- RICE Therapy for Knee Pain
- The method you learned for treating an ankle or knee sprain is probably wrong
- Rest ice compression elevation | Rice Therapy and Price Therapy
- Rice and Price
- RICE protocol or treatments surrounding Prolotherapy applications
- Icing can cause muscle and nerve damage, fatigue, and delayed recovery in elite athletes
- Ice applications can negatively affect athletic performance
- Ice Reduces Strength, Speed, Endurance and Coordination
- Ice hinders healing by decreasing blood flow
- Advising against RICE
- Anti-inflammatories delay healing
- Compartment syndrome
- Ice applications and ligaments
- RICE treatment is totally inappropriate for healing ligaments
- Immobilization and rest delay soft tissue healing
- When and Why to Apply Cold to an Arthritic Joint
- My Experience With Knee Pain, Inflammation, and Icing
- Best Ice Pack After Knee Replacement Surgery
- How Long Should I Ice My Knee After Knee Replacement Surgery
- How To Ice Your Knee After Knee Replacement Surgery
- Best Knee Ice Wrap After Knee Replacement Surgery
- Ice Pack For Knee: Homemade Options (How To Make A Cold Homemade Ice Pack For Your TKR)
- Can You Ice Too Much After Knee Replacement
- Excessive Swelling After Knee Replacement Surgery
- What About Heating My Knee
- How-To Guide: RICE Treatment
RICE Therapy for Knee Pain
Knee pain resulting from common strains and sprains can be treated at home by following a simple plan called RICE, which stands for rest, ice, compression, and elevation.
Knee Pain: Rest
If you strain or sprain your knee, stop or reduce your activity level for a day or two. Depending on the severity of the knee pain, your doctor may also suggest that you avoid putting any weight on your knee for up to two days. If needed, crutches or a cane can keep you moving.
“The amount of time you rest varies,” says Robert Gotlin, DO, director of orthopedic and sports rehabilitation at Beth Israel Medical Center in New York City. “We recommend and promote rest as part of RICE therapy for as long as you have to in order to get the swelling reduced and the pain to an ‘ooooh’ rather than an ‘ouch.’ Rest at least a week, but most muscle strains or sprains are micro-tears of the tissue, and that takes at least three weeks to heal. Don’t exercise or do the activity that caused the knee pain in the first place.”
William Bargar, MD, director of the Joint Replacement Center at Sutter General Hospital in Sacramento, Calif., and spokesperson for the American Academy of Orthopaedic Surgeons, points out that rest can be a double-edged sword. “If you don’t use your joints, they get quite stiff. Sometimes they get worse if you use them. I say to use your symptoms of knee pain as a guide. If, when you do a certain activity, you have significant discomfort or more pain later in the day after doing it on a repetitive basis, you need to cut it out for a while until the pain goes away.”
Knee Pain: Ice
Use a bag of ice or cold pack on your knee four to eight times per day for 20 minutes each time. Don’t hold it on there longer than 20 minutes because it can cause frostbite. To be careful and more comfortable, surround the ice pack with a towel to avoid freezing the skin.
“Usually, I tell patients to use ice after the activity that caused the knee pain but also to use heat before an activity,” Dr. Bargar says. “A little warm-up is helpful, and heat to the joint or a hot shower or tub will help loosen you up, helping to avoid an injury or knee pain.”
Knee Pain: Compression
In an effort to reduce the swelling that’s causing your knee pain, use a compression bandage. These include either elastic-type wraps, such as an Ace bandage, air casts, special boots, or splints. Check with your health care provider on which one to use and how tight it should be.
“In my opinion, compression is more of a personal choice for comfort,” Dr. Gotlin says.
Knee Pain: Elevation
Another way to help reduce the swelling is to elevate your leg on a pillow above the level of your heart. “Just do this for the first day or so to help control the swelling, but no longer,” Gotlin says.
Knee Pain: When to See a Doctor
When should you apply RICE therapy at home vs. going to the doctor?
“It depends on how bad the patient is struggling,” Bargar says. “A lot of people put it off too long and then are faced with a bigger problem down the road, such as the development of arthritis, which is apt to develop after a knee injury.”
Here are some guidelines on when to see a doctor for knee pain from strains:
- The knee is red or has red streaks that spread out from the injured area.
- You can’t move your knee.
- You can’t put any weight on your knee and the pain is severe.
- You can’t take more than four steps without severe pain.
- You experience numbness in or around your knee.
- You have pain in a part of your knee that was previously injured.
- Your knee buckles when you try to use it.
- Your knee appears crooked; lumps or bumps appear other than general swelling.
If you are still unsure, call your doctor for guidance. When you treat your knee pain the right way, you increase the likelihood that you will be up and running at full speed in the shortest amount of time possible.
The method you learned for treating an ankle or knee sprain is probably wrong
If you’ve ever sprained an ankle or knee, you’ve probably heard that a couple of days of rest, ice, compression and elevation — RICE — is the surest route to recovery.
But some, including the doctor who coined the term RICE, now question the “rest” and “ice” parts of the formula.
