Ice is an inexpensive, yet astoundingly effective treatment for pain and swelling. Unfortunately it is a grossly underutilized tool. A big reason for this is that many healthcare providers themselves do not appreciate the benefits of ice packs and other cold treatment modalities for pain or swelling. Some providers simply don’t know about the benefits and therapeutic use of ice. I was one of those providers until my Physical Therapy colleagues enlightened me. Many providers unfortunately propagate misconceptions about the use of ice. If I had a dollar for every patient that related to me “the emergency room told me to ice for 2 days, then use heat,” I’d go on a nice European vacation.

WHAT ICE DOES

Ice initially constricts local blood vessels and decreases tissue temperature. Overall, ice will:

Decrease inflammation

Decrease pain

Speed nutrients to the area

Promote healing

Decrease swelling

Decrease tissue damage

Decrease muscle spasm

4 STAGES OF ICING

During treatment with ice, you will go through the following stages:

Cold

Burning

Aching

Numbness

To be clear, icing is not recommended because it feels great when you’re doing it, but because it is a proven tool in our arsenal against pain and inflammatory conditions! I found early on with clients that this is a point on which you have to beat the poor horse to death several times over. I would direct clients to ice 3 to 5 times a day in their treatment plan. On follow-up, I would ask how many times a day they iced. Some would say “I didn’t ice. It didn’t feel good. I used heat instead.” I had to mentally excuse myself to beat my head against the wall. Heat tends to feed pain and inflammation, no matter how good you think it feels in the moment.

Ice and cold treatments constrict blood vessels, helping to decrease swelling. Even though you may think heat feels better, heat dilates or opens up the blood vessels, like turning on the faucet full blast. If you injured your ankle and it was swollen as big as your head, do you think the swelling is going to be resolved in 2 days? Given this new knowledge, do you really think it’s a good idea to switch to heat on day 3 for your still swollen ankle? Icing is beneficial for sprains, strains and fractures.

Although I can’t imagine icing stiff and arthritic fingers, there is good evidence in the literature for icing arthritic hips, knees, ankles, shoulders, necks, and backs. It is a misconception to ice only known injuries within the first 48 hours. When interviewed on turning 50, Denzel Washington noted he was still very active physically. After vigorous physical activity he noted he ices practically everything, almost like filling a tub with ice and getting in!

For chronic musculoskeletal pain, when in doubt, you can rarely go wrong with icing. On the whole, my clients with chronic shoulder pain from a variety of causes reported icing to be their single most reliable pain management tool. Inflammatory conditions such as tendonitis, “pinched nerves”, and nerve compression syndromes such as carpal tunnel benefit from icing.

In general, you want to be sure your pain is musculoskeletal. Sometimes jaw or upper extremity pain can be signs of a heart attack, even in the absence of any chest pain. Upper and lower extremity pain and other symptoms such as weakness or numbness can be due to a stroke. If your arm, leg, neck or back pain is new, see your doctor to ensure that the pain is musculoskeletal.

Since icing is very effective for decreasing swelling, individuals with congestive heart failure should be closely supervised by their doctor. Reduction of swelling in the extremities may overload the heart.

Clients with Raynaud’s phenomenon are extremely sensitive to cold, and are not good candidates for icing. Under physician supervision, they may benefit from alternating warm and cool packs.

ICE MASSAGE: Freeze water in an 8 oz Styrofoam cup, then tear the edges exposing the ice, yet leaving some of the cup to hold onto. Using a continuous motion, rub the ice over the area of treatment for 5 to10 minutes. I recommend 10 minutes for larger, deeper structures like shoulders or knees. Usually 5 to 8 minutes is adequate for small or superficial structures, such as wrists or elbows. Repeat 4-5 times daily. Numbness is the desired effect and needs to be achieved to be effective.

ICE BATH: Ideal for hand and forearm or foot and ankle. Immerse the part in a bucket of water and then add ice. This is hard core! Typical immersion time is 5 to 10 minutes. Although maximum recommended time is 20 minutes, I’ve only come across the occasional athlete that has reported doing such. If your injury is to your wrist, with no swelling in your fingers, you can leave your fingers out of the ice bath. If your injury is to your ankle and swelling does not extend into your toes, you can leave your toes out. Repeat during the day, preferably 3-4 times. Body part should be continually moving during treatment to create a pumping action to help achieve better reduction of swelling.

ICE PACK: Use a re-freezable ice pack or put crushed ice in a thin towel or plastic bag and place over area to be treated. Keep T-shirt or towel between body part and ice. Use 15-20 minutes. Repeat 4-5 times daily. Maximum ice time is 30 minutes with at least one hour between icings. Again the desired effect is numbness!

