Team Physicians Corner

DOCTYPE = ARTICLE

The Use of Ice in the Treatment

of Acute Soft-Tissue Injury
A Systematic Review of Randomized Controlled Trials
Chris Bleakley,* BSc (Hons), MCSP, Suzanne McDonough, PhD, MCSP,
and Domhnall MacAuley, MD, FISM
From the Rehabilitation Science Research Group, University of Ulster at Jordanstown, Antrim,
Ireland, and the Department of Epidemiology, Queens University, Belfast, Ireland.

Background: There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical
basis.
Study Design: Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries.
Methods: A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible
studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing
a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity
of included trials using the Physiotherapy Evidence Database (PEDro) scale.
Results: Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the
addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies
assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.
Conclusion: Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.
Keywords: ice; cryotherapy; soft-tissue injury; acute

Cryotherapy is perhaps the simplest and oldest therapeutic modality in the treatment of acute soft-tissue injuries.
It is proposed that by decreasing tissue temperature, ice
can diminish pain, metabolism, and muscle spasm, minimizing the inflammatory process and thereby aiding
recovery after soft-tissue trauma.32 The majority of
research studies and reviews to date have used healthy
human subjects to investigate these proposed physiological effects. Although there is evidence that cryotherapy
can reduce deep-tissue temperature in both animal2 and
human subjects,16,46,65 the degree of cooling seems to
depend on the method and duration of application, the initial temperature of the ice, and even the depth of subcutaneous fat.40

Few literature reviews have considered the clinical evidence base. Kerr30 attempted to produce clear, evidencebased guidelines for an optimal cryotherapy protocol; however, the majority of recommendations for practice were
finalized by expert consensus. A recent systematic review
of the original literature provided preliminary recommendations for an optimal treatment protocol40; however, few
clinical studies were discussed, and conclusions were
derived from studies using only animal or healthy human
subjects. To date, no review has measured the quality of
the study methodology or considered the clinical appropriateness of applied treatments within cryotherapy
research.
The current recommendations in standard textbooks on
the clinical use of ice also have many shortcomings,39 and
most physicians rely on empirical evidence. The selection
of parameters in a clinical environment continues to be
made pragmatically, and recommendations in review articles range from 10 to 20 minutes 2 to 4 times per day,29 up
to 20 to 30 minutes,60 or 30 to 45 minutes31,32 every 2
hours. The most recent surveys of clinical practice have

* Address correspondence and reprint requests to Chris Bleakley,

University of Ulster, Jordanstown, Rehabilitation Science Research
Group, Shore Road, Newtownabbey, Co. Antrim, BT37OQB Ireland.
The American Journal of Sports Medicine, Vol. 32, No. 1
DOI: 10.1177/0363546503260757
2004 American Orthopaedic Society for Sports Medicine

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Bleakley et al.

identified variations on the optimal mode, duration, and

frequency of ice application,28,30 yet such factors dictate
the degree of cooling40 and the potential effectiveness of
treatment. In addition, ice is commonly combined with
compression and elevation, making it difficult to determine the value of cryotherapy alone.45,55,61
Although cryotherapy has been promoted in the immediate18,32,41,43,45,52,60 and rehabilitative31,32,55 care of soft-tissue injury, the basis for its application at each stage is
quite different. Immediately postinjury, ice is principally
used to reduce metabolism, thereby minimizing secondary
hypoxic injury and the degree of tissue damage.31,32 In contrast, when applied for rehabilitative purposes, it is used
primarily to relieve pain, which facilitates earlier and
more aggressive exercise.31,32 Currently, many clinicians
do not fully understand the pathophysiological rationale
at each stage and may not be using it to its full advantage.31
Cryotherapy is an accessible and popular treatment
modality for the physician and layman, and its use must
be supported by high-quality research evidence. Therefore,
the aim of this study is to explore the clinical evidence
base for cryotherapy, and the specific objectives are the following:
1. to identify randomized-controlled studies assessing the effect of cryotherapy on acutely injured
human subjects;
2. to assess for the presence of confounding concomitant therapies;
3. to study the modes, duration, and frequency of
cryotherapy treatments employed and assess for
evidence of an optimal treatment protocol;
4. to identify when cryotherapy was initiated in relation to the injury and study the goals of treatment
in each study, that is, for immediate care or rehabilitation; and
5. to make conclusions on the strength of the evidence supporting the use of cryotherapy in treating acute soft-tissue injuries and make recommendations for future research.

METHODS
Search Strategy and Selection of Studies
Relevant studies were identified using a computer-based
literature search on a total of eight databases: Medline on
Ovid (1966 to April 2002), Proquest (1986 to April 2002),
ISI Web of Science (1981 to April 2002), Cumulative Index
to Nursing and Allied Health (CINAHL) on Ovid (1982 to
April 2002), the Allied and Complementary Medicine
Database (AMED) on Ovid (1985 to April 2002), the
Cochrane Database of Systematic Reviews, the Cochrane
Database of Abstracts of Reviews of Effectiveness, and the
Cochrane Controlled Trials Register (Central) (last search
April 2002). For the Medline, CINAHL, and AMED databases, the first two levels of the Medline optimal search
strategy8 were combined with the following medical sub-

The American Journal of Sports Medicine

TABLE 1
Hand Search of Key Journals
Journal
British Journal of Sports Medicine
International Journal
of Sports Medicine
Australian Journal
of Sports Medicine
Sports Medicine
Medicine and Science in
Sports and Exercise
Journal of Sports Medicine
and Physical Fitness
Journal of Orthopaedics and
Sports Physical Therapy
Archives of Physical Medicine
and Rehabilitation
Physiotherapy
Physical Therapy

