Cryotherapy for Joint Pain: How to apply Ice Packs Correctly
Cryotherapy, the use of low temperatures for medical purposes, can be applied to a surprising variety of conditions. On this page we will investigate Cryotherapy in more detail and determine how we can use ice packs to treat joint pain and injuries. We will also look at the proper application of cold packs, other areas of their application, and the advantages professional ice packs have over home-made solutions.
Introduction on cryotherapy
Cryotherapy is the use of low temperatures to facilitate healing. This can range from a local application of ice packs to intentionally inducing hypothermia through special devices for cold therapy. When applied to the whole body, it can even cause the release of endorphins, which will provide additional pain-relief. Cryotherapy is commonly used to treat skin disorders (cryosurgery) and as a means to speed recovery after surgery (hilotherapy). Additionally, cold therapy is also being used to treat migraines and diseases for which you wouldn’t expect it, like abnormal growth inside the uterus. Finally, cold therapy has also found application in the field of fat loss for spot-reduction (cryolipolysis).
On this page we will focus on how cold therapy can be used to treat joint pain and injuries. More specifically, there are a number of factors you need to pay attention to when self-administering cold therapy and if you miss those, you will do more harm than good.
The RICE-protocol: cryotherapy via ice packs as first aid for joint injuries
The standard treatment for joint injuries starts with the RICE- protocol: rest, ice, compression, and elevation. When applying the RICE- protocol (or cold packs in general) there are certain things you need to pay attention to in order to get the most benefit from this protocol. Let’s look at why this protocol works first.
Why RICE works
The main goal of the rice method is to decrease joint swelling after the injury. The degree of swelling dictates how long the recovery will take, as the extra fluid will have to be transported away by the lymphatic system, which can take quite some time. Preventing excessive swelling in the first hours after the injury can shave weeks off your recovery time (something that I experienced myself, but more on that later).
Step #1: Rest
The first step of the RICE-protocol involves resting the injured joint. This is of vital importance during the first 48 hours after the injury, as during that time your body scrambles its defense to stop the bleeding at the injury site. Excessive movement will prevent this process, slow healing, and potentially exacerbate the injury. This is why you should definitely stop your training or competition when an injury occurs.
What exactly does rest mean? The answer to that question depends on the type of the injury, but you should generally not use the injured joint too much during the 48 hours following the injury. After those 2 days the body has already started the healing process and, depending on the severity of the injury, light activity such as careful walking will help with the healing process. (Bleakley et al. 2010, p. 6)
The chance of reinjury is always higher in the months after the initial injury, which is why proper rehab is of utmost importance. Returning to your previous activity level too soon can have devastating consequences. In ankle injuries for example, “ligamentous strength does not return until months after an ankle sprain.” (Wolfe et al. 2001, p. 93). During that time you’re more likely to suffer another ankle sprain and that second sprain will be worse than the first (i.e. the second injury will be a lot more serious).
Step #2: Ice
Step 2 is where cryotherapy comes into play. Icing the injured joint is a very important part of the RICE-protocol. The lower temperatures decrease swelling by lowering internal bleeding in injured joint. By keeping the swelling low and thereby restricting the number of cells in the injured area, you’re making sure that there is enough oxygen for all cells. Since the cold therapy also reduces cell metabolism, the need for oxygen is decreased even further. This is also why preventing excessive swelling is so important: by limiting the number of cells at the site it prevents unnecessary cell death that would occur due to lack of oxygen.
In summary, the purpose of cold therapy is to slow down the metabolism of the cells, thereby decreasing swelling, the need for oxygen, and unnecessary cell death. Additionally, the application of cold packs also decreases inflammation and pain.
This step should never be skipped. Use improvised ice packs (bag of frozen vegetables) if you have to, but definitely ice the joint.
Step #3: Compression
With step 3, compression, we want to further decrease swelling of the injured joint. By applying compressive forces you prevent extra fluid from pooling up in the joint and you thereby cut valuable weeks off your recovery time, as it takes a long time to get rid of excessive swelling.
Some say this is the most important step of the RICE-protocol. In my opinion it’s the one step you can’t justify skipping. Depending on where you injure yourself, rest, ice, and elevation may not be an option, but there’s always a way to apply pressure to a joint. For an ankle sprain in basketball this could be as simple as keeping that sneaker on and pulling the laces tight. Using a compression dressing is even better of course.
The only way you won’t have to make a trade-off between the icing and the compression is by using a professional ice pack. With home-made solutions you’ll decrease the cooling effect if you have the compressive wrap underneath the ice or you’ll compromise the compression, if you have the ice underneath the compressive wrap. This is far from ideal of course, but still better than nothing. Usage of a professional ice pack is much superior though.
