To Ice or Not to Ice: Ice, Rest and Runner's Knee

Welcome to the Performance Place Sports Care podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, it's Dr. Sebastian Gonzales, and thanks for joining me. Who hasn't been sick this winter? Oh, my God. I cannot believe how many sick people I've encountered. I've been sick, I'd say, one and a half times. I feel like the second time was kind of like it was on its way in, and then it didn't really complete, but freaked me out, and I've been trying to stay really, really healthy.

As a result, actually, I've had a lot of throat clearing still. I feel like that stays with me a long time, so if you can, please ignore it a little bit during this podcast. I'm trying my best to get rid of it, and I'll try my best to keep it at bay. Today's going to be a great, great topic on icing, and I had a question come through, and they said, hey, would you suggest icing for knees in runner's knee? And icing for me is, it's a love and hate thing, and I don't really love it much for knees. I know I've personally had a knee condition. I had a, it was a meniscal tear. It was actually from impact. It was a traumatic one, so I was running, I slid in at home, and there was actually a divot in the batter's box, and I just crushed my knee against it.

Actually, I believe, looking back, there's evidence of possibly having a small fracture in the tibia as well. But anyways, this thing swelled up for months, it seemed like. It felt like a huge balloon, and I remember sleeping, and I couldn't really, I couldn't really get over the feeling of it feeling like a bag that was just going to explode inside my knee. So I couldn't get rid of the swelling for the life of me. Eventually, I did have an injection to remedy that, but in regards to regular runner's knee, again, I have a love and hate with ice, and I cannot argue the fact that people love the way they feel after doing icing.

And I'm going to try to go off of some of the research that I've done on icing in the past, because this is going to be a pretty controversial topic, and I know there's a lot of cryotherapy chambers or facilities coming out recently. I don't personally have one at my clinic, but I know that it's hard to argue the fact that people do feel really good when they get out of something like this. So I'll first start with going into a resource that I've actually heard about this for a little while. I don't remember when this was written, but it's on drmarnick.com, so that's d-r-m-a-r-k-i-n.com, and if you search on there, why ice delays recovery, it was interesting.

I've heard that I don't remember if Dr. Mernick was the one who came up with the rice method, but here I'll read verbatim what was on his first part of this page. So this is quoting. When I wrote my best-selling sports medicine book in 1978, I coined the term RICE, so that's REST, ICE, Compression, Elevation. For treatment of athletic injuries, ICE has been a standard of treatment for injuries and sore muscles because it helps relieve pain caused by injured tissue. Coaches have used my RICE guideline for decades, and now it appears that both ICE and complete rest may delay healing instead of helping.

So he was after that, he started citing some research. So in a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. By cooling, or although cooling delayed swelling, which that's interesting to know, by the way, we'll hit on that later. So although cooling delayed swelling, it did not hasten recovery of muscle damage. So this was out of the American College of Sports Medicine in 2013. So a summary of 22 scientific articles found almost no evidence that ICE and compression hastened healing over use of compression alone.

So although ICE plus exercise may marginally help ankle sprain or heal ankle sprains. So that was a reference from the American College of Sports Medicine in January 2004. So this is back from where it all began, I believe. And my logic with this is that, again, people feel really good after doing icing, but does it really help? And I've always had questions at the office. People ask, should I do heat or ice or whatever? And I ask them, you know, what's their goal? What's your goal? If your goal is to decrease pain, yeah, ice is going to get you there. Heat might get you there too, but sometimes ice does it better for people.

Now, it's important to realize that actually ice, or sorry, the inflammatory process or acute, the acute inflammatory process, which means like on a new injury. Like if I, if you turned your ankle, that's an acute inflammatory condition. So inflammation is actually not just one thing, but it's five. There's five parts of inflammation. So there's redness. There's increased heat. There's swelling, pain, and loss of function. And this is what you'll see, they call the five cardinal signs, and you can Google this and it'll pop up everywhere. So really with ice, the only thing we're really combating is swelling and I guess pain as well.

But it really doesn't help out with the other parts because it actually deadens them. So I think the controversial part is when you're using ice to decrease inflammation and you kill pain and some swelling, are you really allowing the area to improve itself? Because the swelling, or sorry, the inflammation is a naturally occurring process. Yeah, it hurts. It's painful. It sucks. It's too bad. But don't you want some of the blood to come in to be able to bring some of the healing components, growth factors, proteins, so on? Let's just say, theoretically, you had a tear in a ligament in the ankle.

