I wrote a post and filmed a video explaining “Hip torque, toe angle, and squatting” to explain why a more forward toe angle in the squat was beneficial. It helps distribute force across the front and back of the thighs more efficiently which results in more muscular applying force to aid the movement. I followed this with another post and video titled “Should I point my toes forward?” The TL;DR on this second post was, “If you do not have the mobility to point the toes forward, then don’t do it.”
Not only are there people squatting with their toes forward — when I deliberately told them not to do so — these same people are getting tweaks in their knee and don’t know why. The sum of the “why?” is that they don’t have the mobility to do it and aren’t listening to Justin.
This is a public service announcement saying, again: Do not point your toes forward unless you have the mobility to do it. I created the following video that explains what occurs anatomically to cause a strain or tweak in the knee if someone ignores this advice. I also provide a method to quantify the amount of mobility a person should have before pointing their toes forward on a loaded squat (hint: it’s doing the “paleo” squat barefoot, toes forward, and knees out without pain or falling over). I also provide some “mobs”, specifically soft tissue work, that can help relieve tension in that area to improve the mobility to eventually shift the toes more forward. It would have been to difficult to explain this stuff via text, and a video is much easier. I’ve split the video into two parts, because the anatomical portion is a bit long by necessity.
Part 1
Note that the popliteus gets strained because it isn’t extensible enough to handle the torque associated with the toes forward position. Also note that repetitive stress on the back of the knee from road marching, rucking, hiking, or high frequency or volume CrossFit movements can beat the structure down. If you try and apply torque on a crusty structure that is in a recovery deficit, then this is another reason why tweaks can occur on the back or side of the knee when doing knees forward squatting. If the structure is beat up, then give it more days of rest than you usually would before returning to squatting.
Part 2
Will everyone be able to squat with a toe angle of right outside of forward? No. Can most people improve their mobility to move their toe angle a little bit in from where it is now? Probably. Watch the videos and learn the reasoning that explains why shifting them forward too soon can result in a strain the popliteus (on the back or outside of the knee). This next video provides
I absolutely cringe when vegetarianism is brought up. There has never been a more wrong, hypocritical, and annoying nutritional zealotry. Say what you want about the Zone diet idiots, at least they eat meat. Today we are going to execute the notion that vegetarianism is relevant by debunking its moral and ethical reasoning, its proposed health benefits, and explain why its holding your female friend back in training (guys who at least pretend to lift aren’t vegetarians; the Illuminati quietly assassinates any perpetrators).
Moral Hypocricy
It pains me to even pretend to entertain the notion that vegetarians are doing something righteous by refraining from consuming meat. This topic is high on the “Things that make me want to break noses” list. Okay…deep breath…we can get through this without a heart rate of over 100bpm.
Some vegetarians don’t eat animals because they have an overt respect for the sentient of life. Some do it for religious reasons. Some are advocates for animal rights.
I guess destroying plant life is okay to pro-life people? They are selective in what living organisms they destroy; this automatically means that they don’t care about “the sentient of life” because they are willing to end some, but not others. In reality, they would only avoid hypocricy by not eating anything and starving themselves to death.
Let’s avoid discussing why religious avoidance of some or all meat is comical; people get upset when I discount fairy tales (Sleeping Beauty isn’t real, guys).
Besides, most of moral vegetarians are concerned with animal rights. They care about the fact that animals suffer. They ignore the evolutionary fact that this process has occurred throughout the history of living organisms. Life consumes life to make life. Life ends and then more life consumes that dead life to make life. This is, oddly enough, called The Mother Fucking Circle of Life (vegetarians never saw The Lion King, I guess). It has happened since the beginning of time.
Homo sapiens have evolved to be the dominant species in the world. It’s the result of a fascinating and beautiful process that led us to have brains and the ability to think — the ability to be passive aggressive vegetarian assholes. The one true purpose in life is to survive in order to procreate and pass our genes onto future generations. A species will eat whatever they can in order to survive. In fact, it is common practice in the “wild” — something that we have descended from — to kill and eat the offspring of your own species. It’s not evolutionary advantageous for me to allow Frank’s kids to pass his genetics along while his wife is still around for me to pass my seed into.