Generally, icing in any combination from above methods, is recommended 3-5 times a day. You may ice more than 3-5 times a day. Follow guidelines for each method to avoid cold damage.

For nerve compression syndromes like carpal tunnel, cubital tunnel and radial tunnel, ice pack is recommended for 12 to 15 minutes. You can find ice pack ideas in my hub, Ice Pack Options and Alternatives for Pain and Swelling, which should be published in the next 5 days.

For tendonitis, such as tennis elbow or tendonitis of the wrist or thumb, I recommend ice cup direct ice massage at least 1-2 times a day, and ice pack 2-3 times a day to make up the difference, for a total of 3-5 times per day. If you can do the ice massage 3 to 5 times a day, great! Although my specialty as an occupational therapist is upper extremity, I have had ice prescribed to me personally for my knees for arthritis as well as occasional patellar (kneecap) tendonitis. I sometimes use ice packs, but tend to cut to the chase and do direct ice massage for my knees.

The nerves are very close to the surface of the skin at the cubital tunnel, or funny bone on the inside of the elbow, and snuffbox, at the base of the thumb at the wrist. Sometimes, such as when the barometer drops, these areas can be sensitive to direct ice massage. You will experience an intense “nerve” ache. You can try an extra layer of towel with your ice pack. Another option is a “Karo Syrup ice pack”.

For neck, upper back, upper chest and shoulder regions, you may use direct ice massage or the ice slushy ice pack 3-5 times a day. Additionally, alternatives for the neck and shoulder region, such as “Karo syrup ice pack” or “rice ice pack”, are helpful.

See my hub, Ice Slushy and Other Cold Therapy Options for Pain and Swelling, for ice slushy, Karo ice pack and rice ice directions and other cold therapy ideas.

Short cut on ice cup/direct ice massage for wrist or hand: Use a medium size/weight towel. Peel cup totally off ice. Turn the ice bottom side up on a towel. One towel and one ice cup will be sufficient for each a.m. and each p.m. Use every opportunity to rub finger or wrist over ice. The ice cup is always ready. If you don’t get much chance to use it, no harm. One standard towel will keep the ice block from puddling for about 4 to 5 hours.

Icing at work: Take ice packs to work with you, especially if you work at a desk. Other clients confirm that it is possible to get in 1-3 icings a day at work. The issue is not being so much busier than the rest of us desk workers that you can’t squeeze it in. The issue is getting a good mental strategy. Plan when and how. Use a cut-off sock, ace wrap, or commercial wrist or elbow wrap to hold your ice pack in place, and continue to ‘drive’ your desk! Use a “splint sock” to hold snack bag-sized Karo syrup cold pack against your wrist or thumb. Take a tube sock and cut off the toes. This is where your fingers will go. Cut a slit for your thumb. The leg portion of the sock will hold the ice pack against your wrist.

More icing at work: In my therapy clinic, I used a large cold pack in a pillowcase on myself. I would throw it over my upper back and upper chest on one side, tuck the excess pillowcase under my arm so it wouldn’t slip off, and continue typing at my computer. The weight of the large cold pack helps it stay in place. The same is generally true for the rice ice and commercial synthetic ice packs too. You could also try putting the ice pack in the hood of a hooded shirt for the neck/upper back region. Another strategy is to use a slightly tight tee shirt to hold your ice pack in place on the neck and shoulder region.

For icing multiple parts: I frequently asked my clients to try icing distally, to the wrists, forearms and/or elbows, as well as proximally, to the shoulder, neck and/or upper back. This is because the cause of the distal pain was often proximal, despite the client only feeling distal symptoms. Many clients have been surprised that icing their neck was more effective than icing their elbow for their elbow pain! Same for wrist etc. Icing both distally and proximally could be a lot of icing, especially if both arms have symptoms. I always recommend shooting for 3 to 5 times a day, but in these cases, I suggest balancing time between distal icing (hand, arm, elbow) and proximal (shoulder/neck/upper back). Over time, your body will tell you what combination is giving you the “biggest bang for your buck”. That is, whether icing to your hands or arms versus your neck or shoulders gives you the most relief.

SUMMARY

Ice is an inexpensive but invaluable tool in managing swelling, inflammation, and pain. Hopefully now you have a better understanding of the benefits of ice, as well as some options and tips for making it easier to comply. You will be in a better position to discuss cold therapy options with your doctor or therapist. Educate if necessary!