The tear is not going to just heal itself if you don't let it. So the body is trying to heal itself. Just like when you cut yourself, just like when you slice your arm, you scrape your knee. You know, no one really stops that process of inflammation. It's just maybe because we can see it. Maybe because we know that after a couple days, you know, the pain will go away and it turns into a scab. I have no idea. But under the surface, inside the body, the same kind of stuff really happens. So my beef is with icing is that people seem to use this as a crutch and they're really starting to use it as pain management.

Now, pain management, although you've got to be comfortable, decreasing pain is okay, but I don't think it's the end all. Sometimes you have to be in a little bit of pain to have motivation. I actually have a good friend who has a mom, I guess just like everybody else. But he texted me not too long ago when he was saying this. So his mom is about 60 years old. She's never done anything in her life to improve her strength, what it sounds like. She's never really exercised. Never really done anything to stabilize your midsection, which in this case, he was asking me about. She was having some back pain and so he sent me a copy of the script from the doctor's office and it said pain medication.

It said physical therapy, stretching, exercise, blah, blah, blah, right? So his question was, what should we do or what should she do? And I said, well, what'd she already start doing? And he said, well, she started taking the pain medication. And I stopped him and I said, look, you know, like why does she care about this all of a sudden? Why does she care about her back pain anyways? And he was like, well, because it hurts. And I'm like, well, so for the last 60 years, your mom hasn't done anything to improve that area because it hasn't hurt. So now you're going to take away the one thing which is motivating her to improve that region and to improve how it functions.

So I kind of recommended to him that I don't, I mean, obviously don't make it so she's in excruciating pain, but, you know, make her feel some discomfort. Make her think about it because maybe that'll almost scare her into improving this area for the long term, you know. So back to ice again. So ice is, if it uses pain deadener for a little bit of time, maybe for the first five days, I'm okay with it. Although I'm on the fence with this as well, because that's when a lot of the inflammatory process happens. But if it mentally gets you over a hurdle, I'm okay with using it just a little bit. In regards to runner's knee, I actually had a patient text me the other day.

She has chronic inflammation, which seems to keep happening in her knee. She runs a bit. And I've been working with her a little bit to, or actually, well, probably a lot over the last year to improve her gait, to improve her stance, her strength of her glutes, the strength of her trunk, to be able to combat that grinding she's getting in the knee, which is just kind of going to, it's going to slowly degrade that cartilage in the knee. And I guess I should start first with, if you guys don't know what runner's knee is, generally speaking, it's chondromalacia patella or patellofemoral pain syndrome.

It is basically when you have the kneecap and the cartilage underneath softening. So chondromalacia means softening or cartilage softening. And a lot of swelling happens around this. So anyways, this girl's been, she's been getting this on and off swelling for a while. And so she asked, well, I got the swelling in my knee again. What do I do? I'm like, well, what have you been doing? You know? Well, she's like, I've been working. She's a nurse. So she's been, she's been walking a lot at work. She does lots of steps. She's always on her feet. And then she goes and runs and, um, she's stopped some of her strength training, stopped some of her rehab.

And she's like, should I ice it? And I said, I don't, you know, I don't think so. You know, maybe we need to get to the root of what's really creating this knee swelling anyways. Um, and if it happens to be the running, then we need to cut the running back a little bit and substitute with some other type of cardio. If it's the walking, perhaps she needs to maybe get better shoes or, or do something to where she's not on her feet, locking, maybe locking her knees out all day. Um, I don't recall what all the specifics of her condition, but, um, I mean, there's some people that have, um, it's called January curvatum.

It looks like where their legs are kind of bowed. So I don't think the stacking and, and anyone in sports medicine, correct me if I'm wrong with this. Um, I believe the stacking on these people of the, the, the femur and the tibia or the, the, uh, both sides of the knee will, um, they don't really stack up well. And creating like ligaments to stretch and strain on one side of the knee, uh, more so than the other and swelling occurs. That's what I believe, but I don't really get a lot of people with January, January curvatum. So I haven't looked into it much. Um, but anyways, so if you're going to use, if you're going to use ice, just be really educated about what it does and what your goal is.

