Category Archives: Anatomy & Physiology

How should we ice, then?

Posted on by
19

Kelly Starrett’s MobilityWOD put out the message that icing is no longer recommended. After a lot of discussion and digestion, I posted a response about whether or not we should still ice. It looked at several issues from the MWOD post, including the cited research. The conclusion was that the research and practice were conflicting, and therefore it’s too inconclusive to definitively throw icing out the window. Furthermore, there were just too many unanswered questions about the effect of ice on things like lymphatics permeability and prostaglandins. The MWOD post also didn’t distinguish between different types of injuries, which is incredibly important.

To clarify, none of this is an attack on Kelly himself. Remember that he’s arguably done more for prehab and rehab in the last few years than anyone else. The fact that he’s so well respected is why I’m researching and discussing the “do not ice” claim in depth. It’s okay to disagree with someone; at the same time it’s still possible to learn from them, support them, or respect them.

Ultimately, the issue of icing comes down to the differentiation between injury types. For a brief literature review, look at yesterday’s post. We’ll try to generally talk about some injury types today and basic approaches to rehabbing them on your own at home.  Take note that injuries are individualistic; each one is specific to a specific individual. Good PTs will have a specific protocol made for your specific injury, circumstances, and activity or performance goals. When in doubt, go to a PT. If you can’t, then always always always do the least invasive rehab and then wait until the next day to see if it’s the same, worse, or better. You’re doing all of this at your own risk.

Contrast Baths vs Acute Icing

First we need to clarify between two different types of icing. “Contrast work”, which can include ice baths, is not the same as icing a specific spot on your body. Trainees anecdotally report positive results with contrast baths or showers to improve general or systemic recovery. However, they are used by some PTs to treat acute soft tissue injuries or general inflammation in a body part. “Soft tissue” would include muscle, tendon, or ligament issues — usually in terms of sprains, pulls, or partial tears (the most common associated with training). “General inflammation” isn’t referring to total body systemic inflammation, but instead refers to something like soreness in the traps and shoulders or forearms from a lot of volume (e.g. lots of overhead work or farmer’s walks respectively).

One of my PT friends has found that ten minutes of cold immersion alternated with a heating pad works best. He uses five cycles of starting and stopping with ice. He found that by ending with heat left the lymphatic channels open and encouraged swelling, but he admits this may be contradictory to what we are learning now (referencing yesterday’s post and how ice seems to increase the permeability of the lymphatics). Remember that this is used for a specific acute injury or a specific body part.

This particular PT has had clinical and personal anecdotal evidence of this protocol working with acute soft tissue injuries. It has helped with lingering injuries that have lasted up to two months and removed the pain after one week of daily treatment. Interesting to say the least.

I think that this approach could be generally applied for systemic recovery, which can also be caused by high volume, frequency, and/or intensity training. In this method, the heat would be applied to the entire body as opposed to just an afflicted area. Think in terms of hot and cold showers, ice baths and hot tubs with spa covers, or ice baths and hot showers. Use caution when dealing with extremes in temperatures and I suggest you ask a PT or doctor before trying it.

The (admittedly) conventional wisdom behind why contrast stuff can work is that the alternating temperatures contract and relax the body and lymphatic channels, which helps push the waste up through the lymphatics. Take note that this also occurs in movement — we’ll talk about it regarding active recovery below. The contracting/releasing of the lymphatics idea is one line of reasoning as to why this helps both general systemic inflammation and acute soft tissue injuries.

Acute, Single Location Icing

Contrast work requires some preparation and a lot of time. For a non-professional athlete who has other responsibilities in life, they’ll need to get the most benefit with techniques that most efficiently use their time. Icing a specific spot will be a little easier, albeit potentially not as effective as what is written above.

Immersion is always better than a bag of ice, and a bag of ice is always better than a commercial ice pack.

Immersion can include a bucket of ice water for ankles or wrists, but it gets a little tricky for elbows, knees, shoulders, or the back. I suggest a standard blue ice bag that you can get at any pharmacy or grocery store. I like these because they don’t produce condensation and therefore don’t drip down your body or clothing. I suggest also getting some heavy ace bandage wraps — they can hold the ice on the awkward spots and they can be used for compression rehab.

The research showed that some superficial tissue damage can occur with prolonged icing as well as the potential “increase of edema” issue. Therefore, the recommendation said not to exceed 30 minutes and probably not 20. We’ll just use 15. Apply the ice on an area that encompasses the painful area and wrap it to ensure solid contact. Set a timer for 15 minutes. The heavy ace bandages can be useful for busy people since they can go about their business despite icing their knee.

Under What Circumstances Should You Ice

One supportive argument for icing is that when it’s applied soon after the onset of injury that it helps prevent secondary hypoxic cell damage. Edema is a result of more blood flow to the area along with the waste products. Specifically an “increase in the permeability of the vessel wall (with a) subsequent increase of the extracellular protein concentration” (Meeusen, 1986 — the article from yesterday). There are varying levels of capillary permeability and cellular response, and it’s dependent on the injury. Icing decreases the temperature of the tissues and reduces blood flow in the area. If icing occurs soon after the onset of injury, then it can help slow the blood flow to an area that is in the process of “increasing the permeability of the vessel wall” and dumping extracellular proteins — the thing that causes edema. This is how icing can prevent secondary hypoxic cell damage.

Of course, that edema is the body’s response to the injury. So we should let it be, right? If the goal is to expedite healing, then no. Look at the “Ancestral Argument” section from yesterday. If we wanted the inflammation process to occur unheeded, then we wouldn’t conduct massage, compression, elevation, or e-stim to the area either. These rehab protocols, combined with icing, return athletes to activity faster, and that’s shown in clinical research (and we’ve probably all seen it in anecdotal situations too).

Take very careful note that the situation I’m talking about here is an acute injury, specifically an acute soft tissue injury. This includes muscles, tendons (attaching muscles to bones), and ligaments (attaching bones to bones). This does not include broken bones, joint dislocations, bursa issues, etc. Your n=1 experience of your orthopedic doctor telling you to only move, compress, and elevate your dislocated finger is not proof that icing is useless.

