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Warmth may be more inviting, but cooling might be just what that injury needs

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Heat or ice? The decision on how to treat an injury can be simplified with a few basic guidelines.
HEAT OR ICE? The answer used to be easy, based on a common standard: Ice for the first 72 hours after suffering an injury, heat after that.

Alas, as with many cut-and-dried rules, it's not always that simple.

"We've been trying to get away from that strict guideline," said Jill Allen, assistant certified athletic trainer at the University of Puget Sound. "I think we were realizing that heat was causing some of the newer injuries to last a bit longer."

Athletes with daily access to training rooms and physical-therapy clinics get optimal care by having their injuries reassessed each day. The rest of us, though, can apply some of the same ideas on our own.

New injuries almost always receive ice. It's part of another easy-to-remember guideline that still applies: RICE (rest, ice, compression, elevation) or sometimes PRICE (starting with prevention of further injury, by stopping use of the damaged area).

Ice not only numbs pain but also constricts blood vessels, limiting blood flow and thus decreasing the amount of swelling that goes into tissues in the injured area, said Lori Sabado, a physical therapist at the University of Washington Sports Medicine Clinic. That's why it's important to ice quickly after suffering an injury, since swelling itself can add to recovery time.

On the second day, check the injured site for swelling and discoloration. Feel to see if it's warm, comparing it if possible with the opposite side under similar circumstances: with a sprained ankle, for example, when both feet are wearing socks, or when both are bare. Swelling, discoloration and warmth all call for continued ice.

"Normally, we ice 10 to 15 minutes at a time," Sabado said, sometimes every hour or two after surgery. At UPS, they ice 20 minutes on, 40 minutes off, "as many times as they can, when it's a fresh injury," Allen said.

Some people ice preventatively after activity and some ice after strenuous exercise or weight-lifting to reduce soreness the next day. Some begin range-of-motion exercises while icing.

"Sometimes, too, with acute injuries," Allen said, "we have people ice before activities, to try to quiet down swelling pain." That's always followed by some kind of warm-up.

Sabado takes the approach that "ice is ice," but cooling options still abound. Immersion in cold (40- to 55-degree) water is often favored in training rooms and physical-therapy clinics. Ice packs can be simply cubed or crushed ice in a zippered plastic bag (adding a handful of salt will keep it slushy and from refreezing completely), gel or other synthetic ice (which should be used with a cloth barrier to prevent frostbite), a slush pack made of one part rubbing alcohol with two parts water and stored in the freezer (also applied with a cloth barrier) or a reusable bag of frozen peas. In ice massage, water frozen in a paper or foam cup, or even an unopened can of juice, is rubbed over the injured area, for not more than 10 minutes at a time.

Most other icing shouldn't be done for more than 20 to 30 minutes; longer might impair healing and can risk frostbite. Icing also isn't used on an infected area because it might curtail the volume of white blood cells that help heal infections. And a few people show signs of an allergic reaction to ice, with hives or bruises.

About the only other drawback of icing is that initial reaction.

"The first time some people try it," Allen said, "I think they're going to jump out of the pool. After 30 seconds to a minute, you shouldn't feel anything. And the next time it doesn't take that long."

However, she added, "We do have some people who say they've never had that effect."

Because heat increases circulation, it can make an injury still in an inflammatory stage worse by increasing the swelling. As pain or swelling begin to subside (or at least not increase), or if ice isn't helping, "That's when I'll try the heat," Sabado said. Often, that does turn out to be around 72 hours after the injury.

At the UW clinic, a heated immersion pool is kept between 102 and 104 degrees, and sessions last 15 to 20 minutes. At UPS, trainers keep their heating pool at about 110. In addition to hot-water bottles and heating pads both electric and microwavable, another home option is a damp towel in a plastic bag, heated in the microwave, then wrapped with a towel or pillowcase.

Both Allen and Sabado also like contrast treatments, which alternate ice and heat.

"Everyone's going to have their method," Sabado said. "I go with 4 minutes hot, 1 cold, then 3 hot, 1 cold, 2 hot, 1 cold, always starting and ending with warm."

Increasingly, Allen likes to pair ice with activity.

"Our theory here is to get on a (stationary) bike and use that exercise to warm up, which will affect the whole joint and the whole muscle." Such a session might consist of 10 minutes of icing and 10 of pedaling, or 20 minutes icing, 5 minutes pedaling, then more ice.

"Some people don't even use heat anymore," Allen said.

All this may sound like a lot of work, but time spent heating and icing — then stretching and rehabbing — is how many elite athletes can keep training and competing. There still is a time and a place for rest, Allen said.

Just not necessarily, it seems, when you're injured.

Molly Martin is assistant editor of Pacific Northwest magazine. She can be reached at 206-464-8243, or P.O. Box 70, Seattle, WA 98111. Benjamin Benschneider is a magazine staff photographer.

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