Year range of search

1988 to December 2001
1995 to December 2001
1984 to December 2001
1987 to December 2001
1978 to December 2001
1988 to December 2001
1986 to December 2001
1989 to December 2001
1988 to December 2001
1986 to December 2001

ject headings and free-text topic words: surgery,

orthopaedics, sports injury, soft-tissue injury, sprains and
strains, contusion, athletic injury, acute, compression,
cryotherapy, ice, RICE, and cold. The remaining five databases had less sophisticated interfaces; therefore, a different search strategy was performed. To maximize the yield
of relevant articles, this strategy sacrificed precision in
favor of sensitivity.9 A series of 68 small searches were performed on each database by combining 13 keywords (surgery, orthopaedic, sport, injury, soft-tissue, sprain, strain,
contusion, compression, cryotherapy, ice, RICE, and acute)
using Boolean logic (AND). In addition, a smaller search
was undertaken on the Physiotherapy Evidence Database
(PEDro) (1966 to April 2002) using five keywords (ice,
cryotherapy, cold, injury, and surgery). This was supplemented with citation tracking of relevant primary and
review articles (n = 63) and all incoming full-text papers
(n = 55). A convenience sample of 10 key journals was also
hand searched to identify articles that may have been
missed in database and reference list searches (Table 1).
To be included within the review, studies had to fulfill
the following conditions: the study should be a randomized-controlled trial of human subjects; it should be
published in English as a full paper; subjects should be
recovering from acute soft-tissue injuries or orthopaedic
surgical interventions; therapy should be inpatient, outpatient, or home-based cryotherapy treatment, used either in
isolation or in combination with placebo or other therapies; comparisons should have been made to no treatment,
placebo, a different mode or protocol of cryotherapy, or
other physiotherapeutic interventions; and outcome measures must have included at least one of the following: function (subjective or objective), pain, swelling, or range of
movement (ROM).
In the first stage of selection, the titles and abstracts of
all studies were assessed for the above eligibility criteria.
If it was absolutely clear from information provided in the

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Ice for Acute Soft-Tissue Injury

253

TABLE 2
Physiotherapy Evidence Database (PEDro) Scoring Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.
11.

Eligibility criteria were specified

Subjects were randomly allocated in groups
Allocation was concealed
The groups were similar at baseline regarding the most important prognostic indicators
There was blinding of all subjects
There was blinding of all therapists who administered the therapy
There was blinding of all assessors who measured at least one key outcome
Measures of at least one key outcome were obtained from more than 85% of the subjects initially
allocated to groups
All subjects from whom outcome measures were available received the treatment or control condition
as allocated or, when this was not the case, data for at least one key outcome were analyzed by intention
to treat
The results of between-group statistical comparisons are reported for at least one key outcome measure
The study provides both point measures and measures of variability for at least one key outcome

Total points

title and/or abstract that the study was not relevant, it

was excluded. If it was unclear from the available abstract
and/or title, the full-text article was retrieved. Full-text
articles were also retrieved for studies with a relevant title
but no available online abstract. There was no blinding to
study author, place of publication, or results. The primary
researcher assessed the content of all full-text articles,
making the final inclusion/exclusion decisions.

Assessment of Methodological
Quality and Data Extraction
All eligible articles were rated for methodological quality,
using the PEDro scale. Derived from the Delphi list,62 this
scale consists of an 11-item checklist, configured by expert
consensus to rate the quality of randomized-controlled trials50 (Table 2). It is routinely used to rate the quality of
randomized-controlled
trials
on
the
PEDro
(ptwww.cchs.usyd.edu.au/pedro). Reviewed studies were
awarded one point for each criterion that was clearly satisfied. As criterion 1 is a measure of the studys external
validity, it was not included in the final PEDro score, giving each study a possible maximum score of 10 on the
PEDro scale. To increase the accuracy of the PEDro ratings, two independent reviewers assessed the quality of
eligible studies. Disagreement or ambiguous issues, which
arose between the first two raters, were resolved by either
consensus discussion or consultation with a third party.

Data Extraction and Analysis

The primary reviewer extracted all study characteristics
and data into summary tables. The type of acute soft-tissue injury and interventions applied was noted. For each
intervention, the mode, duration, frequency of cryotherapy,
surface temperature of the cooling device, subjects tissue
temperature, and concomitant therapies were recorded.
Attempts were also made to determine when cryotherapy

Yes/No
1
1
1
1
1
1
1

1
1
1
10

was initiated in relation to the time of the injury and the

specific purpose for its application, that is, for immediate
care or for rehabilitative purposes in conjunction with
therapeutic exercise. Means and standard deviations for
the four key outcome measures were extracted, and where
possible, individual study-effect estimates were calculated.
This took the form of standardized mean differences
(SMD)24 for continuous data or risk ratios (RR) for dichotomous data, each with 95% confidence intervals (95% CI).25

RESULTS
From the initial examination of citations yielded from the
literature search, 55 studies were included. After review of
the complete texts, 33 studies were excluded, leaving 22
eligible randomized controlled trials to be included in the
review. Figure 1 shows the Quality of Reporting of MetaAnalysis (QUORUM) statement flow diagram,49 summarizing the process of study selection and the number of
studies excluded at each stage, with reasons.