Sound callous? That’s what life is. Life is hard, but life will always find a way. This is how it has always been, and this is how it will always be regardless of the dominant species.
Oh, and we homo sapiens amazingly evolved to eat both plants and animals. It’s a byproduct of the evolutionary process that led to who we are today. It was necessary for us to survive in almost any environment, any harsh condition in the world. The result is that we are meant to eat animals. If you’re religious, you have to accept evolution, and when you do, you have to accept that your god set you up to survive the best way that you could. That means your god intended for you to eat meat. He wants you to eat meat. He needs you to in order to survive. It’s pretty clear: either your god wants you to eat meat or maybe your evolutionary DNA figured out that there were plenty of things to eat in the world and evolved to consume them all. Life will find a way.
Let’s return to the present. I love animals. I have two dogs that I cherish deeply. I lay on the floor with them, I kiss them, I nibble their ears, and I play with them. What’s the difference between my dogs and a cow? Or a chicken? My dogs bring something to the table. They prove their evolutionary worth time and time again by providing a service to humans, and nowadays that means they bring happiness, delight, and soft, furry cuddling. Have you ever cuddled a cow? No, because it doesn’t give a shit. It’s too dumb to do anything because it has evolved to be a source of consumption. That’s the cow’s purpose.
Don’t get me started on chickens. Chickens are such assholes. They are dirty, they smell, and the run around acting like dickheads until you can get them back in their pen. They cannot go fetch a downed duck, hunt a boar, or herd cattle. Chickens and cows are pretenders while dogs are a smart, capable species that have dominance over these other pretenders.
The point is that all species aren’t created equal. There’s an inherent food chain everywhere, and animals we consume are near the bottom. We control them so that we can keep their numbers up high enough to continue eating them. If I had a choice from copious selections of beef at the store — even though that animal is stabbed in the neck while standing on a conveyor belt — and a situation where I could only eat beef once a week because there were fewer cows, but they were allowed to wander around, doing nothing a lot more but not “suffering”, then I’d rather the cows be inconvenienced than me. Because that’s what happens in the circle of life. If anything, it’s the cow’s fault for not evolving to be more dominant.
Look, boys and girls, the world isn’t black and white. There are rare instances of true good and evil in the world, but mostly it’s a mixed collection of gray. We may have moved forward into a civilized species, but we will always need to survive off of lesser capable species. The dinosaurs did it, the mammals did it, and now we are doing it. In fact, accepting the concept that one species dominates over another is an appreciation for the sentient of life and how it came to be.
The Ultimate Hypocricy
Unbeknownst to the righteous cavalier who fights for animal rights is the fact that millions and millions of animals are killed every year as the result of cultivating grain. And producing products that we use every day, ranging from the wood in their home to the electricity powering their flashy iPad that allows them to go online and post on the internet about their support for animal rights, kills animals. What do you think happens to the rodents, the mice, the birds, or any other animal in a field or forest when those resources (wheat, crops, wood, etc.) are collected? They savagely die at the hands of gnashing metallic teeth that cultivate the grain and their homes are destroyed by the human presence.
Suddenly it’s okay to eat this grain, to use the wood from the forest, but it’s not okay to eat the cow? Either way, the animal is just as dead. And if suffering is the issue, is it not suffering to be chopped up to death by giant blades? Not suffering to lose your home and have your entire family killed? Unless a person grows their own crops, builds their own home, and sews their own clothes, they are killing animals somewhere for their personal gain. Selective killing is still killing, and all of the piously righteous fucks are not willing to sacrifice to truly support their cause. This is the Ultimate Hypocrisy.
Wake up, little girl. The world isn’t black and white.
