How to Ice an Injury

Icing is an important part of treatment used for strains, sprains and bruises. When an injury occurs on the body, bleeding may occur in the underlying tissues. Pain and swelling may also be present if the ligaments, tendons and fibers of the injured muscle were also affected. Luckily, applying cold to the area combats pain and swelling and can be used immediately or with rehabilitation. To ice your injury safely and effectively, start with Step 1 below.

Steps
Icing Your Injury
Assess the area. The area that is to be iced should be assessed before icing. When the skin is broken, direct icing of the area can cause more damage to the underlying tissue than good. An area of broken skin that is bleeding needs to be handled differently than an area that’s bruised and swelling. When the area has stitches or is broken, it should be protected using a plastic bag. This will prevent the wound from becoming wet as this can delay the healing process.

Assess your pain level by grading it using a numerical scale. Mild to moderate pain can usually be treated with an ice pack at home, while severe pain requires medical attention. For example:
Mild pain (1 to 3): Pain is barely noticeable, like getting an injection.

Moderate pain (4 to 6): Pain is distracting, like a bee sting or toothache.

Severe pain (7 to 10): Pain is excruciating, like a bad migraine. This pain can lead to loss of consciousness.

Rub oil onto the area if the skin is unbroken. Oil should be rubbed in a small amount on the area that is to be iced. Any oil can be used – even cooking oil.[1] However, this should not be done if the area is broken or it has stitches.
A wet flannel (cold piece of cloth) is placed on top of the oil in the case where the skin is not broken. The wet flannel should not be used when one is using the plastic bag. The flannel and the oil help to protect the skin and therefore prevent the ice from causing frostbite or burning the skin.

Prepare an ice pack. Ice packs can be prepared at home from ice cubes that are placed in a moist and warm towel or a plastic, resealable bag. Ice packs are also available in pharmacies but it is important to have an ice pack in the house to give an immediate intervention when the need arises. When using an ice cube that is placed in a bag, ice chips can be used so that the ice can be permitted to form around the injured body part.

Frozen vegetables can also be used as an ice pack. A good example is a bag of peas. These are able take on the shape of the area and can be taken in and out of the freezer.

If you have neither of these, pour some water in a tumbler and let it freeze. You can then take this out from the freezer and apply it on the affected area, rolling it around all sides of the injury.

Ice the injury. Icing is most effective when done immediately after the injury has occurred. The impact of icing reduces after 48 hours because the area will be inflamed and swollen.[2]
The ice pack should be placed on top of the flannel or bag. Press gently on the injured area and against all the curves. The ice should be moved frequently and should not be allowed to sit in one position.

Depending with the part of the body that is being iced, the area should be elevated above the position of the heart while icing. This will help to reduce the swelling and inflammation on the area.

Reassess the area after 5 minutes. Monitor the color of the underlying skin. If the skin is bright, red or pink the pack should be detached/removed. In case the area is not pink, the ice can be left on top for 5-10 minutes more. The ice can be left on top of that area for 20-30 minutes but it should not be left for any longer. This is because the underlying area may be damaged by the ice when left for more than 20-30 minutes.

This should be repeated every 2-3 hours for the next 24-48 hours. However, the area should be left to warm for 45 minutes before the icing procedure is again repeated. Icing can be repeated if the injured area has normal sensation and if it is warm to the touch.

Hastening Your Recovery
Take painkillers. Certain painkillers can also be administered to reduce the pain and swelling as a combined effect with the ice application. Your doctor will be able to tell you which painkiller is best for you. Common options are Tylenol, Advil, Motrin, and Ibuprofen. Some are available over-the-counter and others are available only by prescription.
Painkillers (or NSAIDs) are very effective. However, your dosage should be monitored as they can have negative side effects if too much is taken. Talk to your doctor about the right regimen for you.[3]
If you’re curious, these painkillers act on the arachidonic pathway in the body which is meant for pain relief. They act on COX1 and COX2 compounds and inhibit them, giving rise to a pain free environment.

Keep the injury elevated. Apart from icing, keeping the part elevated is one of the most important things you can do to speed your recovery. Due to gravity, blood flows down; thus, when not elevated, the dependent part gets filled with fluid. Increased blood flow and swelling can be avoided by raising it above the rest of your body.
If the injury is at the ankle, keep a pillow below and sleep.

If it is on the hand or elbow, keep it elevated at an angle of 30° from the bed by keeping a pillow or two.

This helps the tissue heal faster and also helps in reducing the pain.