Study Quality
The 10 criteria and final scores assigned to each study are
presented in Table 3. Overall, the source of subjects and
their eligibility criteria were well reported. Randomization
was stringently performed, and only four studies1,15,63,64
employed unsatisfactory methods. In contrast, a very
small number of studies provided adequate information on
subjects baseline data,11,15,20,35,38 and only three used concealed allocation during subject recruitment.34,36,38 In general, blinded application of treatment intervention was
also poor; none of the studies blinded the therapists
administering therapy, and just one group of subjects57
was blinded. In addition, in all but four trials6,19,36,59 there
was insufficient blinding of outcome assessment. Intention
to treat analysis was adequately performed in just one
study,26 and eight10,11,27,34,35,47,51,57,64 supplied adequate

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Bleakley et al.

The American Journal of Sports Medicine

TABLE 3
Final Physiotherapy Evidence Database (PEDro)
Scores for Included Trials

No Hits.

Medline

CINAHL

Proquest

WOS

AMED

Cochrane

3321

390

5039

4640

130

1819 (CDSR)
183 (DARE)
3644 (CCTR)

Potentially relevant studies retrieved

for detailed evaluation of full text
(n=55)

Studies excluded after evaluation of full text (n

=33)
Animal subjects (n=3)
Healthy human subjects (n=2)
Experimentally induced injury (n=2)
Non-acute injury (n=2)
Controlled trial / Observational trial / Case study
(n=14)
Inadequate outcome measures (n=1)
Variable subject inclusion criteria (n=3)
No cryotherapy treatment applied (n= 4)
Ice treatment standardized across groups (n=2)

Studies eligib le for inclusion in systematic review

(n=22)

Author

Criterion no.
satisfieda

Cote et al.11
Michlovitz et al.47
Lessard et al.36
Hochberg26
Healy et al.23
Schroder and Passler58
Konrath et al.34
Whitelaw et al.63
Laba35
Sloan et al.59
Edwards et al.19
Cohn et al.10
Wilkerson and Horn-Kingery64
Ivey et al.27
Scarcella and Cohn57
Dervin et al.15
Barber et al.1
Ohkoshi et al.51
Bert et al.4
Levy and Marmar38
Gibbons et al.20
Brandsson et al.6

2, 4, 8, 10, 11
2, 8, 10, 11
2, 3, 7, 10, 11
2, 9, 10, 11
2, 10
2, 10, 11
2, 3, 8, 10
10
2, 4, 8
2, 7, 10
2, 7, 10, 11
2, 8, 10, 11
8, 10, 11
2, 8, 10, 11
2, 5, 8, 10, 11
4, 10, 11
10
2, 8, 10, 11
2
2, 3, 4, 10, 11
2, 4, 10
2, 7, 10, 11

Figure 1. The Quality of Reporting of Meta-Analysis (QUORUM) statement flow diagram. CINAHL = Cumulative Index
to Nursing and Allied Health; WOS = Web of Science; AMED =
Allied and Complementary Medicine Database; CDSR = Cochrane Database of Systematic Reviews; DARE = Cochrane
Database of Abstracts of Reviews of Effectiveness; CCTR =
Cochrane Controlled Trials Register.
information on patient dropout. Between-group statistical
comparisons were well reported, however, and the majority also included measures of group variability. Final values were low, ranging from 1 to 5, with a mean PEDro
score of 3.4 of 10.

Study Characteristics
The study population, intervention, outcomes, follow-up,
and reported results of the assessed trials were extracted
and tabulated. Twenty-two trials were included, using a
total of 1469 subjects. The sample size ranged from 21 to
143, and the mean number of subjects used was 66.7; however, only one study26 undertook a power analysis prior to
commencement of the trial. Patients had a wide variety of
acute injuries. There were no studies using subjects with
muscle contusions or strains, and only five used subjects
with acute ligament sprains.11,35,47,59,64 The remaining 17
studies used patients recovering from a range of operative
procedures: ACL reconstruction,1,6,10,15,19,34,51,58 total knee
arthroplasty (TKA),20,23,27,38,57a total hip arthroplasty,57b
knee arthroscopy,36,63 lateral retinacular release,4 and
carpal tunnel release (CTR).26

Total
score
5
4
5
4
2
3
4
1
3
3
4
4
3
4
5
3
1
4
1
5
3
4

Criterion 1 is not included in final PEDro score.

Table 4 summarizes the mode, duration, and frequency

of cryotherapy; the total cryotherapy treatment time (overall dosage); the time cryotherapy was initiated in relation
to the injury; and the number of days of treatment for each
included study. In total, five different modes were used:
crushed or chipped ice, Cryocuff or cold compressive
devices, commercial ice machines, commercial/gel ice
packs, and ice submersion. Five studies10,47,58,63,64 simply
stated that an ice bag or pack was applied, and 8 studies4,10,23,26,34,58,63,64 used more than one mode of cooling during the trial. Similarly, the duration and frequency of
cryotherapy treatments were not consistent across studies. A total of 13 studies applied cryotherapy continuously
after injury, 7 studies employed an intermittent protocol,
and 5 failed to specify the protocol. With such an array of
icing protocols, the total treatment time subjects received
was extremely diverse. For one group of subjects, the
entire course of cryotherapy treatment consisted of just 20
minutes cooling35 compared to others whose treatment
time ranged from 21657 to 336 hours.58
The temperature of the cooling device and the subjects
tissue temperature reduction were poorly reported.
Although a number of studies4,10,26,27,34,51,57 using commercial machines stated the temperature of water flowing
through the machine, they failed to provide adequate
information on the actual surface temperature of the cooling device. Skin temperature reduction during treatment
was reported in just one study,34 with another measuring
intra-articular knee temperature.51 Three studies4,20,26