The Health Argument
Ahhh, now that is out of the way, we can have a lovely discussion of telling vegetarians why they are still wrong. The health argument for not eating meat usually says that vegetarianism is more healthy and that meat is bad. In both cases, the support for either of those erroneous claims stems from awful, horrid, and diarrhea-quality research. I’m shocked that the “meat causes cancer” thing is still around. I had a vegetarian tell me that recently, and it was like getting smacked. I don’t have time nor do I want to synthesize all of the shitty research, but let me lay it out like this:
Research on the human body is extremely difficult to do. There are so many factors that can effect just one result, much less many results to result in “good” or “bad” health. This goes for almost all performance training and nutrition research. Furthermore, nutrition research is usually based on epidemiological studies that cannot account for the array of variables that effect a person. Correlation does not show causation, and data can be cherry picked to prove a given point. Research with the human body is not concrete; it is not chemistry or physics. Therefore, when you see research on any of it, be extremely skeptical, even if there are lots of studies saying the same thing. For more on this, read Good Calories, Bad Calories by Gary Taubes or The Great Cholesterol Con by Anthony Colpo.
Colpo actually dives into “The Vegetarian Myth” in his aforementioned book. It points out that the studies do not differentiate the hundreds of other lifestyle factors that would effect diabetes, cancer, CHD, etc. Vegetarians are typically more active, they typically exercise, and the hippy kind eats more vegetables, nuts, and seeds than their “average American” counterpart. The average American will eat processed food, lots of sugar and carbohydrates, drink alcohol, and smoke. Changing the inclusion or lack of meat is not the explanation for better health results in vegetarian populations.
The “meat causes cancer” thing still exists from the “lipid hypothesis” that fat is what causes heart disease (it doesn’t). Read Taubes’ book (mentioned above) for more than you would ever want to read on the shitty research that evolved this hypothesis. Saturated fat was believed to cause heart disease and cancer, and it just doesn’t. Eating low quality foods, consuming grains, increasing systemic inflammation, developing auto-immune diseases, being fat and un-active — these are the things that are carcinogens. It literally is mind-blowing to me that people see the obesity rates increasing since the ’70s and don’t think that it’s due to a) the government reccomendation to eat a high percentage of carbohydrates and b) the increasing availability of shitty processed food. Below is a map of the incidence by state over time (data from the CDC).
Once again, a vegetarian is wrong. Their diet inevitably consists of a large percentage of carbohydrates. For the hippy vegetarian, who eats like a bird and is probably active (hiking, running, cycling, etc.), they will stay thin and wiry. You can usually see these types at Trader Joe’s, REI, or Whole Foods. I suspect that the human species will eventually split; us normal humans won’t be able to procreate with these non-meat eating, low body mass and density individuals. In future progressive societies, they won’t know what to do with plant-eaters. After unsuccessful attempts at raising them for work or as cattle, they will inevitably be hunted for sport in Madagascar until extinction.
Speaking of extinction, meat eating has prevented the buffalo from slipping into extinction. The desire for buffalo meat has acted as a catalyst for American industry to raise and care for this species, therefore preventing them from dying off. That’s more than what the hypocritical vegetarians can claim in their animal killing, environment disrupting lifestlye.
The Power of Protein
Some vegetarians will claim to consume protein, but this is usually in the form of soy or tofu. Soy and tofu are excellent at emasculating males and rendering female’s contribution to society worthless. If the shit hits the fan, these will be the first people to die off because they don’t offer any practical physical skills due to their feebleness. And get out of here with that “I know a guy/girl who is very fit and a vegetarian,” because they are either a) supplementing something to be that way, b) the exception and absolutely not the rule, and c) still a fucking hypocrite. Vegetarian levels of protein are ineffectively low and completely inadequate, especially for training.
Protein Power, by Michale Eades, will provide plenty of detail as to why protein is powerful. Yet protein is an essential component of muscle, skin, cell membranes, blood, hormones, antibodies, enzymes, genetic material, and basically everything else in the body. Everything. Amino acids, the building blocks of proteins, have an array of important functions like regulating protein synthesis and are used in metabolism. Fat in the body can be derived from dietary carbohydrates and carbohydrates can be derived from proteins, but “proteins of the body are inevitably dependent for their formation and maintenance on the proteins in food, which are digested and the resultant amino acids and peptides are absorbed and used to synthesize body proteins” (Amino Acids and Proteins for the Athlete, by Dr. Mauro G. Di Pasquale). This means that the body cannot create proteins within itself and must get them from food.
