For decades, the response to a twisted ankle or a pulled muscle has been almost instinctual: grab an ice pack. This reflex is deeply ingrained in our collective first-aid knowledge, largely thanks to the "RICE" (Rest, Ice, Compression, Elevation) protocol, which has been the gold standard for treating soft tissue injuries since the 1970s. From professional athletes to weekend warriors, applying cold is considered a fundamental step toward recovery.

But what if this universal advice is built on a foundation of ice? What if our go-to remedy is actually a roadblock to recovery? A growing body of scientific inquiry is challenging the assumption that cryotherapy helps heal injuries, suggesting it might not only be ineffective for promoting tissue regeneration but could actively delay the body's natural healing process.

This article delves into a critical review of the evidence to uncover the most surprising and counter-intuitive findings. Here are five truths that will change how you think about icing an injury.

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1. The Creator of the "RICE" Protocol No Longer Supports It

The RICE protocol first entered the mainstream in 1978 with the publication of The Sports Medicine Book by Dr. Gabe Mirkin. It was simple, memorable, and quickly became the standard of care taught to athletes, coaches, and clinicians everywhere.

In a stunning reversal, however, Dr. Mirkin himself has since changed his position on the protocol he created. Based on newer evidence, he has publicly disavowed the two core passive components of his original advice: Ice and complete Rest. In 2015, he made his new stance clear:

‘coaches have used my ‘RICE’ guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping’.

The significance of the protocol's original proponent withdrawing his support cannot be overstated. It reflects a major paradigm shift in sports medicine, where new protocols like PEACE & LOVE (Protection, Elevation, Avoid anti-inflammatories, Compression, Education — then Load, Optimism, Vascularisation, and Exercise) are now being proposed. Notably, the "I" for Ice has been intentionally left out.

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2. The Scientific Evidence in Humans Is Almost Non-Existent

Despite up to 88% of athletes using cryotherapy, the practice is built on a shockingly thin foundation of human-specific evidence. A recent critical review of the scientific literature highlights this gap in stark terms.

After a systematic search screening hundreds of studies, researchers found only one relevant human study that met their criteria, compared to 26 animal studies. The findings from that single human pilot study were inconclusive, as it "did not demonstrate a difference between the cryotherapy and the control condition on pain perception, functional capacity recovery and convalescence time."

This raises a critical question: why is the human evidence so scarce? The study's authors shed light on the immense practical challenges. First, it’s difficult to recruit patients in the very short time frame after an injury. Second, to detect even a small 10% difference in recovery rates, they calculated that a massive trial of 396 participants would be required. In short, getting robust human evidence is incredibly difficult, which explains how a cornerstone of sports medicine can be built on such a flimsy scientific foundation.

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3. Icing May Delay the Body's Essential Inflammatory Response

The primary justification for icing has always been its ability to reduce inflammation, which we view as something to be suppressed. However, science offers a counter-intuitive perspective: "the acute inflammatory response has been shown to be necessary to achieve complete muscle regeneration."

Animal studies reveal that applying cold interferes with this essential process by slowing down the body’s cleanup crew. It can:

• Slow Cleanup: Cryotherapy can delay the clearance of dead and damaged tissue from the injury site, a process known as efferocytosis.
• Delay First Responders: It can decrease and postpone the arrival of key immune cells, like neutrophils and macrophages, which manage debris removal and initiate the repair cascade.

This delay isn't just a pause; it has downstream consequences. The source explains that slowing the shift in macrophage types can lead directly to "excessive collagen deposition"—in other words, the formation of more scar tissue. By attempting to obliterate the body's natural inflammatory response, we may be sabotaging the very mechanisms required for a full recovery.

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4. Animal Studies Suggest Icing Is a Double-Edged Sword

While human data is scarce, the 26 animal studies in the review reveal that icing's effect is a matter of "dose and damage"—it is highly dependent on the magnitude of the injury.
For large muscle injuries, the findings are predominantly negative. Icing was shown to delay muscle fiber recovery, slow regeneration, and increase the formation of scar tissue. The review illustrates this with a compelling model based on the data: for large injuries, the "regeneration" curve is visibly flattened and pushed to the right by cryotherapy, signifying a slower, less effective recovery.

For minor muscle injuries, however, the story changes. In these cases, icing was found to potentially limit the expansion of the injury and accelerate regeneration. The model suggests that for minor damage, cryotherapy might contain the problem, allowing the inflammation and healing curves to resolve more quickly. This creates a dilemma: for minor muscle damage, a bit of cold may help, but for the significant tears common in sports, the same treatment appears to sabotage the processes required for a full recovery.

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5. The Only Undisputed Benefit Is Short-Term Pain Relief

While the evidence that cryotherapy promotes healing is weak, the scientific review confirms one clear benefit: it has an undisputed analgesic (pain-relieving) effect. Applying cold numbs the affected area, which is why it feels good immediately after an injury.
However, it is crucial to distinguish between numbing pain and promoting tissue regeneration. There is currently no evidence that this short-term pain relief leads to a faster or better long-term recovery. This presents the central trade-off for athletes and clinicians: using ice for immediate pain management might come at the cost of interfering with the body's biological repair processes.

Based on this, the authors of the review offer a cautious recommendation. They suggest that cryotherapy may be used in the first 6 hours following an injury to reduce pain (and possibly haematoma), but advise that it "should be used with caution beyond 12 hours post-injury," as animal studies suggest it may interfere with healing.