Aim to get ice on the injury as soon as possible and continue icing on and off for the first 24 hours, but no more than 48 hours. The more severe the injury, the closer to 48 hours you could ice. After this deadline, rely on other rehab protocols to heal and alleviate the injury. They will be discussed below.

Lastly, I want to point out that if you notice a significant increase in swelling and you deem it to result from ice exposure, then stop doing it. I have a friend who does a lot of ballistic lifting, smokes regularly, and takes a lot of NSAIDs. Icing ends up making his situation worse, but he is not a relevant piece of data due to his smoking and NSAID use.

A Note On NSAIDs

A major injury will necessitate some NSAIDs. Or deca.

My general philosophy for minor soft tissue injuries is to not use NSAIDs. Quality nutrition (paleo) with appropriate protein and smart supplementation (fish oil, vitamin D, ZMA, and magnesium to start — post on this soon) will help keep non-training systemic inflammation low and facilitate healing these minor issues. Stuff like ibuprofen can be problematic for the gut, yes, so let’s avoid them…unless there’s a more serious injury. In such a case, you’ll probably be prescribed something. To be perfectly clear: I’m not anti-NSAIDs, but save them for the major stuff and let your efficient body and rehab protocols deal with the minor stuff.

Chronic Soft Tissue Injuries

As a general rule, you will not ice chronic soft tissue injuries. As I’ve said a hundred times before, chronic soft tissue injuries are usually due to improper mechanics or conducting mechanics with improper mobility. Barring a past acute injury, there’s an underlying cause as to why this chronic issue exists. Identify and diagnose what that is and fix it — if you don’t then the issue won’t go away no matter what treatment you apply.

Icing can help chronic issues, but only when it is applied after aggressive rehabilitation. If you are self-massaging a tendon to break up scar tissue, you should follow up with movement to get blood flow, lactic acid, and proper structural stress to the tendon. After the movement-based rehab — which is absolutely necessary for recovery — you can ice. This helps people from an anedcotal perspective all of the time. The icing is okay and helpful because you’re essentially re-injuring the area via the “scar tissue breaking massage”. You created an injury, and the motto is that “icing helps acute soft tissue injuries”. That’s why it’s okay.

A specific example is what I did with Brent a few years ago. He primarily did the Olympic lifts, but expressed a mild desire to bench again so that high school football players wouldn’t embarrass him and make him look like a shit head. However, the bench ROM was incredibly painful on the anterior portion of his shoulders, specifically the proximal biceps tendon. When I palpated them, they were significantly raised and inflamed with built up scar tissue. I worked on them with my thumbs, and he squealed like in this video, and then I had him press and bench the bar for some high reps followed by icing. We did this protocol several times (separated by at least a day or two), and in a week or so he was able to bench pain free.

If aggressive massage and movement are not applied to a chronic issue, then I would not recommend ice unless the person wants to use it as an analgesic. Ice relieves pain because it “numbs” the area. In the Reinl video, they claimed that it severed the “muscle and nerve connection”, yet this would take significant cold exposure to do. It does decrease the temperature, but if done within the parameters of our “15 minutes rule”, it’s not an issue. Whether or not icing a chronic issue such as this is detrimental to the recovery process is not known, but, again, the person can ice if they want to relieve pain. My opinion, which is not based on anything in the research, is that icing for 15 minutes will not be detrimental to the recovery process, yet it’s not going to accomplish anything other than analgesia.

Remember that I said that most chronic soft tissue injuries are due to bad mechanics or faulty mobility, but they can be from simply doing too much without enough recovery:

However, the degradation of collagen is also increased after exercise, likely at a greater level than the increase in synthesis. Consequently, for the first 36 h after exercise, the collagen metabolic system is in a negative balance with degradation greater than synthesis (Fig. 1). This may explain that repeated exercise without sufficient rest can leave an athlete in a state of repeated collagen  breakdown, and the development of overuse injury (Magnusson et al., 2010).

— “Tendinopathy in Athletes.” Physical Therapy In Sport, 13, 2012: 3-10.

Hmm, too much volume and frequency with no rest. Sound familiar? This is almost every CrossFit injury ever. It’s also related to the actual acute injuries that occur from not having recovered structures. I wrote about this a long time ago, but hopefully people are starting to pay attention to the prevention and treatment of these things. The prevention is proper programming. The treatment consists of comprehensive recovery methods.

Rehabilitation Modalities for Acute Injuries

If you read yesterday’s post, then you know that the benefit of icing was always linked with at least one other method of rehab. At the very least, the raising of this “to ice, or not to ice” issue should teach or remind you that rehab must be multi-faceted to be efficient. We have addressed icing above, so let’s touch on the others.

Here’s a good spot for a random pic

Elevation

This is useful because it helps the lymphatics clear waste. The lymph system is similar to veins in that they have a one-way track to the center of the body. There are valves that prevent backward movement, and muscular contraction helps pump and pulsate contents through each type of vessel back to the trunk. Elevating a limb will a) help prevent blood or lymphatic waste pooling (which would increase edema) and b) allow gravity to assist the lymph system in pulling out the waste (in the same way that it helps drain the blood flow from the area).

Compression

It’s known that massage helps clear extracellular waste — the stuff of edema (it is known). Compression sort of does the same thing by preventing the increase of swelling and perhaps even helping to squeeze the bad fluid out. It facilitates the clearing of blood and waste from the area, especially when compounded with elevation. We’ll also see that compression with movement is very useful too.

Rest

In the Reinl/Kelly video, they poopooed rest because movement is necessary to recovery. And it is, but an initial period of rest is probably necessary. Let’s use the same “icing timeline” and say rest for 24 to 48 hours; the more severe the injury, the longer the rest. For example, you wouldn’t want to start moving a severely sprained ankle around a couple hours after the injury. Usually you’ll only rest for 24 hours.

Movement

This is the single most important thing for rehabilitation. Ever. I’ve written about this hundreds of times — soft tissue injuries need to heal by receiving stress through a full range of motion. If they heal or scar with no motion, then any new motion will irritate or re-injure the area. And obviously healing with a partial range of motion isn’t helpful for when you eventually hit that end ROM that it isn’t prepared for. I’ve successfully rehabbed hundreds and hundreds of people, and movement is always the reason.