Um, I actually recommend ice more so on, um, disc conditions for the back because we're trying to control a, uh, chemical process. But, uh, down into, uh, a peripheral joint, a knee, a hip, a muscle, I really don't recommend it too much. And really when it comes down to it, if you only have like 30 minutes in your day to spend on working with your injury, if you're going to tell me, well, I'm going to do ice and rest rather than, um, do some of the recommended rehab that I'm going to tell you, no, don't do ice at all. Don't do rest because you can easily spend the 30 minutes doing something more productive than you are just sitting there washing 300, icing your knee and just letting all the muscles degrade eventually over time.

Um, leading into that, that, so that, uh, that article I referenced in the beginning is also talking about rest, um, rest delays recovery. I think it's only, uh, productive for the first five days or so as well. Um, there was an art, there was a presentation I went to just this last year, um, talking about, um, they used actually, they, they, they studied some of these rats, which were, um, they kind of hung them by their tail. I know it sounds barbaric, but so they had their, their front paws on the ground. So they had balance and their back paws were suspended. So basically their legs weren't really touching anything.

So gravity didn't have an effect on them. They weren't walking. They weren't running. They weren't doing anything. So they measured basically, uh, the muscle size after, I think it was two weeks, I believe. Um, I'll have to go back and find this article, but it was actually an astounding amount of muscle degrade or, or, uh, uh, uh, the muscle decrease in size over the course of those two weeks or so. It was something to the effect of, I believe it was 25%. It was, it was a lot. So basically the presenter was talking about, we should get these people really early to be able to walk around if they're, especially if they're post-op.

Um, so if you have an injury, if you're, if you're sitting around and just sulking and just kind of watching 300, um, I would, I would start to walk some. Now, obviously if it hurts, you don't want to go through painful range of motion, but, um, it doesn't mean you can't walk a little bit. Most of the time people can get through some motion. Um, maybe they won't go to into a deep squat. They won't run, but they can probably walk, you know, down, down the street. And this doesn't seem like much, but gravity is a big factor and it does load the muscles. Every time you step, every time you push off, it does condition these muscles to some degree to be able to tolerate load.

And it keeps them in higher quality than it would be that if you just rested. Okay. So I think that's all I have on that. Um, I'm sure if I get any questions, I'll look up more research on icing, uh, and I'll go, uh, so I'll, I'll put this reference again just because I know that you guys might want to look it up. So it's, uh, the website with, uh, Dr. Murnick is, so it's, uh, D-R-M-I-R-K-I-N.com backslash fitness backslash why ice delays recovery. So that's what he wrote. I don't remember when, but it's a really good read. Um, actually it says it was checked in. Now I'm looking at it. It was in October of 2016.

So this is not too old. Um, if you guys have questions for me, for a topic to put onto the podcast, just go onto p2sportscare.com. There should be a area on the site, pretty visible to send a voicemail. And this is not to send a voicemail to book an appointment or anything like that. If you're in the Southern California, Southern California area, this is just mainly to feed topic to this podcast only. That's the only reason we use it. So if you have a question, please submit it. I would love to answer, uh, the question and let everyone else around really learn, um, what's going on with you. Because if you have a question, I'm sure someone else has the same question.

Uh, if you guys want to check out the, uh, the courses I have on p2 sports care as well. Um, that is all on there under courses. Anything I've referenced in regards to balls, bands, uh, and equipment you might use are on resources as well. I do get a little bit of affiliate money from that. Remember, I do have to eat. Um, and this, uh, uh, this website is actually brand new. Um, I just converted over. There's still want to be a couple of glitches, but I'm not kidding you. I spent like 250 hours easily writing content for this stuff. And I started around August of last year, uh, of 2016. And I'm still going now.

I would wake up every day about three, three hours before work. I'd write an article. I'd, I'd read all the, read all the, uh, the research articles I can find in reference to that. I cited them all. Um, I set them out for proofreading, got infographics made, did images. This is, I'm not kidding. The, the most work I've ever done writing anything. And the only B I ever got in my life in, in high school was in English. So if you find any grammar errors, please, uh, point those out. But I did have an editor do a lot of this for me. Um, okay. So thanks a lot, guys. It's p2sportscare.com. I will talk with you soon.