Why the AFL medicos (and everyone else) should stop icing injuries.

sven_inc

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I'm a Physio whose pretty passionate about all things injuries and have put together an article on why we shouldn't be icing injuries anymore. This is despite how common it is to do, and how popular it still seems to be in the AFL.

The long and the short of it is that we have iced for decades for some very noble reasons - to limit swelling, inflammation and pain. And we do this with a view of speeding up the healing process and offering a faster return to activity

Yet when we match these ideas up with what the body actually needs to happen, we see a huge disconnect between the two. This may sound strange, but icing an injury may in fact slow down the healing process and get in the way of what the body's trying to do post-injury.

Icing is still our go to in the AFL and is often a dead giveaway a player is "done for the day" when the ice pack and cling wrap come out. We are dealing with some of the best medical teams in Australian sport, yet it seems my industry may be perpetuating something completely unnecessary.

I think this is all the more important considering how long the AFL injury lists are these days, and how critical it is to turn these guys around and get them back on the field ASAP.

But with a simple shift in perspective I think theres a genuine chance to revolutionize the way the AFL goes about its player management and care.

If anyones interested:


Is this something everyone's across?
 
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Dazzler10

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There was a similar thread to this a year or two ago. Was that yours?

Regardless, interesting stuff. It could take a while to break down the medical dogma if the hypothesis is correct.
 

jason pm

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I'm a Physio whose pretty passionate about all things injuries and have put together an article on why we shouldn't be icing injuries anymore. This is despite how common it is to do, and how popular it still seems to be in the AFL.

The long and the short of it is that we have iced for decades for some very noble reasons - to limit swelling, inflammation and pain. And we do this with a view of speeding up the healing process and offering a faster return to activity

Yet when we match these ideas up with what the body actually needs to happen, we see a huge disconnect between the two. This may sound strange, but icing an injury may in fact slow down the healing process and get in the way of what the body's trying to do post-injury.

Icing is still our go to in the AFL and is often a dead giveaway a player is "done for the day" when the ice pack and cling wrap come out. We are dealing with some of the best medical teams in Australian sport, yet it seems my industry may be perpetuating something completely unnecessary.

I think this is all the more important considering how long the AFL injury lists are these days, and how critical it is to turn these guys around and get them back on the field ASAP.

But with a simple shift in perspective I think theres a genuine chance to revolutionize the way the AFL goes about its player management and care.

If anyones interested:


Is this something everyone's across?
Thanks again sven, another interesting thread from you, I have read a few articles re the ineffectiveness of icing and I am a bit surprised that it is still widely used.

I think a well established practice such as icing gets embedded in the psyche and it takes a long long time for new research/conclusions/best practice methods to filter down to the coal face of treatment.

I also found it interesting in the link that they mentioned Wif Hof breathing methods, I first became aware of him roughly 12 months ago and from my experience it has along with Yoga and Meditation been a revelation for my health. I was a chronic asthmatic from my childhood and had been on twice daily Ventolin and preventative medication for it for 40+ years, if I missed one of the twice daily sessions I would feel short of breath. I gave the Wim Hof breathing method a go and long story short I now no longer need any asthmatic medication and this has been ongoing now for around 6-7 months, over the same time I also went off Cholesterol, blood pressure and gout medication, my blood/urine tests have shown my Cholesterol/blood pressure/gout to be well within normal guidelines. To put it mildly my GP was flabbergasted that I would go off my medication of my own volition and even more so that it would work well for me.
 

John Who

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Thanks again sven, another interesting thread from you, I have read a few articles re the ineffectiveness of icing and I am a bit surprised that it is still widely used.

I think a well established practice such as icing gets embedded in the psyche and it takes a long long time for new research/conclusions/best practice methods to filter down to the coal face of treatment.