Keep in mind that the movements need to be progressed. I’ll repeat one of my rehab rules:

When rehabbing, try the least invasive movement and then wait until the next day to see if it’s the same, worse, or better. 

The key is the “least invasive movement”. If you can’t put weight on your sprained ankle, then just move it through a range of motion. If you’ve already moved it through a full ROM, then add light resistance. If the light resistance doesn’t make it worse, than slightly increase the resistance or number of reps. In this Q&A post I give an example of an ankle rehab protocol. Is it comprehensive? Perfect? Perhaps not, but it’s a progressive plan. I might tweak those icing recommendations a little, but the basic tenets are there: ice initially, then progressively load it. I’d add compression and elevation to the protocol — these should be done as much as possible when not icing or moving the afflicted area.

The concept revolves around a progression. I get creative with how I’m going to work a structure. At first, it might need to be in isolation, but the structure is always integrated back to compound movements. And it’s steadily, but consistently progressed. This is so important because you guys are so friggin’ impatient with your progress or don’t attempt to make any at all. I’ve talked to so many people who have an injury and they decide not to squat for three months. I’m not suggesting you squat with weight, but a body weight squat is a starting point. If that’s too much, then figure out a way to put work on the area. It’s your hip flexor? Then lift your thigh up. Groin? Move your thigh in and out, get on the yes/no machines (adduction/abduction) — just do SOMETHING.

It’s impossible to be comprehensive because there are so many different types of soft tissue injuries. Just know that you can ice initially, but then you need to perform movement that applies an adaptive stress to the injured structure. The structure has been reduced in its ability, so you have to progress it back to its uninjured state. This is the same exact concept of making a muscle strong, but now you must limit the stress to what that particular structure can handle.

Throughout the rehab process, I deem it acceptable to ice after the movement rehab, and especially if it’s still tender during rehab. Movement or massage may sort of “re-injure” the area by applying a stress that it isn’t adapted to. After recovering, it should be able to handle that same stress again easier, and that’s why you will progress to doing more in the next rehab session. Nevertheless, if the rehab resembles a re-injury (determined case-by-case), then icing after the movement rehab is probably not going to be detrimental. If edema occurs as a result of icing, then don’t do it anymore; it usually won’t swell with minor soft tissue stuff.

Whether or not you need to ice, compression and elevation will help. But, to hammer this point home, consistently moving the injury and progressing the adaptive stress over time is necessary to returning to normal function.

Movement With Compression

Wrapping your segments or joints with heavy ace bandages and then performing rehab movements will help them recover. The first reason is because it helps clear the cellular waste through the lymphatics through the effective methods of compression and muscular contraction. But the compression also applies a bit of tack and stretch to the muscles, which is similar to ART treatment where pressure is put on a tendon or muscle belly while the muscle lengthens and shortens through a full ROM. If you have used the “voodoo bands” — a term I absolutely hate — then you’ve experienced this before. I’ll be doing a post on this topic soon, but just note that light to medium wrapped segments or joints with rehab movement will add a bit of resistance compared to simply doing the movement without the compression. I’ve successfully used this on ankles, wrists, knees, and elbows.

Cryokinetics

This is the concept of icing to reduce pain, and then taking joints through a full range of motion actively or passively. I do not suggest any of you try this without the aid of a PT, because your Tommy Tough Guy attitude will probably just lead to you making your injury worse. However, if you’re going to be a Reasonable Rick, then you could do something like this: ice the knee, then passively take the knee through a full ROM. Just remember that since the ice is an analgesic, it’s going to block any pain you would normally experience. That pain is your body’s signal of saying, “Hey, don’t do this because it could or is causing injury.” We often push beyond this in our standard “movement based rehab”, but not receiving this message of pain could mean you do too much. The most stressful thing I would have you do after icing is a body weight squat in your living room.

Sequence of Events

Injury occurs. Ice it. Compress it. Elevate it. After day one, start figuring out how you can apply progressive stress via movement. After rehab, it is okay to ice. Otherwise, try to compress and elevate the injury as much as possible. Rinse and repeat, but ween off of the icing (since it will eventually not do much other than numb the pain after the early stages). For chronic issues, review the earlier sections of this post.

Conclusion

This all started with a conventional wisdom-breaking statement that said, “Do not ice.” After reading, discussing, and digesting all of the information, yesterday we concluded that the “do not ice” statement is premature and unspecific. It will depend on the type of injury and how icing is employed. This post looks at the benefit of icing and how to place it in a proper rehabilitation program. Whether or not you decide to ice is ultimately up to you. It can be helpful in some cases, irrelevant in others, and in a few cases (mostly within the context of non-injury pathology) it can be harmful. Most of all, I hope that this brings an awareness of comprehensive rehab. Kelly argues that a person should know how to work on your body and I agree. Icing is an effective rehab tool if you use it properly. It’s a tool that trainees, lifters, and athletes have access to even if we can’t get to a PT, yet it’s just one piece of rehab. Knowing how important compression, elevation, and — most of all — progressive and consistent movement are in treating an injury will make you a more knowledgeable trainee and help you perform better.

Should you use ice?

Posted on by
68

There was a big clamor in the rabble rabble about this post by Kelly Starret’s MobilityWOD.com. If you’re new, Kelly is a physical therapist who has a goal of helping amateur and professional athletes learn how to work on their bodies to help keep them performing and injury free. The post above was a video with Dr. Gary Reinl (Edit: not a doctor) and it stated a message that said, “Stop icing. It is bad for you.”

I immediately began researching and discussing this ‘controversial’ topic with various physiologists and physical therapists. I’ve been trying to figure out a way to address the issue, and the best I can think of is a regurgitation of all of the thoughts that we’ve had. Let’s take it step by step.

The Reasoning for Not Icing (from Dr. Starrett and Reinl)

When an injury occurs, the body has a response in order to heal it. Inflammation is the complex response from vascular tissues to repair damage. The body aims to remain in homeostasis, so when something different occurs (i.e. too much sun, a training stress, or a sprained ankle) it attempts to rectify the problem to return to an uninjured state. This is an amazing process; go to a museum and look at bones from humans who broke their leg, never had it casted, and continued to live on it. You’ll see how the bone grew back together to allow some sort of function, even if it was impaired. Life will find a way. Many people use delta-9 thc gummies to manage discomfort during recovery, which can help alleviate pain and reduce inflammation.

