation ice can be used following these flareups for many months. I had to ice my shoulder after I played basketball for 7 months, but it allowed me to keep playing. I would heat the shoulder up before, and then ice it down after. This is very common. Golden Rule of Foot: When In Doubt, Ice. Heat  when used at the wrong time is the cause of too many set backs. Ice, as long as you do not produce frost bite, rarely causes the increased swelling which is our Enemy in a sports medicine practice. Golden Rule of Foot: Swelling slows healing and must be treated daily. A great form of anti-swelling measure is Contrast Bathing. It can be started 4 days after an acute injury, and normally several days after each flareup like you had. Make sure you learn this powerful tool. Rich Good luck. I will place these emails on my blog because it is a common battle. I hope both sides are laughing alittle. Listen to your body after you try anything. Know that as your symptoms change daily/weekly, you may have to change how you are using heat and ice at home, or with a health care provider. Rich If ice feels great, so be it. If ice irritates, and you do not know how to change the method of application or time utilized, change to one of the many forms of heat. I do not believe however that chronic swelling after an ankle swelling can never be proven to be linked to the ice program. How is that possible to make that correlation? LOL I hope at least one of my readers can see how wonderfully gifted health care providers can get caught on generalizations, and won't change when the exceptions walk into the office. 

Ice or Cold Therapy helps in Injury Rehabilitation

Golden Rule of Foot: When in doubt to heat or ice, use ice.

The goal of ice or cold water is to control inflammation, minimizing the swelling which occurs following an injury, or an aggravation of a previous injury. Why is this swelling so bad? Actually, swelling does get a bad name. With this increased blood flow to an injured area, the body brings in the building blocks for healing that injury. Very important!!! However, the body normally over does it, opening the flood gates to excessive swelling that can get in the way of healing. A simple ankle sprain can be swollen for weeks and weeks. It is the excessive swelling that slows the healing process by cutting off the micro-circulation to the area. Chronic swelling in the achilles tendon for example has been known to completely stop the healing process. This excessive swelling also adds excessive stiffness, adds instability by floating joint surfaces, and interfers with normal motion. It is the excessive swelling that must be minimized by immediate treatment of acute injuries or sudden aggravations of previous injuries.

There will soon be a post of R.I.C.E. therapy for acute injuries that everyone learns in high school/college, but somehow most forget. The I. stands for Ice. As soon after an injury you can put ice on, the faster it will heal!! All athletes know that by controlling the swelling, injuries heal so much faster.

The basic sciences teach us that the inflammatory phase of an acute injury lasts around 4 days. Heat in any form is considered the enemy during this time. Therefore, most teach ice for 72 to 96 hours after an injury or aggravation, then switch to heat only. This, however, does not take into account that symptoms will go up and down based on gradually getting back to full activity. Therefore, ice can be used in some form or another for months. I commonly recommend an ice pack or soak after strenuous activity during the return to activity period for 2 weeks longer than anyone (doctor, therapist, or patient) thinks necessary. It is that important.

Ice gets a bad name since it minimizes blood flow after those initial 4 days. Some believe ice should never be used after the first 4 days. But patients continue to push the limits as they rehab, needing ice sometimes for up to a year after strenuous activities. We all want normal to better blood flow after an injury. But excessive blood flow from utilizing too much heat at the wrong time (following aggravation) can slow the healing way down.

The best way of applying ice is soaking with ice water getting the temperature around 55 degrees. The patient in the photo above is ice soaking for 20 minutes following a cortisone shot to the heel. This is usually attained by cold tap water and 1/2 tray of ice cubes in a 3/4 filled basin. However, if you have cold sensitivities, poor circulation, or are experiencing nerve pain, please consult your doctor/therapist before using this cold environment. Soaking in cold water is normally for 20 minutes, and the foot remains stiff for approximately 1 and 1/2 hours after this. No physical activities are allowed in this time period. The stiffnes could lead to other muscle pulls, etc.

Ice can be applied sometimes easier, and less painfully, with cold packs. These may or may not be reusuable. Never use a reusuable ice pack that is stiff; it should be soft and malleable when applied to your skin. Normally, these can go directly onto your skin, but many prefer a moist towel between the ice pack and the skin. Some skin surfaces are too sensitive for direct ice secondary to nerves or bony prominences. The towel must be moist with cold water to allow the full effect of the cold to penetrate your skin. Patients have used frozen peas as ice packs for years successfully. Supposedly, frozen corn or mixed vegetables hold in the cold better due to the denser material and last longer. Definitely mark the packages "Do Not Eat." You can use ice packs 20 minutes every 2 hours to quickly calm an inflammed area as long as you pay attention to the circulation. Unless you have to ice pack the bottom of your foot, most patients can perform ambulatory multi-tasking with ice packs somehow secured to enable them to get around. Ice soaking does not allow ambulatory multi-tasking.

When you have a small inflammed area, like a bunion, you can use ice massage effectively. Take an ice cube in a towel, and using circular motions, gradually massage the area for 5 minutes. As the minutes pass, massage deeper and deeper into the tissue. The massage helps push out the fluid, while the ice calms down the inflammation. Ice and massage is a powerful way of eliminating inflammation. Many will freeze water in a dixie cup, peel away the top of the cup, and then massage. The frozen sport bottle routine for plantar fasciitis is another example of ice massage commonly utilized. Fill a plastic bottle 1/2 with water and freeze it standing up (not you the bottle). The water expands during the freezing process. Place a towel on the floor and then the bottle. While you are sitting or standing, gradually with more pressure roll the sore area over the bottle for 5 minutes. You get the most effective self-treatment ever by mixing anti-inflammation, massage, and stretching of the injured tissue. After a 5 minute ice massage, the area remains tight for 30 minutes, so avoid strenuous activity during this time. For example, do not run right after ice massage.

The final form of ice used commonly is Contrast Bathing. Please see the post entitled "Secrets of Contrast Bathing" for a full discussion. This slowly introduces heat into the rehabilitation.

Soaking in warm water after the first 4 days of an injury or aggravation in a mild injury is very soothing. The injured area normally feels great with this for 1 or 2 hours, but then the negative effect of the heat may surface causing overall more swelling and stiffness. As you start to use heat, be willing to listen to what your body is saying. Generalizations may say one thing, but your body the other. Only if you understand the basic principles, can you experiment successfully with these very powerful tools of rehabilitation: Heat and Cold. I hope at least some of the basic principles are now clear.