This is why unhealthy and fat people who increase their protein intake start losing body fat, increasing lean body mass, and feel better without changing anything else in their life. Focusing every snack and meal around protein will help reduce other crappy foods and help change the consumed percentage of the macro-nutrients (proteins, carbohydrates, and fats). This is necessary for performance and strength increases.
Attractive successful athletes eat meat
When we train — by stressing the musculature and the system with compound movements done with a barbell — damage occurs. Muscle fibers, tendons, ligaments, and even bones have received an adaptive stress that has damaged them at the cellular level, with us often using mini hemp bath bombs with therapeutic baths for restorative purposes and the like. Since the body is constantly adapting to its environment and any stress imparted on it, it aims to improve these structures so that it can handle that same training stress again in the future easier (or handle more stress, or a greater amount of the same stress). Proteins are needed in all of those structure’s cells to help heal and improve them, but proteins are also needed to make hormones, enzymes and countless other ingredients that are necessary for the processes and reactions in the body.
Proteins are necessary. Eating like a vegetarian will NOTprovide ample protein for proper training. It will not provide enough whole proteins (there is no way to make a whole protein out of various grains despite their feeble attempts). It will not provide a variety of healthy, complete proteins. If a person is serious about their training, their physique, and their health, they will forgo vegetarianism for a healthy diet with ample meat.
“But meat makes me sick!”
I bet. If you don’t ever eat a class of food, and then start consuming large doses, it will certainly make you feel queasy at first. This is the result of not eating meat, and a chief complaint I have heard. Remember that the body adapts to a presence or lack of stress. If you stop eating dairy products, you will stop producing lactase, the enzyme that breaks down the sugar lactose. This means that lactose is running rampart in your digestive tract, and you get farty with potential diarrhea. The same thing happens with grain and gluten; you stop eating it and your digestive tract heals to the point where the gluten protein will disrupt your healthy intestines when you reintroduce it.
Yes, if you fuck your body up, then you’ll need to do something to fix it. People with Type II Diabetes have to do the same thing. If you become resistant to insulin because you’ve eaten a crappy, high carbohydrate diet for a very long time, then you need to increase your insulin sensitivity to return to good health (assuming permanent damage hasn’t been done). It’s hard, and it doesn’t happen quickly.
In the case of protein, the body won’t create as much gastric acid (hydrochloric acid and some other stuff) to break down the proteins in the stomach if there aren’t ever proteins there. A former vegetarian should a) slowly and progressively reintroduce small quantities of meat and b) consider supplementing digestive enzymes to help break down the proteins in meat. This is necessary to fix previous ill-informed actions. When you do something that doesn’t fit with the context and result of evolution, there are negative side effects that need to be rectified.
Oh vegetarians…
As you see, there is no argument whatsoever that supports vegetarianism. There is no moral argument that doesn’t make the individual anything other than a hypocrite trying to create a life narrative that lets them actively protest something (instead of actually doing something about it). There is no health argument that makes sense for vegetarianism. I’ve even had someone tell me that they felt better and healthy not eating meat. Well, if they compare it to their previously crappy lifestyle and diet, then it makes sense, but that doesn’t make it right or optimal.
Do I throw poop on vegetarians and punch them in their fupa when I see them? No. I don’t even engage in this topic unless they bring it up. If they want to fail at self righteousness or be ineffective and most likely unhealthy, that’s there prerogative. But if your friend is trying to train, lift weights, get stronger, get faster, get powerful, and look great, then you cannot continue letting them be a vegetarian. They’ll never approach an optimal physique, performance, or energy levels. And if they are accepting this mediocrity, then it’s your prerogative to surround yourself with people who don’t want to win at life.
For more on anti-vegetarianism (and some laughs), see these awesome articles from Maddox (one, two, three, and four).