Step #4: Elevation
By keeping the injured joint elevated (i.e. above heart-level), you’re making sure that gravity can assist in removing unwanted fluid from the injury site. This helps with decreasing swelling even further. So once you have applied compression and ice, just prop your injured joint up on a table for example.
Cold Therapy 101: about the proper application of ice packs
When applying ice packs there are a few things you have to pay attention to. Depending on what kind of cold pack you use, you should put something between the ice and your skin to prevent frostbite. This can be as simple as using a small towel, a wash cloth, or a couple of paper tissues. Keep this interface material slightly moist to improve the distribution of the cold.
The duration of the application obviously differs depending on the type of the injury and the type of ice pack used. The recommendations range from 5 to 20 minutes. You should always err on the safe side, as excessive cold can cause skin damage, muscle tissue damage and even impede the immune response. The cold pack can be applied every two hours in the first 48 hours after injury.
When applying ice packs for the first time, you should always check how the skin reacts to the cold after the first couple of minutes of cryotherapy and stop if you notice red marks, blisters or other adverse reactions of the skin. Use a thicker layer of tissue between your skin and the ice to prevent the skin from getting too cold.
Other applications of cold packs and cryotherapy
Cold packs and cold therapy in general can be used for more than “just” joint injury treatment. Let’s look at some of those other applications:
When cramping you should drink water with electrolytes (N.B. sugar is not an electrolyte!), relax the cramping muscle, and can then gently stretch and massage it. Additionally, you can apply an ice pack to the affected muscle to further reduce the pain and the swelling.
Studies on the efficacy of ice packs in relieving headaches present interesting results. At least three studies have been performed on whether cold packs can relieve headaches and their findings are clear: cryotherapy can be beneficial for headaches (in more than two thirds of the people tested). Today you can buy ice packs that fit perfectly over your head and thereby provide optimal cooling, while you are not inconvenienced by having to hold the cold pack.
Muscle soreness and increased recovery
The benefits of ice baths have been discovered a long time ago and they’re still being used around the globe. Their actual advantages are subject of controversy though and while some athletes swear by ice baths, others prefer contrast baths (or showers). The reported benefits of ice baths include increased recovery after hard training, reduced inflammation, and lower muscle soreness (among others). Another “benefit” of this form of cold therapy is the release of endorphins in reaction to the cold. In other words: you will happy when it’s over. Who would have thought?
Running ultramarathons through the desert
The Badwater Ultramathon, proclaimed to be “the world’s toughest foot race”, has its participants run 135 Miles (217 km) with a cumulative elevation gain of around 13,000 feet (ca. 5,800 m). Since this race takes place in mid-July and leads through Death Valley, temperatures on the course can reach up to 120 °F (49 °C).
In the 2005 Badwater Ultramarathon Scott Jurek, who is considered to be an ultramarathon legend by many, made headlines for his use of cold therapy during the race. During the marathon he periodically stopped to lie down in a cooler of ice, which he hoped would help him deal with the heat (more on that on CNN.com). He won the race, but started a debate about which artificial aids should be allowed and which should be banned.
My personal experience with cold packs
I started playing basketball over 10 years ago, but luckily, I have only had to deal with two sports-related injuries (knock on wood). I was side-lined by two ankle sprains: for the first time in 2005 and for the second time in 2009.
In 2005 I had little to no experience with ankle sprains and if you asked me about cryotherapy I would have recounted that one scene in Terminator 2. In other words: I had no knowledge about these important things. Nonetheless, I did rest and elevate the sprained ankle after the injury, but I didn’t use ice packs or compression. As a result, the ankle ballooned to a ridiculous size and it took me over three months to get back to action. I had no torn ligaments, but the swelling made wearing normal shoes impossible (thank god it was summer).
The second time, in 2009, I knew better and followed the RICE-protocol closely. I had iced the ankle several times before going to bed and rested the ankle on pillow overnight. It was still painful the next morning, but I already felt like the cold therapy had helped. While I was only walking at the pace of an elderly snail, I didn’t need any help to get to the doctor’s office (I did need a lot of time though).
After 6 weeks I was back to playing light basketball with an ankle brace on: twice as fast as in 2005. This second time around I also performed a lot more light activities such as walking and ankle mobility in the pain-free ranges of motion. And that definitely sped up healing as well.
The difference between those two ankle sprains was tremendous. Following the RICE-protocol and using cold packs prevented much of the swelling, which in turn enabled me to keep wearing normal shoes. The first time around I had to go barefoot with that one leg most of the time, because the swelling was too severe to even put a sandal on.