Vol. 32, No. 1, 2004

Ice for Acute Soft-Tissue Injury

255

TABLE 4
Cryotherapy Protocol Employed Within Included Studiesa

Study

Cote et al.11
Michlovitz et al.47
Lessard et al.36
Hochberg26a
Hochberg26b

Rx duration
(hours)

Mode

No. days
treated

No. Rx/day

Total
cryotherapy
time
(overall
dosage)
(hours)

Time/place of
cryotherapy initiation

Water bath + exs

Ice pack
Gel pack + exs
Commerical m
Crushed ice;
commercial p
Cryocuff
Crushed ice
Cryocuff
Ice bags
Commercial m

0.3
0.5
0.3
12

1
1
4
1

3
3
7
3

1
1.5
9.3
36

Third day postinjury

128 hours postinjury
At home after discharge
Immediately after surgery

0.3

Continuous

18

Continuous
3

18

336

Immediately after surgery

Unclear
Unclear
Prior to tourniquet release
Unclear

Konrath34b
Whitelaw et al.63a
Whitelaw63b
Laba35
Sloan et al.59
Edwards et al.19
Cohn et al.10a
Cohn10b
Wilkerson and Horn-Kingery64
Wilkerson64
Ivey et al.27
Scarcella and Cohn57a
Scarcella57b
Dervin et al.15
Barber et al.1

Crushed ice
Cryocuff

Crushed ice
Commercial
Cryocuff
Commercial
Ice bag
Ice pack
Commercial
Commercial
Commercial
Commercial
Cryocuff
Commercial

0.3
0.5
Continuous
Continuous

0.5
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous

1
1
Continuous
Continuous
1
1
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous

14

35 days
post D/C

1
1
1.5
4
1
Acute phasec
Acute phasec
3
9
9
2.5
3 (POD 1-3)
3 (POD 46)

Unclear
Unclear
Unclear
Unclear
Day 02 since injury
Within 24 hours of injury
In operating theatre
In operating theatre
In recovery room
Acute stagesc
Acute stagesc
In recovery room
In operating theatre
In operating theatre
Unclear
After application of postoperative dressing

Ohkoshi et al.51
Bert et al.4

Commercial m
Continuous
Commercial m/p Continuous

Continuous
Continuous

2
12

0.3
0.5
36
96

1.5
64
64
216
216
5560
64
48
average
48
27

Levy and Marmar38

Cryocuff

Continuous

Continuous

64

Gibbons et al.20

Cryocuff

6 (at least)

13 (at least)

78

Brandsson et al.6

Cryocuff

Continuous

Continuous

24

Healy et al.23a
Healy23b
Schroder and Passler58a
Schroder et al.58b
Konrath et al.34a

p
m

p
m
m
m
m

After surgical wound was covered

Immediately postsurgery in
recovery room
After skin closure and dressing
were applied
Immediately after the surgical
procedure
After surgical wounds were
closed

a
Rx duration = treatment duration; No. Rx/day = number of treatments per day; + exs = Exercises incorporated with cooling; commercial m = Commercial icing machine; Commercial p = Commercially produced ice pack; = information not reported; D/C = discharge; POD
= Postoperative day.
b
The superscripts a and b after the study reference number depict that a single study applied more than one cryotherapy protocol
c
Acute stage of injury not specified.

stated that cryotherapy was initiated immediately after

surgery; however, they failed to provide a quantifiable
time period. Likewise, others stated that cooling began
prior to tourniquet release,58 in the recovery room,27 in the
operating theatre,10,19,57 or after wound closure and dress1,6,7,38,51
Most studies using subjects post
ing application.
ankle sprain initiated cryotherapy between day 1 and 3
postinjury.11,35,47,59 One study64 initiated cryotherapy in the

acute phases of injury but again failed to state a definite

time period. Few studies reported the specific goals of
cryotherapy, and it is not clear whether cooling was
employed for immediate care or for rehabilitative purposes. Only two studies11,36 stated that cryotherapy was
applied in conjunction with exercise, for rehabilitative purposes. It seems that the majority of studies,1,10,20,26,27,34,38,57,58 despite continuing cryotherapy for

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Bleakley et al.

days and even weeks after the immediate stages of trauma, chose not to incorporate functional movements or
exercise.

Outcome Measures
Pain (visual analogue scale and/or analgesic consumption)
was the most common outcome measure, but only two
studies provided adequate data for function.57,64 Few
dichotomous measures were used, and the majority of
studies recorded continuous measures over short time
periods (for example, 1-week postinjury). The longest
reported follow-ups were measures of pain, swelling, and
ROM recorded at 4 weeks postinjury58; however, insufficient data were available for effect size calculation. The
longest follow-up data from which an effect size could be
calculated was a measurement of knee ROM recorded 2
weeks postsurgery.38 In total, nine studies6,19,20,23,34,57-59,63
failed to provide sufficient data for any of the key outcome
measures, and it was not possible to calculate individual
study effect estimates (either SMD or RR).