Reinl and Kelly talk about how inflammation is necessary and give examples of Reinl questioning athletic trainers as to why they would want to block inflammation. It’s the body’s natural defense against injury, so why block it? They also talk about how the lymph system remove cellular waste from the inflammatory process. However, just like veins, the lymphatics require movement in order to function and actually clear that waste. They talked about Reinl’s machine, which is apparently just an e-stim machine with electrodes that, when placed, will contract muscle. This helps clear the waste through the lymphatics via muscle contraction and can be used when the area is too painful to move on (i.e. the patient cannot walk or flex the knee, so the electrodes to the contracting).

Finally, they get to the icing issue. They say that icing increases the permeability of the lymphatics which creates a back log of “congestion” and edema (swelling) into the injured area. They also say that icing blocks the muscle/nerve connection, and Reinl asks a good question: “How could shutting off the connection between the muscles and the nerve (which effects the fully muscle-dependent lymphatic system) help the evacuation of deoxygenated blood and waste?”

It all seems very compelling. But there are many questions.

The Ancestral Argument

Part of what they talk about is that the body has evolved to deal with injury. The argument is that the body’s natural function is to go through the inflammatory process. Why interfere with this process? The body knows what to do, so let it.

I understand the argument, and agree with it to an extent, but it doesn’t hold up in all cases. I’m all for paleo eating (it’s what I do and what I recommend), but to exactly emulate paleolithic lifestyles doesn’t make sense. Aside from the fact that one day you wake up and you’re squatting to take a shit, it ignores the fact that the demands are different. Let’s ignore sedentary people, because we are all active — we actually lift. Was it common in our paleolithic ancestors to squat 500 pounds? Or to put 350+ lbs overhead? No. We know that their lifestyle included intermittent periods of low activity with high activity. Nevertheless, they were not subjected to forces and stressors that we are. At the very least, we can agree that the lifestyles are very different.

This means that the treatment of complications or injuries will be different. There are problems in the medical community (e.g. an over-emphasis on prescribing drugs), yet it is still an advanced and wondrous field that keeps people alive and heals them faster than if we were relying on our bodies to do it alone. I don’t think it’s crazy that something like icing would be off limits just because it wasn’t a method used by our paleolithic homies. To clarify, that is not Reinl’s or Kelly’s argument, but the ancestral argument was brought up several times. My only point is that the argument isn’t good enough, because it doesn’t prove anything. There are more efficient ways to everything, including heal, and just because a method wasn’t available to our ancestors doesn’t mean it should be off the shelf.

This post may seem dry, so I give you this

The Big Issues

I can tell you right now that this issues is inconclusive. I read the cited research (I’ll talk about it below) and everything. The most important aspect of this is that they did not address what kind of injuries this concept applied to. Does it apply to acute or chronic issues? Does it apply to muscle bellies or tendons? What about ligaments? Bone breaks? None of this was addressed, yet it’s entirely relevant.

Also, the e-stim machine is more or less promoted. This really bothered some people. They looked at it as a self promotion type situation. Some even make the claim that Kelly is just distinguishing himself from the norm to solidify his following. I don’t think these things are true, but money has done worse things in the world. I think the major point when discussing the e-stim machine is that normal people are not going to be able to use it. They won’t have access to it, and if they did, they won’t have the knowledge to place the electrodes or how to use it within the context of recovery. Sure, there will be some rich (and crazy) CrossFitters that have already purchased it, but they still won’t use it as effectively as a PT. There’s a reason they go to three years of school. And even if the average trainee knew where to put the electrodes, that doesn’t give them the anatomical and physiological context of how to optimally use it through their healing process. The point? The trainee or lifter who won’t have constant access to a PT still needs to use the methods of recovery at his disposal. The e-stim machine will not be one of those things. This is one reason why I think declaring “no icing” as pre-emptive given the context of what people can use at their home.

Speaking of “no icing”, there isn’t anything definitive in the research. It’s definitely an analgesic, but there’s inconclusive evidence for what it does with swelling and inflammation. One of my first questions was, “How quickly does ice increase the permeability of the lymphatics?” and it’s not in any research (to my current knowledge). Since the consensus is inconclusive, it seems premature to exclude this method of rehabilitation — especially within the context of the trainee that is rehabbing from home. 

Note that ice is not something to use by itself. If we look at the conventional wisdom of RICE, it still has compression and elevation (the rest part is temporary, maybe 24 hours). Ice shouldn’t be used as a solitary method of rehabilitation. It’s should always used within the context of soft tissue work, muscular contraction (e.g. movement), compression, and elevation. Kelly, or any other PT, may have the luxury of eliminating icing because they have other rehabilitation methods (e.g. e-stim) at their disposal. But we all aren’t professional athletes and don’t have regular access to physical therapists. And even if we did, most physical therapists are pasty, flabby, internally rotated non-lifting goobers — they help 70 year old grandmas return to walking instead of helping a powerlifter, weightlifter, or CrossFitter return to competition. Highlight this concept in your mind, because I’ll return to it later.

My opinion right now is that icing should be black listed if and only if it is detrimental to the patient in all scenarios. That is not the case.

I’m not against Starrett and Reinl because I’m an icing fan boy. I’m only skeptical of the definitive advice in light of the consensus of information. I’ve preached to you for almost three years to be skeptical of authority, and so I’m just doing the part to synthesize the information for your availability. If anything, the message should be, “Do not ice under these circumstances.”

The Cited Research 

The first study cited in the MWOD post was ‘The use of Cryotherapy in Sports Injuries,’ Sports Medicine, Vol. 3. pp. 398-414, 1986. I have a copy of that portion and have read it several times. The section on “The Effect of Local Cold Application on Inflammation and Oedema” is pretty inconclusive. It says that some researchers “have shown that cold can inhibit as well as enhance inflammation” (Schmidt et al. 1979). Then, another portion says that the results from observing ice treatment on the inflammatory response in experimentally induced ligament injuries in pigs “indicate a diminution of histological evidence of inflammation” — an over-complicated way to say “results showed cellular decrease of inflammation” (Farry et al. 1980).

