Should Athletes Return to Sport After Applying Ice?
A Systematic Review of the Effect of Local Cooling on Functional Performance

Bleakley CM, Costello JT, Glasgow PD.  Sports Med 2012; 42 (1).

Topical cooling, using ice or other forms of cryotherapy, is a common treatment for acute athletic injuries to provide cold-induced analgesia to reduce pain before athletes return to play. A recent systematic review suggested that athletes should use caution when returning to play immediately after joint cooling because there is insufficient evidence to explain the effects of cooling on joint position sense. Without an understanding of the effects of cooling on joint position sense, athletes returning to play immediately after cooling could potentially be predisposed to injury or impaired performance.  The purpose of the current systematic review was to examine the effect of tissue cooling on outcomes relating to functional performance, and to discuss their relevance to the sporting community.  Thirty-five studies were included in this review, with outcome measures including strength, power, vertical jump, endurance, agility, speed, performance accuracy, and dexterity.  Studies included healthy human participants who were treated with local cooling (studies using whole-body cryotherapy in environmental chambers and cold water immersion above the waist were excluded).  Subjects must have completed at least one of the previously mentioned outcome measures both before and after a cooling intervention.  There was a wide variation in the type (ice bags, ice towels, ice massage, and cold water immersion) and length of ice application in these 35 studies, but most studies used cooling times greater than 20 minutes.  Overall, it appears that muscle strength was reduced after ice application, although some studies reported small increases in muscle strength.  Similarly, muscle endurance results were conflicting with some studies reporting decreases and others reporting increases.  Five studies reported decreases in endurance used cold water immersion for less than 45 minutes with temperatures ranging from 10 to 18°C.  Four studies reported increases in endurance used cold gel packs, ice towels, or cold water immersion for less than 30 minutes with temperatures ranging from 3 to 17°C.  Cooling had a negative effect on vertical jump, sprint, and agility, as well as hand dexterity and throwing accuracy.

This systematic review highlights some common inconsistencies of cryotherapy treatment.  Because there are few guidelines for ice application, many clinicians and athletes follow the “20 minute” prescription, regardless of desired physiological outcome or without considering potential negative effects of returning to play while still cold.  Cold-induced analgesia can be attained in about 10 minutes; so if the goal of ice is to temporarily reduce pain, a longer treatment may not be the most appropriate treatment.  During athletic competitions, ice may be applied during short breaks in play or during half-time, but the effects on proprioception remain unclear.  In one of the included studies, short ice applications (3 minutes) did not affect vertical jump, agility, or sprint performance.  This may indicate that clinicians should avoid using ice for longer periods of time during competitions to limit declines in performance.  Until more research using better-developed prescriptions of cryotherapy is completed, we are not able to fully understand the effects of muscle or joint cooling on return to play.  The authors of this systematic review recommend short cold applications combined with a progressive warm up before continuing athletic activity. Do you consider the desired physiological outcome before deciding on a treatment time?  Have you noticed decreased performance when athletes return to competition immediately after ice application? 

Written by: Kimberly Rupp
Reviewed by: Jeffrey Driban

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Bleakley CM, Costello JT, & Glasgow PD (2012). Should athletes return to sport after applying ice?: a systematic review of the effect of local cooling on functional performance. Sports medicine (Auckland, N.Z.), 42 (1), 69-87 PMID: 22121908