Effectiveness of Treatment
A total of 12 treatment comparisons were made. Table 5
subgroups the studies according to treatment comparison
and provides the sample size, overall PEDro score, and
effect size estimates for individual studies (SMD, RR).
Fourteen studies1,4,10,11,15,26,27,35,36,38,47,51,57,64 provided sufficient data for calculation of individual effect sizes (SMD,
RR) for at least one of the key outcome measures. These
values are provided in the right-hand columns, with a positive SMD or RR representing an effect in favor of the
treatment group (for example, group A if the groups are
compared as A versus B). Any significant differences
between groups reported in the text are based on the P
values (P < 0.05) provided in the original studies.
Although it is evident that a number of studies carried
out the same treatment comparisons, the effect sizes from
individual trials could not be pooled for statistical analysis. This was due to heterogeneity of the study population,
intervention mode and dosage, timing and type of outcome
measures, or insufficient reporting of data.
Ice Versus Heat/Contrast Bath. There was some evidence that cryotherapy was more effective than thermotherapy after ankle injury. A single study11 found that
ice submersion with simultaneous exercises was significantly more effective than heat (SMD, 1.38; 95% CI, 0.35
to 2.29) and contrast therapy (SMD, 2.35; 95% CI, 1.13 to
3.37) plus simultaneous exercises, at reducing swelling
between 3 and 5 days post ankle sprain.
Ice Versus Ice and Electrical Stimulation. A single
study47 compared the effect of ice alone to ice and simultaneous high-voltage electrical stimulation after acute ankle
sprains. There was no significant difference when comparing ice alone and ice combined with low-frequency electrical stimulation (28 pulses per second) in terms of swelling
(SMD, 0.47; 95% CI, 1.34 to 0.44), pain (SMD, 0.64; 95%
CI, 1.51 to 0.28), and ROM (SMD, 0.69; 95% CI, 1.56 to

The American Journal of Sports Medicine

0.24). Similarly, there was no significant difference comparing ice alone and ice combined with higher frequency
electrical stimulation (80 pulses per second) in terms of
swelling (SMD, 1.39; 95% CI, 2.3 to 0.36), pain (SMD,
0.62; 95% CI, 1.5 to 0.31), and ROM (SMD, 1.36; 95%
CI, 2.3 to 0.3).
Ice Versus No Ice. Ice alone seems to be more effective
than applying no form of cryotherapy after minor knee
surgery. A single study36 compared the effect of an intermittent icing protocol combined with knee exercises to
exercises alone, after minor arthroscopic knee surgery. The
application of ice immediately before a rehabilitation program significantly decreased pain as measured by the
affective component of the McGill Pain Questionnaire
(SMD, 0.59; 95 CI, 0.02 to 1.17). The study also reported
that subjects applying cryotherapy used significantly less
prescription and nonprescription analgesia and had a significantly better weightbearing status; however, insufficient data are provided for the calculation of an effect size.
In contrast, there were no significant differences between
groups in terms of knee girth (SMD, 0.35; CI, 0.24 to 0.93)
and knee ROM (SMD, 0.38; CI, 0.21 to 0.97) 1 week postsurgery.
Ice (Continuous) Versus Ice (Intermittent). Using subjects post-CTR, Hochberg26 compared the effect of continuous cryotherapy to intermittent 20-minute ice applications
over the first 3 postoperative days. Subjects applying continuous cryotherapy had a significantly greater decrease
in pain (SMD, 1.09; CI, 0.4 to 1.7) and wrist circumference
(SMD, 2.2; CI, 1.43 to 2.9) in comparison to those using
cryotherapy intermittently. This was the only study to
compare the effectiveness of two different cryotherapy protocols, and although it appears that continuous cryotherapy should be the treatment of choice after surgery, the
modes of cryotherapy application were not consistent
across the two groups.
Ice and Compression Versus Ice and Compression. Four
studies23,34,58,63 compared two different methods of applying simultaneous compression and cryotherapy, but few
conclusions could be reached. Poor reporting of data meant
that individual effect size could not be calculated for any
of these studies. Furthermore, two studies58,63 did not provide adequate information on the mode of cryotherapy, and
all failed to specify the duration and frequency of the ice
application.
Ice and Compression Versus No Ice. There is marginal
evidence that a single simultaneous treatment with ice
and compression is no more effective than no cryotherapy
after an ankle sprain. Laba35 found that a single application of ice and compression, in addition to standard rehabilitation treatment (ultrasound, mobility, and proprioceptive exercises), produced similar levels of swelling (RR,
0.76; CI, 0.5 to 1.02) and pain immediately posttreatment
(RR, 1.5; CI, 1.24 to 1.76) and at discharge (RR, 0.88; CI,
0.62 to 1.14) when compared to those receiving standard
treatment only. Sloan59 also found that a single application
of simultaneous ice and compression was as effective as no
treatment in terms of reducing pain, swelling, and ROM
post ankle sprain. Similarly, Edwards19 found that the con-

Ankle11
Ankle11
Ankle47a

Ice vs heat
Ice vs contrast
Ice vs ice + E-Stim (Freq 28 pps)

99
21
21
50
110
34
80
60
50

ACL1
ACL51a
ACL51b
THA57
LRR4
Ankle64b
TKA38
TKA20
ACL6

Ankle64a 34
TKA27
90
TKA57
24
ACL34b 100
19b
ACL
63
ACL15
78

0.62 (1.5 to 0.3)

0.64 (1.51 to 0.28)

Pain

0.24 (0.35 to 0.82) (T);

0.59 (0.02 to 1.17) (A)

1.09 (0.41.7)

N/A

N/A

N/A

N/A
N/A
1.5 (1.241.76);
0.88 (0.621.14)