Then in that same study, “swelling was greater in the ice treated limbs”. They even had swelling in the non-injured limbs that were iced. The icing protocol wasn’t elaborated on, but there was another study where they looked at 1 hour cold submersion in rabbits with a “crush injury to the forelimb” (the crush fetish people are loving this). There was increased oedema/swelling in 4, 6, to 24 post-exposure and none in the non-injured control forelimb (McMaster & Liddle, 1980). But hey — notice that these studies were done on animals. I’m not saying animal studies aren’t relevant, but they don’t definitively prove anything either. And who ices for an hour anyway?

One study (note that it is only one) showed that the moment ice is on the skin the “permeability of the superficial lymph vessels increases” (Muuesen et al. 1986). The increase is the greatest at 8 minutes and persists after application, but “by 25 minutes post-treatment the permeability of the lymph vessels will have returned to pretreatment levels.” Keep in mind that this study was only looking at cold applications. Many clinical studies — in which cold treatment is actually used with compression and elevation — do not show volume increases after cold treatment.

The totality of the “icing causes swelling” argument is summed up in three studies. One was a guy noticing swelling his hand (n=1) and the other were on animals (pigs and rabbits). Also, the rabbit injury was a “crushing”, or a breaking of the bones” type of injury. This is completely different than an acute muscle, tendon, or ligament injury and obviously unrelated to chronic injuries.

Furthermore, there was a clinical study (Basur et al. 1976) that showed much faster healing (9.7 days of mean disability) in patients who received cold treatment within the first 48 hours followed by crepe bandaging (compression) while the other group only had the compression (14.8 days of mean disability). A different study (Hocutt et al. 1982) showed that cryotherapy (icing/cold therapy) started within 36 hours of injury allowed patients to return to full activity after sprained ankles on an average of 15 days sooner than late cryotherapy or early heat therapy.

Finally, the conclusion of the paper that Dr. Starrett cited to show you that you shouldn’t ice concluded with:

Clinical studies on the effect of cryotherapy on acute sport injuries, and on the rehabilitation of the injured athlete, seem to agree that cryotherapy does improve recovery from injuries. However, it should be noted that these studies generally combine different first aid recommendations (cold, compression, elevation).

It goes on to point out that further research is necessary. Questions include whether it’s “necessary to cool the injured area to temperatures near freezing point or is it better to use a more moderate cooling method?” Essentially it means that there are unanswered questions. However, this study — again, the one that Dr. Starrett used to tell you not to ice — doesn’t reach a conclusion to not ice because of edema. And remember, the cited research concerning edema was done with animals.

Also, the 2008 study (“Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?” JEM, 2008; Feb. 25; 65–68) is a lit review…of only ten studies. The abstract itself says there were six relevant trials in humans, but four of them were thrown out because of bad research. Two of the human studies had good enough research, and one of them was in support of cooling while the other lacked statistical significance. Then, of the animal studies, four of them showed reductions in edema from cooling! Of the two systematic reviews, one was inconclusive and then the other suggested that ice may hasten return to participation. Where in that literature review is it providing enough evidence to stop icing? The result is undoubtedly inconclusive, but of the studies that actually have decent methodology, they all say that icing helps. Are these two studies supposed to convince me that icing is ineffective or detrimental? The sure as hell don’t.

Am I saying that Kelly Starrett is a horrible human being and we should never listen to him again and throw poop on him when we see him? No. But I’m just pointing out two things: 1) The research he cited doesn’t conclude what he says it does, and if anything provides actual support for icing, and 2) The research on this stuff in general is inconclusive. I can probably find any quote to prove a point from a peer reviewed study to show you that you should ice. I can do the same to say that you shouldn’t ice. I’ll say it again: the research isn’t conclusive. Furthermore, the physiological reasoning for why things occur isn’t known either.

Physiology Questions

The video talked about how ice severs the muscle/nerve connection, stops prostaglandins, and increases the permeability of the lymphatics. These were some questions I thought of as I watched the video and digested it (I’ve left a lot out):

1. How fast does ice increase permeability in the lymhatics to cause the back flow of waste back into the injured area (and increase swelling)?

2. How fast does ice block prostaglandins?

3. If number 1 and 2 are actually the case, what effect does this have on the recovery process?

4. How much does icing inhibit inflammatory processes?

I don’t have an opinion of a PT or physiologist on this next point, but there are two ways to look at stressors on the body: the immediate effect and then the adaptation. For example, when we train and apply a full body stress, there is an immediate structural and hormonal response. Then, a couple of days later, there is an adaptation that looks different than the initial injury stress we applied through training. We can potentially see the short-term effect of something like icing and its effect on the lymphatics and prostaglandins (the latter’s response to icing is not known to physical therapist friends), but do these stressors accomplish some kind of favorable adaptation? Unfavorable? Either way we don’t know.

Here are some responses that I received.

Justin: this is all news to me about the permeability of lymphatics leading to increased swelling.

That comes from a friend who just received his doctorate. Sure, it may be that something that is “progressive” isn’t necessarily a part of the curriculum, but reading, analyzing  and understanding research is a part of any doctoral program so you would think it would have come up before. In the limited research I’ve seen, the main “ice increases swelling” is seen in animals or in treatments of ice by itself.

I think a better question would be does ice block prostgladins as opposed to reducing them, how much does it reduce them, and most importantly, does this result in decreased healing?

Again, this is information that is not known. Remember that the physiological mechanisms behind most of what is observed are fuzzy. This is one example.

Benefits (of icing) other than numbing and decreased nerve conduction velocity (they go hand-in-hand) would be a localized decrease in cellular metabolic rate which relates back to preventing the initial inflammation from increasing and reducing secondary hypoxic cell damage.  This is why this can be bad when someone is past the acute stages of an injury.

It’s common practice for ice to be used early in the injury process, and it’s to “reduce secondary hypoxic cell damage”. It’s not necessarily used on a specific location after this process because, as it says immediately above, it decreases the cellular metabolic rate. Notice that this focuses on an acute injury, and is not specific to a certain type of injury.

What’s the conclusion? 