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Conclusion: Time to Put Old Advice on Ice?

The long-standing practice of icing injuries appears to be based more on tradition than on solid human evidence. Emerging research suggests that what we've been doing for decades might not be the universally helpful intervention we once thought it was.

While cryotherapy clearly has a role in managing acute pain, its continued use for accelerating healing is now highly questionable. The science is clear: our body's healing process is a controlled fire, not a wildfire to be extinguished. The question is no longer if we should use ice, but why we still do. Is it finally time to put this old advice on ice for good?

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REF: Cryotherapy for treating soft tissue injuries in sport medicine: a critical review

Shoulder pain is one of the most common and frustrating ailments an active person can face. Whether it’s a dull ache from rotator cuff tendinopathy (an injury to the tendons surrounding the shoulder joint, often from overuse) or a sharp pain that limits your daily activities, it can disrupt work, sleep, and exercise. For years, the path to recovery often involved a predictable sequence of scans, injections, and sometimes surgery.

But what if much of that common wisdom is wrong? A major new international clinical practice guideline, published in the Journal of Orthopaedic & Sports Physical Therapy, challenges many long-held beliefs and treatments. Based on a comprehensive review of the latest scientific evidence, it offers a new roadmap for managing shoulder pain. Here are the five most surprising and impactful takeaways that could change how you think about and manage your shoulder health.

1. You Probably Don't Need That Scan (At Least, Not Yet)

When your shoulder hurts, it’s natural to want to see what’s going on inside. However, the new guidelines strongly advise against ordering diagnostic imaging tests like an MRI or ultrasound in the initial management of suspected rotator cuff tendinopathy.

This new advice helps you and your doctor avoid a common, costly trap: chasing findings on a scan that may have nothing to do with your pain, which can lead to a cascade of unneeded interventions and "overmedicalisation." Instead of rushing to see inside the joint, the guidelines suggest focusing first on what has the strongest evidence for success: targeted rehabilitation. The experts state that imaging should only be considered if your symptoms fail to improve after a maximum of 12 weeks of appropriate nonsurgical management.

Even more surprising is what happens when imaging is finally needed. The guideline prioritises diagnostic ultrasound over MRI. Why? Because it offers similar diagnostic accuracy for rotator cuff disorders at a lower cost.
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2. Think Twice Before Getting an Injection

Injections are a go-to treatment for rapid shoulder pain relief, but the new evidence suggests a more cautious approach. The guidelines now recommend against using corticosteroid (cortisone) injections as a first-line treatment. While a shot might reduce pain and disability in the short term (effects are seen for up to 8 weeks), the evidence shows that an active approach, namely a dedicated exercise program, delivers more lasting benefits.

What about newer, often expensive treatments? The guideline also recommends against using Platelet-Rich Plasma (PRP) injections and Hyaluronic Acid injections as first-line treatments, citing conflicting or insufficient evidence that they work.

3. That Common Shoulder Surgery? It Might Be No Better Than a Placebo.

This is perhaps the most powerful finding referenced in the new guideline. While the document focuses on non-surgical care, it highlights a critical conclusion from a previous evidence review regarding subacromial decompression surgery—one of the most common orthopaedic procedures for shoulder pain.

The evidence is stark: for rotator cuff tendinopathy, this surgery provides no clinically important benefits for pain or disability when compared to a placebo (fake) surgery. This finding powerfully reinforces the guideline's theme of avoiding overmedicalisation and fundamentally questions the value of a procedure performed on countless patients who have not found relief from other treatments.

4. Exercise Is Your Best Bet—And You Can Do It at Home.

Amidst the recommendations against common treatments, one approach stands out with the strongest level of supporting evidence: exercise. The guidelines state that an active rehabilitation exercise program is the recommended initial treatment for reducing pain and disability, giving it a Grade A level of evidence (the highest level of recommendation, backed by strong, consistent scientific findings).

But the most empowering finding is how you can do it. According to the evidence reviewed, supervised, in-clinic exercise programs are not more effective than dedicated home-based exercise programs. This is a revolutionary finding for patients. It means you don't necessarily need to spend time and money on frequent clinic visits. The power to heal is truly in your hands, through consistent, dedicated effort at home.

5. Your Physiotherapist Should Skip These Common Treatments.

Knowing what works is as important as knowing what doesn't. The new guidelines provide patients with clear, evidence-based knowledge to help them become more informed partners in their care.

For the most common type of rotator cuff issue (noncalcific tendinopathy), the guideline panel explicitly recommends against using two common passive treatments during physical therapy:

• Therapeutic Ultrasound (Recommendation 33, Grade B - Moderate evidence)
• Extracorporeal Shock Wave Therapy (Recommendation 29, Grade C - Weak evidence)

​If your treatment plan relies heavily on these modalities, this new evidence gives you a basis for asking your clinician about shifting the focus toward more active, exercise-based rehabilitation.

Conclusion: A New Path for Shoulder Health

The latest evidence on managing shoulder pain marks a clear shift in thinking. It moves away from a reliance on passive, quick-fix approaches like scans, injections, and surgery. Instead, it champions an active, patient-driven model centered on education and, most importantly, exercise. This new path emphasises that consistent, dedicated effort is the most proven way to overcome pain and restore function.

Armed with this new evidence, how can you become a better advocate for your own care and partner with your clinician to build the most effective recovery plan?

REFERENCE: Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline