Some of the most common questions we hear after an injury are, “Should I use ice or heat? Movement or rest?”. While all rules have variations to account for individual circumstances, more often than not the answer will be ice and movement. Let’s break that down.
Immediately after an injury, there is inflammation. Like the name suggests, this is a hot condition and is helped by using ice. The hallmarks of inflammation are heat, swelling and tenderness to the touch. Ice helps all of that. Normally, we recommend using ice 2 -3 times per day for the first few days after an injury. The upper limit of frequency for using ice is ten minutes per hour. Continuous ice can cause frostbite. Another risk for frostbite occurs with using ice directly on the skin. Normally, a cold pack is separated from the skin by a layer of cloth. If your ice pack stings to the touch, use a thicker piece of cloth. Your ice pack can be kept in the refrigerator section, not the freezer. That way it will be soft and conform better to your injury. Most refrigerators keep food around 38 degrees. That is plenty cold!
In a severe injury, the acute inflammatory stage can last for 3 to 5 days. This is the time for ice and also the time for rest. After that, the body shifts focus to repairing the injury with less inflammation. This sub-acute stage is probably still a good time for ice but it is also the time to begin moving the injured area. The way to tell if the injured area is still inflamed is to check for tenderness to pressure. Another way to tell is that pain from inflammation is present even when you are not moving. So if your sprained knee is aching while you are lying in bed and it is tender and puffy to the touch, it is inflamed and would benefit from ice.
Movement during this time prevents the injured area from filling in with scar tissue. The most common mistake we see is people who wait until there is no pain to begin moving. This results in decreased range of motion and often, permanent disability. Early mobilization is the key to a full recovery. In the case of our hypothetical sprained knee, this means performing range of motion activity such as using a stationary bike, not activities with high forces like playing tennis or basketball. Let common sense and pain guide you as you return to full function.
After 4 to 6 weeks, you enter the chronic or remodeling phase. During this phase, emphasis should be on obtaining full range of motion and developing strength. At this point, there should be no pain at rest, no redness and no palpable swelling or tenderness. There is likely to be some pain when you attempt to stretch the muscles. This is the phase where heat is often recommended, but the best form of heat is actually exercise, not a hot pack. Why is this? Heat applied to the surface only penetrates about a half inch. Your problem is usually much deeper than that. Another reason is that heat applied externally usually only gives relief for a short time, often a half hour or less. Heat generated by muscle activity will last for 24 hours. Finally, exercise is not only warming the muscles, it is strengthening the muscles and restoring normal range of motion. As a result, we rarely recommend or use heat to help recover from an injury.
To illustrate, I’ll tell a story about one of my injuries. One Sunday evening, I fell hard onto my driveway, smashing my left palm and right knee onto the cement. After my wife helped me up and into the house, we applied ice to my knee and my left elbow. I didn’t hit the elbow but I could see it was swelling. After about a half hour, I couldn’t move my elbow at all and I realized it was fractured. I decided to go to the local hospital and get it X-rayed. Sure enough, there were signs of fracture, so the doctor put my elbow in a cast and offered pain medications (which I declined). Back at home a few hours later, I developed a burning pain and numbness running down my forearm to my little and ring fingers. I realized that I should never have let them cast me, because the cast was trapping the swelling in my elbow and crushing my ulnar nerve. Good thing I didn’t take pain meds or I would have woken up in the morning without the use of my hand.
I went back to the hospital and had them cut off the cast. The next morning, I went to a radiology lab I use and got an MRI of my elbow. The fracture was much more clearly visualized. The bone was split lengthwise at the elbow and there was a lot of swelling. I then went to an orthopedist I know and asked for his advice. He asked if it hurt, probably because I didn’t look to be in obvious distress. So he put a syringe in my elbow to draw out blood that had leaked into the space between the separated sections of bone. The syringe completely filled with blood. So put another syringe on the needle and it too filled with blood. His eyebrows raised. Then he put another and another and finally, blood stopped coming out of my elbow. It was such a relief, I told him it felt like my elbow gave birth. I asked the doctor what I could and could not do during recovery. He said I couldn’t externally rotate my forearm for six weeks, but I could begin moving it as I felt able.
I wore a sling for four weeks to prevent accidental movement. All I did the first week was wiggle my fingers and gently make a fist. I used ice, acupuncture and a little massage on the forearm to reduce inflammation and muscle spasm. I increased my range of motion during the second week. By the third week, I began doing isometric resistance exercises with my forearm and increasing my range of motion. By the fourth week, I was lifting light weights and doing deep massage in the muscles to prevent scar tissue build up. By the fifth week, I had regained full range of motion and the ability to make a strong fist. I increased the weights. By the sixth week, I was doing bicep and tricep exercises with 30 pound dumbbells. When I returned to the orthopedist, he said there were two ranges of motion I would not get back after an injury like mine. To his surprise, I could do those motions with ease.
If I had worn the cast or even the sling without doing any exercises or treatments during those six weeks, I would indeed have lost the full function of my elbow. This is one example among many of the value of early mobilization.