Across the board from a variety of people, including myself, the opinion is that outright saying “do not ice” is premature. There is merit to the increased permeability of the lymphatics (as a result of icing), but in specific cases (e.g. in specific pathology or where edema already exists). There is also merit that Kelly’s clinical observance has been that people heal without ice (whether they heal better or not, I do not know). At the very least, icing can help reduce pain in recent acute injuries. At best it can reduce secondary hypoxic cell damage to result in a faster overall healing process (when combined with other treatment methods like appropriate movement, compression, and elevation). There are even studies that show it reduces edema, but the rest are inconclusive. At worst, it is creating more swelling and congestion and interfering with recovery processes, but the clinical research and practical experience generally do not show this.

Personally I have observed ice helping myself and people I have worked with recover from injury or training stress. Does that mean I am right and Kelly is wrong? No. Within the context of looking at the research and the practical experience of using it, it doesn’t make sense to draw a line in the sand and say, “Never ice again.” If it were something causing exceptional problems, then I would agree. But it doesn’t. Again, keep in mind that this is even more so the case because most of us need to be able to treat most injuries on our own because we won’t have access to physical therapists all of the time. I disagree with throwing out a potentially useful rehabilitation technique because of a philosophical distaste.

This shouldn’t turn into, “Justin says we can ice, so let’s ice,” — my friends who hold doctorates in physical therapy and anatomy and physiology agree. What we agree on is that the context determines the application of ice. Does this sound familiar? The world is full of individuals with individual sets of circumstances. There is no cookie cutter approach for strength and conditioning or injury rehabilitation. The rehab protocol is dependent on the person and their type of injury. Tomorrow we’ll discuss some methods of when icing would make sense…and when it won’t.

Finding the Psoas

Posted on by
32

A few weeks ago I did a post on hyperlordosis and how the psoas is a primary contributor to it and back pain. Issues with the psoas and hip flexors are pretty common since most people sit during a large portion of their day, and it can cause pain anywhere from the sacrum to the scapula (ass to shoulder blade). The following is a nice visual on what the psoas looks like when stationary and during various hip movements (the captions aren’t in English, just look at the image after reading the hyperlordosis post):

I recommended that if you were hyperlordotic to try working on your psoas. Instead of just mashing around in your guts, I wanted you to learn where your psoas was so that you could work on it. There are a few good techniques to use, but you have to be accurate with you’re massage. At worst, you could occlude your abdominal aorta; at best you’d just be doing a pointless massage. It’s best to get a 출장 massage from a professional. Here is the info on how to find the psoas on yourself:

To begin, lie on your back, pull your knees up, and let them fall to the side opposite to the posas you want to work on. This will let your intestines move away from the target area. Start about two inches from your belly button — you’ll be between the button and your hip bone. You are feeling around for a muscle that runs longitudinally with your spine. If you are incredibly tight, it can feel like a hard sausage. To confirm that you are touching your psoas, flex your hip (pull your knee up) slightly; the psoas should contract. Another way is to lift your head to contract your rectus abdominis; the psoas will be off to the side of the area that contracts. It may take a few minutes to become acquainted with the psoas your first time; be patient, virgin.

Most of you wrote back saying that you couldn’t find it. I don’t have to ask to know that you weren’t patient during your search. When palpating deep tissue, you have to allow your fingers to sink through the superficial tissue — stuff like fascia or connective tissue can prevent immediate palpation of the deep stuff. I’ve made a video “finding the psoas” is broken down crayola style.

If you have any issues with this process, then post the questions to the comments.

Case Studies – Nerves

Posted on by
25

The human body is incredibly complicated. I’ve been through various anatomy, physiology, and biomechanics classes that have given me an appreciation of the body, but being able to study on cadavers was life changing. It was amazing to hold a human heart in my hands knowing that it belonged to a living, breathing person who had hopes, dreams, aspirations, a family, children…a life. To hold that person’s heart, one of the most important organs yet a symbol of vitality and love, was something I’ll never forget.

More to the point, the musculoskeletal system was fascinating. Instead of looking at bones or models of bones and muscles, I could see them right in front of me. The rectus femoris attaches on the anterior inferior iliac spine and travels down to integrate with the other three parts of the quadriceps to a common tendon that attach to the patella, which shifts into a ligament that attaches on the tibial tuberosity on the anterior side of the proximal tibia. God damn it, isn’t it beautiful? Seeing it gave me an immense appreciation for the complexity of life and how it evolved to be that way.

I love and appreciate this kind of shit, and I love and appreciate teaching people to optimally train their bodies to perform and be as healthy as possible. There’s a lot going on when we train, eat, sleep, or experience life. It takes effort to keep things on track, yet there’s a lot that can easily go wrong. I’m often surprised that some people have made it as far as they have; the crack addict still breathes years after being addicted and the ignorant guy who deadlifts with a horribly flexed lumbar still hasn’t blown out a disc. Humans are a hardy species.

I have two friends that have had nerve issues to the point that it has effected their training. Shawn has made his way through law school and still manages to train about four times a week. “Mace” is a soldier who has been blown up and shot. They have very different backgrounds and different nerve related issues that they have either fixed or improved.

I want to point out that I’m not a medical doctor. I’ve had several medical doctors comment that I know anatomy better than they do, but I think they were just being nice. Anything I say should not be taken for medical advice; when in doubt, go see a doctor. But let’s face it, some times we — people who train regularly — do not have the resources to see a doctor. Does this mean you should try adjusting your vertebral segments on your own? Absolutely not. But there are ways that you can work on your body to improve your ailments (it’s the premise behind MobilityWOD). Most of us can handle the minor repairs in our house; it’s only when there is a major issue (a flooded basement, the hot water heater craps out, etc.) that we’ll get ‘professional help’. Our bodies should be no different. Let’s look at how we addressed some nerve related issues.

Shawn

Earlier this year Shawn started noticing that his left hand was feeling numb. Specifically it was his pinky finger and half of his ring finger. When he pressed, he noticed that his wrist felt extremely unstable, especially at the top half of the range of motion. He felt as if he had no sensory feedback, kind of like when your foot falls asleep. Shawn can deadlift close to 405, but when he was doing 315 one day it felt hard, and the bar just fell out of his hand halfway up. He realized something was wrong and had it looked at. He was told he had carpal tunnel.