I also found it interesting in the link that they mentioned Wif Hof breathing methods, I first became aware of him roughly 12 months ago and from my experience it has along with Yoga and Meditation been a revelation for my health. I was a chronic asthmatic from my childhood and had been on twice daily Ventolin and preventative medication for it for 40+ years, if I missed one of the twice daily sessions I would feel short of breath. I gave the Wim Hof breathing method a go and long story short I now no longer need any asthmatic medication and this has been ongoing now for around 6-7 months, over the same time I also went off Cholesterol, blood pressure and gout medication, my blood/urine tests have shown my Cholesterol/blood pressure/gout to be well within normal guidelines. To put it mildly my GP was flabbergasted that I would go off my medication of my own volition and even more so that it would work well for me.
Your story just highlights the crucial role diet/exercise/stress release have on our general well-being. Congrats by the way!
 

jason pm

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Your story just highlights the crucial role diet/exercise/stress release have on our general well-being. Congrats by the way!
Yep, I revamped my diet around the same time as well, I try and stick to a moderate LCHF lifestyle although I'm not fanatical about it. Prevention is always better than cure if possible.
 

John Who

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I can see it as both right and wrong when using ice initially. Though I think the thread emphasis is relating purely on the inflammatory process post-injury.

What we need to also take into consideration is that when there is swelling, there’s also a chance of internal bruising and micro-bleeding that is not visible to the naked eye. Ice helps to constrict the blood vessels and helps to prevent further leaking of blood if such a scenario is occurring.

In AFL match day practice, or any other average sprain/strain events, how is anyone to know if it’s purely an inflammation process as opposed to an inflammation process with some added blood vessel rupturing/leaking?

So I personally think ice is a fair thing to do initially. Not necessarily for days but certainly in the first few hours applying ice to me, would be a pro more than a con.
 

Ronald Risher

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This was discussed here



It would be interesting, if its very common in part because of this MBI method that she says is faulty and has been banned overseas.
 

Total_Juddshanks

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Interesting read (as it always is when the OP posts)

I wonder though, in a week to week sport like AFL is reducing swelling and inflammation a higher priority than rapid healing?

I'm guessing a lot of times AFL players do muscle or joint injuries which would probably rule them out of strenuous physical activities for 1-2 weeks if they're average joe public, but the focus of club doctors and physios is getting them to a position where they can play through the injury without missing a week. Even if it takes a bit longer to heal as a result, they'll accept their elite midfielder playing at 80% output for 3 weeks, rather than have him miss a game.

Logically, even if they're promoting healing, excessive swelling and inflammation around a joint are going to restrict movement and impair a players ability to perform in the short term- at the most basic level you can't play if you can't put your footy boot on.
 

harrythetiger

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Interesting read (as it always is when the OP posts)

I wonder though, in a week to week sport like AFL is reducing swelling and inflammation a higher priority than rapid healing?

I'm guessing a lot of times AFL players do muscle or joint injuries which would probably rule them out of strenuous physical activities for 1-2 weeks if they're average joe public, but the focus of club doctors and physios is getting them to a position where they can play through the injury without missing a week. Even if it takes a bit longer to heal as a result, they'll accept their elite midfielder playing at 80% output for 3 weeks, rather than have him miss a game.

Logically, even if they're promoting healing, excessive swelling and inflammation around a joint are going to restrict movement and impair a players ability to perform in the short term- at the most basic level you can't play if you can't put your footy boot on.
Icing is pretty much a day-done thing though isn’t it?
I don’t know enough to comment on events after game day but I’ve never seen a player come back on after having ice applied to an injury.
 

jorel6669

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Thanks again sven, another interesting thread from you, I have read a few articles re the ineffectiveness of icing and I am a bit surprised that it is still widely used.

I think a well established practice such as icing gets embedded in the psyche and it takes a long long time for new research/conclusions/best practice methods to filter down to the coal face of treatment.

I also found it interesting in the link that they mentioned Wif Hof breathing methods, I first became aware of him roughly 12 months ago and from my experience it has along with Yoga and Meditation been a revelation for my health. I was a chronic asthmatic from my childhood and had been on twice daily Ventolin and preventative medication for it for 40+ years, if I missed one of the twice daily sessions I would feel short of breath. I gave the Wim Hof breathing method a go and long story short I now no longer need any asthmatic medication and this has been ongoing now for around 6-7 months, over the same time I also went off Cholesterol, blood pressure and gout medication, my blood/urine tests have shown my Cholesterol/blood pressure/gout to be well within normal guidelines. To put it mildly my GP was flabbergasted that I would go off my medication of my own volition and even more so that it would work well for me.
Jeremy McGovern used Wim Hof to get up for last year's grand final.
 