Never use warm compression. Warm compression will cause blood vessels to dilate and open. This then causes more flow of fluid and blood from cells to the affected area, worsening the symptoms, exacerbating pain and swelling. It’s only advised that you allow the area to warm up between cycles of cold compression. This is so the injured tissues don’t freeze. You need appropriate blood circulation – not too much and not too little.

If problems arise, discontinue use. If any joint problems like arthritis or muscle spasms start after your icing regimen, abandon this technique. A larger culprit is at hand and should be handled by a doctor. The same goes for symptoms of the common cold or gout. Cold compressions should be strictly avoided as these will worsen the symptoms of these ailments.

Understanding Ice and How It Works
Know if icing is right for you. Falling on your hand, twisting your knee or ankle, falling on your foot when its turned inwards, or lifting a heavy weight the wrong way can all lead to injuries that need icing. If you suffer from the following symptoms, icing may be appropriate for your condition: Pain. This occurs because the fluid from inside the cells comes to the outside compartment where it shouldn’t be present. The abnormal collection of fluid leads to stretching of the area which then irritates the nerve endings in that region and leads to pain.

Swelling. The tissues undergo force, causing the fluids from the inner cell to come outside the cell. This gives rise to a temporary swelling.

Bruising. The cells present in the tissues as well as the blood vessels maintain fluids for equilibrium. But when a person falls, the force of that action drives the fluid from blood vessels into the tissues leading to formation of swelling.

Difficulty in moving the joint. It is difficult to move the part that has got injured as it gets swollen and inflamed. The fluid that is present leads to restriction of movement as there is no space for the joints to act.

Know when to avoid icing an area. Icing of an injured area is usually important and helpful, but there are certain circumstances where precaution should be taken. Here are some situations where you should avoid icing an injury:
When the area is located in a place that has poor sensation to cold. This is because the area may develop frostbite easily owing to the fact that it has low sensitivity to cold.

When the area has poor blood circulation. This is because the cold pack can easily damage the underlying skin that may result in the death of that tissue.

If you have diabetes. This is because increased sugar in the blood interferes with the nerve endings on the skin and this may cause you to lose sensitivity to cold.

When the area is in a poor condition like an ulceration or wound. This is because placing an ice pack will delay healing of the wound and even cause further damage.

If you have a cardiac condition, do not ice your left shoulder. It is incredibly important to avoid using ice packs on the left side of the shoulder if you have a cardiac condition. You do not want to negatively affect your blood flow around your heart.
Ice packs should not be used on the side or the front side of the neck. This is because the icepack may interfere with the blood circulation thus affecting the other systems of the body.

Know how icing helps. The immediate treatment of an injured area with ice is important as it helps in:[1]
Reducing and preventing the swelling that causes inflammation

Decreasing the bleeding into the tissues

Decreasing muscle spasms and pain

Decreasing the pain on the injured area

Increasing vasoconstriction of the blood vessels
Increased vasoconstriction helps to decrease the blood flow to the affected area thus reduce swelling and inflammation. This will all help to reduce and prevent the accumulation of fluid into the injured tissue that may cause swelling and thus delay the healing process.

Know when icing is normally used. Athletes and those who work out and/or lift weights incorrectly are at high risk for injuries that require icing. However, even those who fall in the bathroom on a slippery surface or women who wear stilettos and twist an ankle may find icing beneficial. In rehabilitation, ice is used to restore the normal functioning of the injured part of the body. The ice helps to enhance other treatments (for example, exercise) and also helps to decrease pain and muscle spasms.

An individual in rehabilitation will likely be encouraged to ice an injured area before exercising or to exercise the area with the ice pack on top. This helps to ease pain and allow movement of the injured area.

Icing can also be used in cases where one has chronic pain. An athlete that has chronic pain that tends to increase after each football game may ice the injured part after each session of football to prevent swelling and inflammation.

Tips
The application of ice is not usually comfortable but the results of the treatment outweigh the temporary discomfort that may be experienced.

Warnings
One should ensure that they do not fall asleep with the ice on top of the injured area.

Sources & Citations
Khan et al. Overuse Tendinosis, Part 1: A New Paradigm for a Difficult Clinical Problem (part 1). Phys Sportsmed. 2000

Tseng et al. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. Journal of Strength & Conditioning Research. 2013,

Millar et al. Inflammation Is Present in Early Human Tendinopathy. American Journal of Sports Medicine. 2010.

John Ebnezar, Textbook of Orthopaedics.

Joshi, Essentials of Orthopaedics: An Applied Physiotherapy.

Ebnezar John, Essentials of Orthopaedics for Physiotherapists.

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