To me, that’s a bullshit over simplification. The pinky and ring finger are precisely where the ulnar nerve travels to. That tells me there is something occluding or impinging his ulnar nerve, but the question is where? After being told he had carpal tunnel, Shawn was conscious of his wrist position when typing (he was working at a law firm while finishing his degree), yet the issue never went away. That told me it didn’t have much to do with the wrist.

I started thinking about three other places: the elbow, shoulder and neck. If someone is particularly tight in their internal rotators of the shoulder, I could see that pinching down on the brachial plexus and causing issues, but I’d sort of expect there to be some shoulder or inner biceps pain. There wasn’t really any of that, but file that info away. I started asking Shawn about what his elbow was doing when he is sitting. He primarily sits in class, at work, in his truck commuting, or at his desk at home. It turns out that his medial elbow was often mashed down on the arm rest of his chairs or the door of his truck (you know, the “I’m a big guy and my elbow is sticking out my window” style of driving a truck).

I collected all of this data and created a non-invasive prescription for Shawn.

1. Stop sitting with the medial elbow in contact with surfaces.

2. Complete nerve flossing 4x/day (more on this below).

3. Stretch the internal rotators of the shoulder and tie in the neck 2x/day.

By not impinging the nerve, we should free up that medial elbow and allow the nerve signal to pass through the area. By stretching the shoulder and neck, we could account for any possible tightness in the area that could impinge on cervical or brachial nerves. Lastly, the nerve flossing seems to be significant in treating the issue. To perform it, a person would reach their arm out laterally from their side so that their whole arm is horizontal. The palm is up, which supinates the forearm and slightly externally rotates the shoulder. They then look forward with good spinal posture and gently laterally flex their neck away from the outstretched arm. They would hold for a count, and then return their head to neutral position.

Kinda like this, but keep the wrist straight and laterally flex the head away from the arm. Click picture for source.

Within a week or so, Shawn noticed improvement in his numb fingers. His wrist felt more stable when training, and his grip strength returned. His fingers became sensitive to regular temperatures of water; they would feel like extreme hot or cold on the pinky and half of ring finger while the rest of the hand felt a moderate temperature. My guess is that because his fingers had lost innervation for several weeks, his body adapted to not feeling anything. When the neural innervation returned, his sensitivity was heightened to the temperatures. Now, several months later Shawn doesn’t have any issues with his fingers or wrist.

“Mace”

This guy is a crazy asshole in the Army who has made a really solid effort on getting killed in or out of combat. When his humvee was blown up by an IED, it started a series of issues that eventually resulted in two herniated discs in his back that cause localized and sciatic pain. When he was trying to jump off of a building to avoid an RPG, the explosion took his feet out from under him and he dislocated his left shoulder and tore his labrum. At least the grazing AK round on his leg didn’t leave any lingering damage.

Mace’s issue is in his right shoulder. He noticed that his right deltoid was just not being innervated, and this resulted in a lop-sided press. “Brute force and ignorance” didn’t seem to help, so we started collecting info on his situation. Unlike Shawn, who had no history of cervical injury, Mace probably has some kind of cervical issue that could be causing this. He could have a brachial plexus issue. Who knows? He’d have to wait to wait a bit to see a military doc, so I figured we might as well try:

1. Nerve flossing, same thing as what Shawn did.

2. Working on shoulder mobility, especially internal rotation stuff.

Before trying this treatment, Mace’s deltoid simply wouldn’t innervate properly (he sent me a video, it’s weird). He found that if he did the neural flossing at home, it would help innervate his deltoid and he’d get a decent press workout. He found that if he did it as part of his warm-up at the gym that he would still favor his right shoulder. Regardless, he still does it at the end of his training session. Despite our efforts that improved the issue slightly, his “shit is still fucked up”. He will see a neurologist soon and hopefully they can shed some light on where his issue originates and whether or not he can do basic treatments to keep him operational.

Recap

Nerve issues are not incredibly common in the training world. Hopefully this post gives you two perspectives. In Shawn’s case, we were able to identify what caused his issue, created an effective rehab program, and completely eradicated the problem. In Mace’s case, he has some more serious stuff going on that is going to require actual medical attention. We can discern the difference through collecting data on our “patients”. I was quickly able to identify what was probably causing Shawn’s problem by critically thinking with anatomical knowledge. I knew Mace’s issue was going to require “proper medical attention” since there wasn’t really one cause we could point to, but I still thought we could improve it to some degree (we did).

In either case, the assessment and “prescription” were derived from a knowledge of anatomy and physiology. I’ve explained in the past why anatomy is important for people who coach or train, but took it to a different level here. Coaches, trainers, or “fitness professionals” owe it to their clients to continuously learn about the human body. That doesn’t mean they should have to take bullshit continuing education credits on stupid pieces of equipment, coaching, or nutrition, but should focus on the hard sciences applied to relevant scenarios. I didn’t do anything special here; PT’s or chiros may have better solutions. Yet I was able to eliminate or improve serious problems that hampered two friends’ training.

And it all starts with anatomy and physiology.

 

The Butt Wink

Posted on by
28

Awesome quote:
Evan: Do you cycle (insinuating road biking)?
Dr. Metzler: Periodically.

Periodically I get questions on whether or not the “butt wink” is an issue. The first thought that comes to mind is “who the hell thought of the term ‘butt wink’?” Winking requires the closing of an orifice, and everybody knows that in order to close your outer sphincter, you have to clench your butt cheeks together. You can’t do this while squatting, and if you do, you’re doing a half squat. So stop, god dammit.
Editor’s Note: Yes, there’s more than one sphincter. What?
2nd Editor’s Note: I don’t recommend Google image searching “butt wink” with the safe search “off”.

How awesome is this picture?