More important than the minor inconvenience of not being able to wear shoes was the significantly shortened rehab time. With the first sprain I was walking on crutches for 2 months and could only start actual rehab (i.e. work on getting back to my previous level of movement skills) more than 3 months after the injury. The second time around I started rehab a few days after the injury and was back on the court, albeit just to shoot some hoops, 6 weeks after the injury. That’s a huge difference, all thanks to some self-administered cryotherapy and the RICE-protocol.
Which are better: professional ice packs or home-made solutions?
When injuries happen unexpectedly, you’re most likely not prepared to deal with them properly. In cases like these you may have to make do with a bag of frozen peas, a wet towel, and a bandage. This is a lot better than doing nothing of course, but unless you want to eat peas for days on end you have to look for a better solution. This is where professional ice packs come in. So let’s look at the advantages of professional cold packs.
No trade-off between the compression and the cold
During the melting process, ice will change its shape, which is why it’s difficult to use ice under a compressive dressing. Using ice on top of the compressive dressing you make a compromise in terms of losing a lot of the cold.
There is no such trade-off when using a professional ice pack.
They are reusable
A bag of frozen peas can only be used once, lest you want some slowly festering vegetables in your fridge. Reusability, however, is very important for injury treatment and especially if you want use the cold pack regularly to fight joint inflammation after training. This is where cold packs score big time.
They are more convenient
Just strap that ice pack on and do what you want since you have your hands free. Home-made solutions can’t hold a candle to professional products in that regard.
Available in perfect-fitting shapes for a wide variety of body parts
Regardless of whether you want to cool your ankle, knee, shoulder, elbow, or even head: you can get ready-made ice packs in just that shape that will fit perfectly and allow for compression to be applied, if need be.
Enable you to take the best possible care of injuries
Using a professional cold pack for your RICE-protocol will ensure that you’ve taken the best possible first care of your joint injury. As I’ve shown from a scientific point of view and my personal experience, the difference between properly applied RICE and half-hearted first aid can be huge. The question is: how much is cutting more than a month off your rehab time worth to you?
Cryotherapy is a very valuable tool for all athletes and as we’ve seen earlier, it can even be used for other ailments such as headaches. Since the cost of applying cold is ridiculously low, I encourage everyone to derive benefits from cold therapy in some way, either through professional cold packs or other solutions.
Injury treatment is certainly the one area in which all of us can benefit from a professional cold pack, and if you’re a serious athlete you can even implement cold therapy into your training to boost your recovery, which will ultimately speed up your progress.
Sources and further reading
RICE – Acute Sports Injury Care – Sports Injury Info (2012). Available online at http://www.sports-injury-info.com/rice.html, updated on 2/02/2012, checked on 25/06/2012.
Bleakley, Chris M.; O’Connor, Seán R.; Tully, Mark A.; Rocke, Laurence G.; Macauley, Domhnall C.; Bradbury, Ian et al. (2010): Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. In BMJ 340, pp. c1964. Available online at http://www.bmj.com/content/340/bmj.c1964.pdf%2Bhtml.
Coleman, Sydney R.; Sachdeva, Kulveen; Egbert, Barbara M.; Preciado, Jessica; Allison, John (2009): Clinical efficacy of noninvasive cryolipolysis and its effects on peripheral nerves. In Aesthetic Plast Surg 33 (4), pp. 482–488. Available online at http://www.ncbi.nlm.nih.gov/pubmed/19296153.
Diamond, S.; Freitag, F. G. (1986): Cold as an adjunctive therapy for headache. In Postgrad Med 79 (1), pp. 305–309. Available online at http://www.ncbi.nlm.nih.gov/pubmed/3941818.
Landy, S. H.; Griffin, B. (2000): Pressure, heat, and cold help relieve headache pain. In Arch Fam Med 9 (9), pp. 792–793. Available online at http://www.ncbi.nlm.nih.gov/pubmed/11031383.
Robbins, L. D. (1989): Cryotherapy for headache. In Headache 29 (9), pp. 598–600. Available online at http://www.ncbi.nlm.nih.gov/pubmed/2584002.
Wikipedia (Ed.) (2012): Scott Jurek – Wikipedia, the free encyclopedia. Available online at http://en.wikipedia.org/w/index.php?oldid=498569524, updated on 20/06/2012, checked on 24/06/2012.
Wolfe, M. W.; Uhl, T. L.; Mattacola, C. G.; McCluskey, L. C. (2001): Management of ankle sprains. In Am Fam Physician 63 (1), pp. 93–104. Available online at http://www.aafp.org/afp/2001/0101/p93.html.