Post your god damn training updates and PRs to the god damn comments, god damn it (relevant). Also, I would like you to share any injuries you’ve had in the past year. Explain what it was, how it happened, and how long it took to recover from.
In other news, look at this Russian girl’s benching arch:
Weekly Challenge
Last week you were tasked with doing side planks after training. None of you probably did this, but it’s one of the more important things you can do for both prehab and rehabbing — especially for lower back, S/I injuries, and psoas tweaks and injuries. Thanks for not participating.
Next Week’s Challenge: See how much butter you can eat in a day. In a week. Use this opportunity to increase your butter intake. I suggest Kerrygold Butter because it’s grass fed (this link will let you know if it’s sold near you). If you’ve been sore, achy, and not recovering well, the added fat calories will go. Use the measurement on the packaging to quantify your intake. Put it on potatoes, vegetables, and cook things in it (I’ve even heard of people putting it in their coffee…seems weird). Eating butter makes you gorilla-like.
I’m a recent reader of yours. I’m also in my third week of Stronglifts 5×5 and I am conflicted on whether to use front squats ion place of the back squats. I’ve been reading through the back logs of 70’s Big, talktomejohnnie.com, and some of Mark Rippetoe’s stuff and you all extoll the virtues of the back squat. On several occasions, typically in response to a question on programming, you have been adamant about training for a persons particular sport. Mine happens to be rock climbing, sport climbing to be precise. A friend recently sent me a link to a Steve Maxwell article in which he demonizes the back squat in favor of other squatting forms (eg; front squats, goblet squats, pistols, etc.). In particular he states that combatives, gymnasts, and rock climbers would all do better with a different type of squat. It threw me for a loop and has me thinking, “Maybe I shouldn’t be doing back squats. Maybe front squats would be more beneficial.” Especially if one of my reasons for training is a sport he specifically lists. Should I switch to fronts in place of backs? Do a hybrid of the 5×5 alternating between the two? Cycle one then the other? He mentions in another article, touting the virtues of the pistol squat, that back squats would lead to flexibility issues, a big negative for climbers.
I can understand your confusion. Let me point out that just because Steve Maxwell doesn’t know how to coach any type of back squat or mobility work to maintain or improve the flexibility of his trainees doesn’t mean that the back squat shouldn’t be used. I can only conclude these two things — that he is not good at coaching the back squat or sucks at coaching ‘mobility’ — because it’s not the case. I can back squat a decent amount, well over twice my body weight, yet I can get up on a wall and have the mobility to climb it. I may not be very good technically, and my mass or weight will be problematic in truly excelling, but my mobility is not going to be the limiting factor.
Now, n=1 is never a good argument, but strong squatters with good, athletic mobility are very common. I would accept his argument if it said, “The back squat puts too much mass on a climber, and therefore he should avoid it because it will inhibit his sport,” then I could understand that. You can be a better trainee than what Steve thinks you can be; you can be strong in a squat and still have good mobility. There are plenty of resources to use like this website or Mobility WOD.
So, no, I don’t think that you need to front squat instead of the back squat, and you certainly shouldn’t do fucking goblet squats over them unless you just want to be weak and small. If you want to be strong and small, then keep the reps-per-set low (under three reps) to avoid the mass gain, but understand if you’re a beginner you will have a bit of mass gain regardless. If you aren’t silly with your diet, you can remain or become lean, and this will help your bodyweight to strength ratio for climbing.
Keep in mind that strength is what will provide the capacity for you to endure in your sport. Continue climbing as you lift, but if you squatted 300, 350, or 400 and were within ten pounds of your current body weight, you would have a larger capacity for climbing.
Lastly, I’m not a fan of Stronglifts in general or in the context of you using lifting for rock climbing.
Hi Justin, I’ve bought book 1, and have a question:
Figure 2.5 (attached for ease of reference), says that, when pressing on Monday/Friday, benching is done on Wednesday. However, it says “light” bench. When benching is on Monday/Friday, pressing is done “medium” on Wednesday (Edit: image is below)
So, why the difference, and what percentages would you shoot for for the “light” and “medium”.