The butt wink is a made up term to refer to the alleged posterior tilt of the pelvis at the bottom of a squat. Posteriorly tilting the pelvis is the same motion you’d make if you wanted to hit your pubic bone against a wall (guys will probably crush their junk in the process). It’s important to note that observed butt winks are McCarthy’d when a person is doing a body weight squat (i.e. without a barbell). During a body weight squat, the trainee is told to keep their back in hardcore extension to avoid the wink. There are a few trainees that need this kind of cuing to achieve a proper spinal alignment, and those who don’t get in the habit of over-extending their thoracic and lumbar spine. The body weight (BW) squat is commonly (and incorrectly) taught as a precursor to a barbell squat, and the progression is misleading since they teach incorrect extension and mechanics during a barbell squat.

The BW squat is an incorrect first step because of the means and the end. The mechanics of it are unimportant since it isn’t loaded with additional weight and the squat itself is routinely executed safely after dropping a deuce everyday (two or three times if you’re me — yeah c’mon). It is also used as a conditioning tool — NOT a strength builder. Trying to claim that the BW squat will build strength is like saying non-alcoholic beer gets you drunk. Floozy.

Every person’s body dimensions will not be able to fit the mold of an “upright torso” anyway. A person with long femurs and a short torso must lean over when squatting all the way down in order to manipulate their body to have a stable center of mass (unless they are wearing Lady Gaga’s heels). Furthermore, some trainees won’t have the flexibility to get to the proper depth in a BW squat. If the same trainee places a barbell on their back, it provides a little more external resistance that helps push them down into proper depth. This is similar to PNF (proprioceptive neuromuscular facilitation) stretching; elongating a muscle as it attempts to provide a resistance to the stretch. A trainee in this situation is not using enough weight to cause harm (anywhere between 45 and 95 lbs), and in fact the weight is helping them achieve proper depth, let their muscles stretch, and working all of the muscles around the knees and hip through a full range of motion. A coach who has their thumbs anywhere but in their ass can easily teach this correctly.

The above addresses the lack of logic in battling against a “butt wink” in a BW squat and dealing with an inflexible trainee, but what about the wink itself? Does it happen under a load? If it does, should we all be concerned? Frankly, I’ve never had a situation where there’s a “butt wink” worth worrying about. Lifters should be taught to shove their knees out when squatting, whether they are doing high bar, low bar, or front and overhead squats. Shoving the knees out avoids any impingement, bony or soft tissue, and is explained in detail by Mark Rippetoe in several sources. Not shoving the knees out is probably the culprit for most “butt winking”, so the point is almost moot.

Let’s say there is a little “winking” (I keep putting it in quotes because the term is fucking ridiculous) going on when barbell squatting. It’s unlikely that it’s caused by tight hamstrings since those hamstrings are allowing a full depth squat (with knees out). There are two reasons I’ve thought of for this happening. The first is related to the “over extended back thing” that is taught in the BW squat. If a trainee over extends their back under a load, the spinal column is now in an inefficient position to transfer force. There are two points where problems typically occur: where the thoracic spine meets the lumbar spine, and where the lumbar spine meets the sacrum. If either area is “over extended” tremendous forces are no longer passing through them to the pelvis (and subsequently legs) and instead are pinching the posterior and opening the anterior portions of vertebral segments. Not good.

You can do this all day with a BW squat.



Don’t think it can happen? Well it does. Aside from hearing about it regularly, a 70’s Big reader recently wrote in and told me they herniated a disc because they were trying to over-correct the horrid “butt wink”. That’s a damn shame. You need your trunk to be straight when lifting so that your spine doesn’t look like a parabola (one that has the y coordinate squared). A coach with clean thumbs can take care of this.

Let’s say that a trainee is taught to over-extend their back on a BW squat, and then does the same thing on light barbell squats. The weight won’t be significant enough to hurt them (and it shouldn’t when teaching squat technique), but their pelvis will naturally pull out of this over-extension at the bottom of the squat. This will appear to be flexion, and it is because the pelvis posteriorly tilts to go back into a neutral alignment because it was extended too far to begin with. A shitty coach says, “Flexion! You are banished from the bar to only perform ‘air squats’ until you get it right!”, but it’s their own fault for teaching the asinine over-extension position. This issue constitutes nearly ALL of the “butt wink” cases that occur when the trainee is correctly shoving their knees out (if they aren’t shoving the knees out, then the aforementioned hip impingement will create the wink).

The pelvis, yo.

The other cause for a “but wink” could be anatomical. In coaching it is extremely important to identify different body dimensions and how they affect mechanics. After observing many limbs and trunks, I started noticing differences in pelvis length. The pelvis itself starts at the sacrum (below the last lumbar vertebrae), wraps around your sides in the form of the iliac crest, and then the pubis closes in from each side on the front of your body at a connection called the pubic symphysis. Usually pelvis variations aren’t a big deal, but if a person has a very long pelvis it alters how they look when squatting or deadlifting. Their low back never looks like it’s extended and can even look like it is lumped out, appearing to be in flexion. Instead, their pelvis may be long enough such that it doesn’t produce a fancy lordotic curve when in position (particularly the bottom of a squat and the start of a deadlift). I’m not saying this is the case all of the time, but it is definitely a possibility; it isn’t crazy to assume pelvises come in varying lengths/widths while we commonly accept that spinal columns, femurs, tibias, humeri, and radii/ulnas all vary in size and shape.

While I’ve noticed varying pelvis lengths in adults, it’s more noticeable in children and adolescents. I haven’t studied a whole lot on bone development, but this age group seems to grow femurs and pelvises before spinal columns. Looking back, the majority of kids I’ve coached are included in this anatomical observation. A trainee with a long pelvis will probably look like they are doing something wrong, but may just look funny because of their anatomy. This structural issue may be what is causing the dirty thumbed coach to shout “butt wink”.

Hopefully after learning some of the anatomy and conceptual lessons here you have a better understanding of why the “butt wink” is horse shit. In general, trainees should shove their knees out when squatting and this will allow proper depth. If a “wink” is occurring in a BW squat, it doesn’t fucking matter because it’s a Body. Weight. Squat. It’s used for conditioning and deuce dropping. When someone McCarthies a “butt wink” on a weighted squat and the trainee is shoving their knees out, that person is either a shitty coach, a pervert, or flamboyant because they are clearly staring at the lifter’s ass. Properly coached squats don’t really have “butt winks”, and if they do, I think it can be explained by their anatomy (and they aren’t a big deal anyway).