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Grin

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I'm a Physio whose pretty passionate about all things injuries and have put together an article on why we shouldn't be icing injuries anymore. This is despite how common it is to do, and how popular it still seems to be in the AFL.

The long and the short of it is that we have iced for decades for some very noble reasons - to limit swelling, inflammation and pain. And we do this with a view of speeding up the healing process and offering a faster return to activity

Yet when we match these ideas up with what the body actually needs to happen, we see a huge disconnect between the two. This may sound strange, but icing an injury may in fact slow down the healing process and get in the way of what the body's trying to do post-injury.

Icing is still our go to in the AFL and is often a dead giveaway a player is "done for the day" when the ice pack and cling wrap come out. We are dealing with some of the best medical teams in Australian sport, yet it seems my industry may be perpetuating something completely unnecessary.

I think this is all the more important considering how long the AFL injury lists are these days, and how critical it is to turn these guys around and get them back on the field ASAP.

But with a simple shift in perspective I think theres a genuine chance to revolutionize the way the AFL goes about its player management and care.

If anyones interested:


Is this something everyone's across?
Links to trials and peer reviews?
 

Total_Juddshanks

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Icing is pretty much a day-done thing though isn’t it?
I don’t know enough to comment on events after game day but I’ve never seen a player come back on after having ice applied to an injury.
Yep, my comment was more directed at how teams go about treating players who are borderline whether they can play the following week.

I think most weeks teams sustain 3 or 4 minor injuries that never make their way into the injury list because teams just RICE it after the final siren and play them hurt the next few weeks till it heals.
 

gavaniacono

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Always good to hear from you Sven. Some time ago you addressed posture as a way of treating problems in diverse areas of the body, something I related to from experience to which you further added valuable information.

This icing issue is another one where my instincts and observations went against my doc's advice, instead I followed what seemed to work for me and voila, quicker recovery.

I am 56 in pretty good nick, sprained both achilles tendons when excessively jumping in a basketball game. A day later couldn't walk. Doctors advised after scans thay I had micro tears and he advised daily icing minimum 30 minutes, and complete rest for some weeks. I tried this for a few days and felt no improvement when moving to the bathroom or another near location. Other advice such as strapping and heel elevators helped in the moment but when removed there was no improvement, possibly deterioration as the pain was worse.

I discovered that being mobile within limits and no ice brought quite a speedy recovery. Within 3 weeks I was walking normally and able to stand on the balls of my feet with limited pain. Actually, rather than pain I felt this stretching to give a pleasant feeling to the achilles. I still cant run but walking is fine, my gait is back to normal, and the achilles stretching i feel to be like a massage rather than painful. I still have some weeks to go before I will be back to normal, but it is clear to me the movement within limits which increases on a daily basis works much better than the doc's advice.
 

YippeeYiYeo

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A few weeks ago i also read an article that the scientist that invented RICE (Rest Ice Compression Elevation) now agrees that it is wrong.

Speaking from personal experience, any soft tissue injury i had the quickest recovery/rehab from immediately compressing for the first 30-60 minutes, them would ice it after. Rest is obvious while elevation didnt seem to matter much.

Compression was the most important for reducing swelling and getting me back on my feet, but whether it was best for overall healing who knows.
 

Godchin

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I was literally thinking about this and the amount of "bro-science" that goes on in the AFL.

All the ice packs and ice baths and players doing static stretches on their hamstrings for minutes at a time, etc.
 

sven_inc

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what about cold spray?
It's a good question. Cold spray is by the most superficial option where it doesn't necessarily effect as deep into the tissue compared to something like ice. Most would use it for some form of temporary pain relief - which is fair enough if that's your immediate goal. You just need to make sure you understand why you choose to use it. If it's to attempt to speed up healing then it's probably a waste of time.
 

sven_inc

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Always good to hear from you Sven. Some time ago you addressed posture as a way of treating problems in diverse areas of the body, something I related to from experience to which you further added valuable information.

This icing issue is another one where my instincts and observations went against my doc's advice, instead I followed what seemed to work for me and voila, quicker recovery.

I am 56 in pretty good nick, sprained both achilles tendons when excessively jumping in a basketball game. A day later couldn't walk. Doctors advised after scans thay I had micro tears and he advised daily icing minimum 30 minutes, and complete rest for some weeks. I tried this for a few days and felt no improvement when moving to the bathroom or another near location. Other advice such as strapping and heel elevators helped in the moment but when removed there was no improvement, possibly deterioration as the pain was worse.