N/A

N/A
N/A
4.43 (3.35.24);
4.49 (3.415.4)
0.14 (0.97 to 0.7)

0.43 (0.95 to 0.1)

0.75 (1.55 to 0.1)
N/A
N/A

N/A
N/A
0.33 (0.7 to 0.12) (VAS);
0.17 (0.6 to 0.3) (A/gesic);
0.09 (0.5 to 0.4) (IV)

N/A

0.6 (1.64 to 0.5) (VAS);

0.3 (0.75 to 1.36) (A/gesic)

1.21 (0.02.2) (VAS)

N/A
Overall score:
0.35 (0.27 to 0.42)
0.55 (0.32 to 1.38)

0.75 (0.31.2) (VAS[D2]);

0.41 (0.04 to 0.85) (A/gesic)

N/A

N/A

Function

Swelling

1.02 (0.16 to 2.05)

0.8 (0.27 to 1.9) (A/gesic)

0.89 (0.26 to 1.92)

0.64 (0.191.08) (day 7);

0.89 (0.421.34) (day 14)
N/A

1.14 (1.0; 1.28)

0.39 (0.44 to 1.18)

N/A
N/A

N/A
N/A

0.76 (0.51.02)
N/A

(1.56 to 0.24) (day 1);

(1.45 to 0.24) (day 3)
(2.3 to 0.3) (day 1);
(1.3 to 0.5) (day 3)

0.38 (0.21 to 0.97)

N/A
N/A
N/A
N/A

0.69
0.58
1.36
0.39

ROM

0.35 (0.24 to 0.93)

2.2 (1.432.9)
N/A
N/A

N/A

1.38 (0.352.29)
2.35 (1.133.37)
0.47 (1.34 to 0.44) (day 1);
0.14 (1.01 to 0.75) (day 3)
1.39 (2.3 to 0.36) (day 1);
0.09 (0.96 to 0.8) (day 3)

Effect size (95% CI)

5
3
4

2
3

4
4
5

3
1

4
3
4
5
4
4

3
3
4

5
4
2
3
4
1

5
5

PEDro (10)

a
Studies are grouped according to the treatment comparisons employed. A positive standardized mean difference or risk ratio represents an effect in favor of the treatment
group (for example, group A if the groups are compared as A vs B). Effect size = relative risk ratio; ROM = range of movement; PEDro = Physiotherapy Evidence Database; Ankle = ankle
sprain; = outcome not measured; E Stim = electrical stimulation; pps = pulses per second; No Rx = no treatment; T = total McGill Questionnaire score; A = affective component
McGill questionnaire score; CTR = carpal tunnel release; I/C = simultaneous ice and compression; Same = mode of compression constant across groups; TKA = total knee arthroplasty; N/A = data not available; ACL = anterior cruciate ligament reconstruction; Arth = arthroscopy; I = ice treatment; C = compression; VAS = visual analogue scale; A/gesic =
oral analgesic consumption; I/V = intravenous analgesic consumption; THA = total hip arthroplasty; Diff = mode of compression differed across groups; LRR = lateral retinacular
release; P = placebo; I/A inj = intra-articular analgesic injection.
b
The superscripts a and b after the study reference number depict that a single study applied more than one cryotherapy protocol

I/C + P vs P vs I/C and I/A inj

I/C vs C (Diff Mode)

I/C vs C (same mode)

I/C vs ice

143
63
54

Ankle59
ACL19a
ACL10

45
48
76
44
100
102
30

Arth36

Ice vs No Rx

30

30
30
30

Ice (continuous) vs ice (intermittent) CTR26

I/C vs I/C
TKA23
ACL58
ACL34a
Arth63
I/C vs No Rx
Ankle35

Ankle

Ice vs ice + E-Stim (Freq 80 pps)

47b

Injury

Intervention

TABLE 5
Effect Size Estimates for Individual Studiesa
Vol. 32, No. 1, 2004
Ice for Acute Soft-Tissue Injury
257

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Bleakley et al.