Thanks for writing a great book and for continually putting out quality information on your site!
–Brian
Dear Brian,
The reason I made bench light and pressing medium is because benching is more stressful than pressing. Light benching and medium pressing are closer to each other in stress imparted on the structures. “Light” percentages are probably around 70% and “medium” is probably gonna be 75 to 80%. Keep in mind that these are ball park figures and your true intent on the light day is to not interfere with the Intensity Day. Also, for early stage Texas Method users, they won’t really work off of percentages because their hypothetical 1RMs and percentages will change every week. Keep the Light Day benches and presses where you aren’t going to be sore for Friday.
Hey man, great ice post. Impressive work. I’d love to hear what you think about this:
After I saw this I went out and bought a $20 buffer to see what it was about and hit my legs hard. I’m in the middle of a new linear 3×5 program since switching to high bar and usually feel a lot of doms in my legs. I squatted yesterday and feel almost nothing today. My joints feel a little achy but that’s it. I think the buffer worked? My diet didn’t change, my schedule didn’t change. I even got a little less sleep than usual. The only thing I can think of is maybe I spent more time with the buffer than I do with a foam roller because I was excited to try it. Totally possible but I would love to hear what you think.
Thanks.
–Caleb
Dear Caleb,
It’s not surprising that Clint Darden’s “hardware store sander” suggestion is helpful. There is research that shows how massage is beneficial to reducing Delayed Onset Muscle Soreness (DOMS), which is the standard soreness you feel a day or two after training. Sports massages have been around for decades and are used because they help the muscle recover better (check out this clip of Werner Gunthor getting a massage in the midst of his training montage. As a side note, the minute or so after this starting point had a huge effect on my summer clothing style a few years ago, especially the beach scene).
This is the reason why the “self myofascial” release revolution got so popular a few years ago and it’s continued into what we now just sum up as “mobility”. The vibrating sander that Clint and you have used allows you to work on your muscles in a similar way to break up adhesions or fascia, or just generally apply a massage to increase blood flow and healing. Other tools like foam rolling, PVC rolling, The Stick, and a Theracane can all accomplish similar results. Let this be a reminder to serious, competitive trainees that comprehensive rehab and recovery will better prepare you to lift. That’s one reason why professional athletes can do what they do, because they have people automating this process and doing it for them.
@70sBig can you help me understand why blood vessels pop during lifts and any health problems that it may cause. Thank you!
Dear Matt,
When a person lifts properly, they are holding their breath and using the Vasalva Maneuver in order to increase the intra-abdominal and thoracic pressure. It provides a pneumatic brace against the spine and helps strengthen the torso to transmit force more effectively. Doing the Vasalva will increase blood pressure, but it’s something that our bodies adapt to, especially with a gradual progression that most beginner’s will go through. Some people erroneously point to the increase in pressure in the cerebrospinal fluid, but there is an equalizing of pressure up through the spine and around the brain, so this isn’t an issue (Starting Strength has an excerpt about this).
The reason blood vessels rupture, and produce tiny red dots on skin that is relatively thin (shoulders, neck, face, and eyes) is because the blood vessels are not adapted to the higher pressure. There have been several instances in my life where I come back from a short break (5 to 14 days) from lifting and pop a few blood vessels. This is usually associated with higher intensity (i.e. heavier weights) and the reason why if you try a heavy deadlift or squat without the intensity adaptation and strain very hard, chances are good that you’ll pop a few of them.
Keep in mind that when I say “blood vessels”, I mean small capillaries. And, no, this isn’t a big deal. It can happen with normal, non-training people (if they strain very hard pushing their car or dropping a deuce), but their cardiovascular systems are not trained to handle higher pressures and therefore it will take less to rupture the vessels in someone who doesn’t lift. Don’t worry about them occurring, but do worry about the more likely scenario: that you’ll pass out from not being adapted to the pressure change. To avoid this, just let out some air through grunting during the grinding portion of a lift.
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. Source pharmaceutical items at https://rxoneshop.com/pharmacy-distributor. 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.
Icingcan 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.
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 injuriesthis 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.