I discovered that being mobile within limits and no ice brought quite a speedy recovery. Within 3 weeks I was walking normally and able to stand on the balls of my feet with limited pain. Actually, rather than pain I felt this stretching to give a pleasant feeling to the achilles. I still cant run but walking is fine, my gait is back to normal, and the achilles stretching i feel to be like a massage rather than painful. I still have some weeks to go before I will be back to normal, but it is clear to me the movement within limits which increases on a daily basis works much better than the doc's advice.
Glad to hear you're making some inroads mate. Achilles can be frustrating! If this helps at all I put together something on Achilles that may be of use. The things mentioned can often be seen in the AFL guys who suffer similar issues if you go looking them.

 

sven_inc

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I was literally thinking about this and the amount of "bro-science" that goes on in the AFL.

All the ice packs and ice baths and players doing static stretches on their hamstrings for minutes at a time, etc.
I think everyone's doing the best with the information they have, while trying to seek out the next best thing as it comes along. Personally I think there is so much to gain by just taking a step back and looking at what we already think we "know" and double checking it's correct. So much of what we thought was "fact" turns out to be missed perspective, poor application or just plain incorrect - of which icing an injury sits squarely in the latter.
 

Duke Of Earl

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Kinda lazy write up

I read it and did some research - basically there is no conclusive evidence about ice in soft tissue injury. This is really unsurprising when it comes to cheap/low-risk/first-aid type interventions. And no one would expect ice to have large effects - so an adequately powered study would need lots of people, good design, good follow up, etc. This costs money which is not easy to get. All we can gather is that a) ice does nothing or b) ice has small positive effect that we haven't been able to properly measure yet or c) ice does harm which we haven't been able to measure.

Ice is good for relieving pain though, that's a no brainer. Plus it's cheap, better than using drugs and works fast. So agree with you there

Your opinion about ice being detrimental to healing is unsubstantiated hand-waving and loose physiological reasoning... no offence

1. Agreed - movement is so important. Way back in the day the normal advice was as much bed rest as possible - bad for back pain especially and now we recommend otherwise
2. Massage - again I wouldn't be surprised if the evidence for massage in speeding healing was similarly low level or inconclusive. 'Flush out congestion in the area' blah blah. It feels good though and you couldn't bash massage as you'd be out of a job lol
3. Voodoo Floss - ''It’s genuinely one of the most valuable techniques I’ve ever seen or used'' ''supercharges waste removal'' - bro you aren't even trying here
4. MARC Pro.. costs $800. 'Brilliant for assisting the removal of swelling' - but swelling is a clinical sign of inflammation? Which is what we need to heal?

In the end I couldn't tell what you were recommending. Ice reduces pain and maybe reduces swelling and makes people feel good!
 

sven_inc

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Kinda lazy write up

I read it and did some research - basically there is no conclusive evidence about ice in soft tissue injury. This is really unsurprising when it comes to cheap/low-risk/first-aid type interventions. And no one would expect ice to have large effects - so an adequately powered study would need lots of people, good design, good follow up, etc. This costs money which is not easy to get. All we can gather is that a) ice does nothing or b) ice has small positive effect that we haven't been able to properly measure yet or c) ice does harm which we haven't been able to measure.

Ice is good for relieving pain though, that's a no brainer. Plus it's cheap, better than using drugs and works fast. So agree with you there

Your opinion about ice being detrimental to healing is unsubstantiated hand-waving and loose physiological reasoning... no offence

1. Agreed - movement is so important. Way back in the day the normal advice was as much bed rest as possible - bad for back pain especially and now we recommend otherwise
2. Massage - again I wouldn't be surprised if the evidence for massage in speeding healing was similarly low level or inconclusive. 'Flush out congestion in the area' blah blah. It feels good though and you couldn't bash massage as you'd be out of a job lol
3. Voodoo Floss - ''It’s genuinely one of the most valuable techniques I’ve ever seen or used'' ''supercharges waste removal'' - bro you aren't even trying here
4. MARC Pro.. costs $800. 'Brilliant for assisting the removal of swelling' - but swelling is a clinical sign of inflammation? Which is what we need to heal?

In the end I couldn't tell what you were recommending. Ice reduces pain and maybe reduces swelling and makes people feel good!
🤦‍♂️ Come on mate, it's easy to take pot shots. Keep an open mind.

Let me keep it simple for you.

I'm recommending that we don't use ice any more to treat injuries.

Why? Because the reasons we use it contradict what needs to happen for the tissue to heal. The end goal is to recover and be back fit again as soon as possible - everything about the effects of ice contradict this.

- Pain is needed to tell us whats appropriate to do. It's noble to try and settle "too much" pain, but there are better options than ice anyway.
- Inflammation is needed to clean up and start the repair process. So why are we trying to limit or prevent this?
- Swelling is the accumulation of waste at the end of this cycle. We need to help this get removed faster, not stop it from being there in the first place.

We should not attempt to stop or delay these for one very simple reason - they're normal. If you ice to stop them, guess what happens when you take the ice off? It just goes back to doing it again...

Instead, we need to get out of the body's way and instead focus on things that improve swelling removal - not restrict it. It doesn't matter what you choose to do, all that matters is that it respects the physiology of healing - which is fact. I chose to reference things like movement, voodoo floss (despite your sledge, its still a brilliant option), massage (despite your derision, it works) marc pro (you've missed the point) etc because I find they genuinely work - my apologies for passing this free information on to you. Feel free to recommend something you've found works and i'll add it to the article if it's legitimate..

This isn't "unsubstantiated hand-waving and loose physiological reasoning". The phases of healing are fact. The effect ice has on tissue, blood flow etc are also fact. They don't match up. Either way there are far better options out there if you're open minded enough to give them a go.

Here's an example. Most Quad tears can take 4-6 weeks from injury to return to sport (especially in the AFL). We ice it, rest it, compress the area and elevate as per usual. In short we get in the way. But we get better anyway because the body is steadfast in doing it's job. So at the end of the day we're happy that a Quad tear takes 4-6 weeks and that ice plays a supporting role.

HOWEVER. Clinically, you can turn that same person around in 4-6 DAYS by doing other things that respect the body's physiology. Stop icing it, move it respectfully, stop compressing it and stop elevating it and instead do things that speed up waste removal at the other end and there's just no contest anymore. I see it everyday clinically. Hence why I'd like to let put this out there for people to consider.
 

HairyO

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1. Ice is used to reduce pain, not just swelling. People shouldnt just be reaching for painkillers.

2. Often scans cant be performed while there is swelling, so ice is used to minimise the swelling, meaning the scans can be performed earlier and the clubs can find out quicker what treatment is required and when a player is next available.

On the weekend Grant Birchall was injured again. He didnt have ice I suspect because while minor, he and the doctors knew he would not be playing again this year and his career has most likely come to an end.

I dont think Cotchin had ice on his injury the other week either.

So its not a case of clubs need to learn. Im sure the clubs are well aware of the best practice across all sports related injuries and treat as appropriate.
 

sven_inc

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1. Ice is used to reduce pain, not just swelling. People shouldnt just be reaching for painkillers.

2. Often scans cant be performed while there is swelling, so ice is used to minimise the swelling, meaning the scans can be performed earlier and the clubs can find out quicker what treatment is required and when a player is next available.

On the weekend Grant Birchall was injured again. He didnt have ice I suspect because while minor, he and the doctors knew he would not be playing again this year and his career has most likely come to an end.

I dont think Cotchin had ice on his injury the other week either.

So its not a case of clubs need to learn. Im sure the clubs are well aware of the best practice across all sports related injuries and treat as appropriate.
The reality is that almost all injuries are iced in the AFL. If not while on the bench during the game, but at some point afterwards.

The industry as a whole is still in the dark ages in a lot of ways. This is one of them. We are slow to reconsider long-held beliefs because so many dig their heels in instead of being open minded and testing things out for themselves.

The problem is that ice is still considered best practice, but it shouldn't be.

I know for a fact major league baseball are on their way to becoming completely "ice-less" in their rehab protocols. Not many of the 390 pitchers still use ice.

The guy who developed the RICE protocol has come out and said he was wrong. He's changed his mind and no longer recommends the use of ice.

Once AFL clubs see the impact of forgoing ice for other techniques itll be widespread in to time.

And FWIW:
 

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