tinuous use of ice and compression had similar benefits to

no treatment in terms of improving pain and ROM when
applied postsurgically; however, insufficient data were
provided for these later two studies.19,59
Ice and Compression Versus Ice. Only one clinical study
has compared ice and compression to ice alone.10 The combination of treatments appeared to be significantly more
effective than ice in terms of reducing the amount of intramuscular (SMD, 4.43; 95% CI, 3.3 to 5.24) and oral analgesia (SMD, 4.49; 95% CI, 3.4 to 5.4) administered
postACL reconstruction. These results must be interpreted with caution, however, as the mode and duration of ice
treatment were not controlled for across groups.
Ice and Compression Versus Compression. The majority
of included studies have tried to disentangle the effects of
ice from compression by comparing a variety of treatment
combinations. In four studies, it was difficult to compare
the efficacy of each modality4,20,38,64 as the mode of compression differed between the intervention and control
groups. On the contrary, eight studies strictly controlled
for the type of compressive bandages used across comparison groups1,15,19,27,34,51,57,64; however, there seemed to be little difference in the effectiveness of ice and compression
and compression alone.
Wilkerson64 found no significant difference in the time of
restricted activity after ankle sprain in subjects treated
with compression alone and simultaneous ice and compression (SMD, 0.14; 95% CI, 0.97 to 0.7). Using subjects
postACL reconstruction, others reported no significant
differences between groups in terms of function,34 pain,19,34
and swelling1,19,34; however, insufficient data were reported and effect size could not be calculated for these outcomes. Similarly, Dervin15 found no significant differences
in subjective pain scores (SMD, 0.33; 95% CI, 0.77 to
0.12) and the amounts of intravenous (SMD, 0.09; 95%
CI, 0.53 to 0.35) and oral analgesics (SMD, 0.17; 95% CI,
0.62 to 0.27). In a group of subjects post-TKA, Ivey27
found no significant difference between groups with
regard to the amount of injected morphine (SMD, 0.43;
95% CI, 0.95 to 0.1) postsurgery. Scarcella57 found no significant difference in subjects post-TKA in terms of ROM
(SMD, 0.39; 95% CI, 0.44 to 1.18) and the time to independent ambulation (SMD, 0.75; 95% CI, 1.55 to 0.1).
The study57 also reported that the analgesic consumption
in each group was almost identical. Correspondingly, in a
subgroup of patients recovering from total hip arthroplasty, Scarcella57 reported no significant differences in analgesic consumption postsurgery; however, insufficient data
were provided and effect size could not be calculated.
Only two studies reported significant differences
between subjects treated with ice and compression and
compression alone. Although Barber1 found no differences
between groups in knee ROM after ACL reconstruction
(RR, 1.14; 95% CI, 1.0 to 1.28), a significantly decreased
analgesic consumption was reported in favor of the ice and
compression group; however, inadequate data were provided. Again using subjects postACL reconstruction,
Ohkoshi51 treated two groups with simultaneous ice and
compression and a third with compression only. The ice
and compression groups were cooled to slightly different

The American Journal of Sports Medicine

temperatures using a commercial ice machine (5C and

10C). Subjects using less extreme cooling (10C group)
with concomitant compression had significantly lower subjective pain scores (SMD, 1.21; 95% CI, 0.00 to 2.2) and
analgesic consumption (SMD, 0.88; 95% CI, 0.27 to 1.91)
compared to those using compression alone. In contrast,
there were no significant differences in subjects treated
with simultaneous cooling (5C group) and compression
and those treated with compression only in terms of subjective pain scores (SMD, 0.6, 95% CI, 1.64 to 0.5) and
analgesic consumption (SMD, 0.3, 95% CI, 0.75 to 1.36). A
better improvement in ROM was observed in the 5C
(SMD, 1.02; 95% CI, 0.16 to 2.05) and 10C groups (SMD,
0.89; 95% CI, 0.26; 1.92) when compared to compression
group; however, these differences were not significant.
Therefore, despite eight trials comparing the effectiveness of ice and compression to compression alone, only
two1,51 reported significant differences in favor of ice and
compression. Both Barbers1 and Ohkoshi et al.s51 studies
were of low quality, scoring just 1 out of 10 and 4 out of 10
on the PEDro scoring scale, respectively, and therefore the
strength of their conclusions is limited. Generally, there
was very little evidence to suggest that the addition of ice
to compression has any significant effect. It must be noted,
however, that all but one of the studies64 were undertaken
postsurgery, and any conclusions are restricted to hospital
inpatients with postsurgical wound dressings.
Ice and Compression Plus Placebo Injection Versus Ice
and Compression Plus Injection Versus Placebo Injection.
Brandsson et al.6 found that ice and compression plus a
placebo injection were significantly more effective than
placebo injection alone at reducing postoperative pain. The
addition of a pain-killing injection to ice and compression
therapy significantly improved the analgesic effect further; however again, no data were provided and effect size
could not be calculated.

DISCUSSION
Cryotherapy continues to be employed in both the clinical
and sporting environments to treat acute soft-tissue
injuries as well as postsurgical patients within a hospital
setting.42 A number of review articles have advocated the
use of cryotherapy in both of these contexts,31,41,42,55 and
others have scrutinized its physiological and clinical
effects.30,40,43,45,52,61 This is the first study to systematically
review the literature, assessing the clinical evidence base
supporting the use of cryotherapy based on the highest
quality research evidence. The review is restricted to
English language, however, and as the inclusion criteria
for study population were broad, some of the information
contained was difficult to compare and synthesize. The
included randomized controlled trials scored an average
PEDro score of only 3.4, and the contrast in treatment protocols means that comparison within and across studies is
often impossible. Moreover, persistent methodological
problems and the failure of the majority of studies to carry
out a power analysis may prevent wider extrapolation of
evidence.

Vol. 32, No. 1, 2004

Soft-tissue injuries such as contusions, strains, and

sprains are the most common injuries in Gaelic football,12
soccer,22 and rugby.21 To date, however, no randomized
studies have assessed the efficacy of ice in the treatment
of muscle contusions or strains, and only five studies have
assessed the effect of ice on acute ankle sprains. Single
applications of combined ice and compression seem to be
as effective as no treatment after an acute sprain; however, these conclusions must be taken with caution. Aside
from the paucity of high-quality studies undertaken, this
particular research question may also be subject to a
unique set of problems inherent to cryotherapy research.
Given the strong empirical evidence base and the popularity of cryotherapy treatment with the layman, it may be
difficult to randomize a subject to a no ice group. This is
particularly evident in Labas35 study, in which 60% of subjects randomized to the no ice group had already applied
ice as a self-treatment prior to recruitment.
Evidence from a recent systematic review suggested
that intermittent 10-minute ice treatments are most effective at cooling injured animal tissue and healthy human
tissue.40 The effectiveness of this particular protocol has
not yet been tested on injured human subjects; however,
Hochberg26 found that intermittent 20-minute applications are less effective than continuous ice treatment after
CTR surgery. The strength of the studys conclusions is
greatly limited, however, as Hochberg26 crucially failed to
control for the mode of cryotherapy across the continuous
and intermittent groups. No individual study has rigorously compared the efficacy of different modes, durations,
or frequencies of ice treatment, and preliminary recommendations for an optimal cryotherapy protocol cannot be
made.
Other systematic reviews5 have provided evidencebased guidelines on optimal treatment parameters by subgrouping trials to highlight a dose-dependant pattern.
Although it was the authors intention to carry this out,
subgrouping trials according to the mode or duration of
cryotherapy was impossible due to clinical heterogeneity
and the large number of trials supplying insufficient treatment detail.
Within clinical practice, ice is commonly combined with
compression and elevation, making it difficult to determine the value of cryotherapy alone.45,55,61 A number of
studies have compared a wide range of combinations of ice
and compression in a bid to try and disentangle their relative efficacy. Only one study10 compared simultaneous ice
and compression to ice alone. This study does little to separate and quantify the individual effects of ice and compression as both the modes and durations of cold treatments applied across groups were starkly contrasting.
Twelve studies compared the effectiveness of concomitant ice and compression to compression alone, but only
eight well-controlled studies1,18,22,30,37,55,61,64 used the same
mode of compression between intervention and control
groups. The initial consensus seems to be that the addition
of ice to compression is no more effective than compression
alone. However, such a conclusion is limited, as in all eight
of these studies, postsurgical dressings or socks were used
to separate the injured area of the body and the cooling

Ice for Acute Soft-Tissue Injury

259

device. The thickness of dressings varied from gauze57 to

cast padding and an elastic bandage27; such barriers have
the potential to mitigate the cooling effect of cold compress.
To maximize the therapeutic effects of cryotherapy, an
optimal tissue temperature reduction of 10 to 15C may
be necessary.40 Skin temperature reductions to below
13.6C may be needed to achieve local analgesia,7 and perhaps lower tissue temperatures of between 10C and 15C
may be required to maximally lower metabolism.33,56
Generally, the surface temperature of the cooling device
and the subjects tissue temperature reduction during
treatment were poorly reported in this review. The only
study34 that monitored skin tissue temperatures during
treatment reported a maximum reduction to just 28C.
Correspondingly, there is evidence from many studies13,14,37,53 that it is difficult to achieve optimal tissue temperature reductions when cooling is applied over postoperative dressings. The interaction between the cooling surface and the subjects tissue is vital in determining the
effectiveness of treatment and must be considered in
future studies, particularly within a postsurgical environment.
There have been some deleterious side effects of
cryotherapy previously documented. A number of case
studies have reported the occurrence of skin burns54 and
nerve damage3,17,44,48 after as little as 20 to 30 minutes of
cooling. Within this review, there was just one reported
case of cold-induced nerve palsy, possibly caused by a continuous 40-minute ice application in the recovery room
postsurgery.10 None of the other studies reported any incidences of skin burns or nerve palsies, despite applying continuous ice treatments for between 6 and 226 hours.
Cryotherapy is a versatile modality and may be used in
the immediate18,32,41,43,45,52,60 and rehabilitative31,55 phases
of injury management. However, a common source of confusion is the basis for its application at each phase.
Immediately postinjury, ice reduces tissue metabolism,
thereby minimizing secondary hypoxic injury, cell debris,
and edema. The sooner after injury cryotherapy is initiated, the more beneficial this reduction in metabolism will
be.31 A number of studies35,47,59 began cryotherapy between
24 and 48 hours after injury and therefore may not have
optimized this positive physiological effect. It may be easier to initiate early cryotherapy in studies using surgical
patients. Although most surgical studies stated that
cryotherapy was initiated either immediately after surgery, in the operating theatre, or after dressing and wound
closure, few significant differences were reported. Again,
this may be due to concomitant compression or wound
bandaging mitigating the cooling effect and preventing
adequate metabolic reduction.
Outside the immediate stages of injury management,
cryotherapy may be most effective when combined with
exercise.31,32 Adequate cooling can reduce pain, spasm, and
neural inhibition, thereby allowing for earlier and more
aggressive exercises. In the current review, many studies1,10,20,26,27,34,38,57,58 continued cryotherapy treatment for
days and even weeks after injury but chose not to integrate therapeutic exercise. Although cryotherapy in isola-

260

Bleakley et al.

tion may reduce the need for analgesics in the subacute

phases of recovery, early exercise may be the most important component of treatment.31,32 Only two studies11,36
incorporated exercise with cryotherapy, during the subacute phases of recovery, and both recorded results significantly in favor of cryotherapy. Nonetheless, it seems that
the majority of studies in this review have not fully considered the pathophysiological basis of cryotherapy and
may not have used it to its full potential. Future studies
must seek to optimize cryotherapys effects at each phase
of injury management to provide clinicians with clearer
evidence of its potential effectiveness and versatility.

CONCLUSION
Many more high-quality studies are needed to ensure that
clinicians and sportsmen are following evidence-based
guidelines in the treatment of acute soft-tissue injuries.
Primarily, these must focus on developing modes, durations, and frequencies of ice application, which will optimize cryotherapy during immediate and rehabilitative
care. Similarly, an optimal mode and duration of compression treatment must be highlighted. This evidence will
highlight the respective value of each individual modality
and if appropriate provide the basis of an optimal method
for treatment combination.
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