Before attempting any treatment, determine whether you need to call your doctor. “If you can’t walk more than three steps, you need to see a doctor as soon as possible to protect yourself from further injury,” says A. Lynn Millar, author of the American College of Sports Medicine’s patient guide to sprains and strains. The same holds true if you are in a lot of pain, if the joint looks abnormal (such as bent in a strange way) or if you have significant swelling. But for injuries that cause only minor swelling and pain — and that allow almost a full range of motion — Consumer Reports’ experts suggest the following:
Forget complete rest
The old wisdom called for completely stopping activity until an injury healed. New research suggests that gentle exercise within the first 48 to 72 hours, such as “drawing” the alphabet with a sprained ankle two to three times daily, is more beneficial.
In 2013, a review of studies on therapies for ankle sprains — which are by far the most common minor injury — by the National Athletic Trainers’ Association gave top marks to such early movement. “By contracting and relaxing a joint, you improve blood flow, which improves healing,” Millar explains.
The NATA study also found that balance exercises are important for reducing the rate of re-injury, a frequent complication of sprains. To find exercises, ask your doctor or go to acsm.org and type “sprains” in the search box.
Gabe Mirkin, author of “The Sports Medicine Book,” where the RICE acronym first appeared in 1978, used to advocate icing right after a sprain or strain because cooling an injury delays swelling and reduces pain.
But he changed his recommendation after reviewing the latest research. For example, a study published in 2014 by the European Society of Sports Traumatology, Knee Surgery & Arthroscopy found that icing injured tissue shuts off the blood supply that brings in healing cells. “Ice doesn’t increase healing — it delays it,” Mirkin says, and the NATA study backs him up: It gave icing a grade of C.
Mirkin now recommends skipping ice altogether, unless pain is unbearable. (If that’s the case, apply ice packs only two or three times total, for 15 to 20 minutes at a time, with at least an hour in between.)
A better option for reducing pain and improving short-term function, according to the NATA review, is an over-the-counter nonsteroidal anti-inflammatory medication such as ibuprofen (Advil, Motrin IB and generic) or naproxen (Aleve and generic). But use these drugs only for the first 24 to 48 hours, because they, too, slow down recovery by suppressing inflammation. Instead, use acetaminophen (Tylenol and generic), which has no anti-inflammatory effects.
What stays the same
The recommendations from Consumer Reports’ experts still call for compression and elevation. So go ahead and wrap a mild strain or sprain of your arm or leg with an elastic bandage to help reduce swelling. But once swelling subsides, unwrap. Otherwise, research shows, the injured joint may develop long-term problems such as osteoarthritis. You can also minimize swelling by elevating the limb throughout the day and overnight — by propping a sprained ankle on a pillow, for instance.
Copyright 2015. Consumers Union of United States Inc.
For further guidance, go to ConsumerReports.org/Health, where more detailed information, including CR’s ratings of prescription drugs, treatments, hospitals and healthy-living products, is available to subscribers.
Rest ice compression elevation | Rice Therapy and Price Therapy
- Traditional treatment of sports injuries includes use of the PRICE principle (Protection, Rest, Ice, Compression, Elevation), nonsteroidal anti-inflammatories, physical therapy modalities, and corticosteroid injections.
- Recent evidence has raised concerns over this traditional treatment.
- Evidence about regenerative medicine, including platelet-rich plasma and stem cell therapy’s effectiveness in treating a variety of sports injuries has emerged, ranging from tendinopathy and muscle tears to ligament and chondral (cartilage bone) injuries. 1
Rice and Price
- The RICE Protocol is Rest, Ice, Compression and Elevation
- The PRICE Protocol adds Protection (brace or cast), Rest, Ice, Compression and Elevation
For many athletes a doctor’s recommendation of the RICE protocol for healing their sports related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism from a surprising source, the doctor who created the RICE treatment guidelines, Gabe Mirkin, MD.
In a recent article on his own website, Dr. Mirkin admits that both ice and rest (key components of RICE) may delay healing. This insight comes nearly 40 years after Dr. Mirkin authored the The Sportsmedicine Book (1978), where he coined the acronym RICE for the 4 elements which became the standard of care in treating soft tissue injuries- Rest, Ice, Compression and Elevation. Coaches, physicians, physical therapists and the lay public have recommended and followed the “RICE” guidelines for decades, but as Mirkin states:
- “it now appears that both ice and complete rest may delay healing, instead of helping.”2
RICE protocol or treatments surrounding Prolotherapy applications
For many years doctors have questioned the legitimacy of the RICE protocol. As far back as 2001, in our book, Prolo Your Sports Injuries Away, we dedicated large sections to talking about the deleterious effect RICE had on patients. As opposed to RICE we talked about how Prolotherapy and later Platelet Rich Plasma Therapy and Stem Cell Therapy treatments and “MEAT” (Movement, Exercise, Analgesics and Treatment) , in our opinion, healed the athlete faster and made weakened tissue stronger without the need for surgical intervention.
Icing can cause muscle and nerve damage, fatigue, and delayed recovery in elite athletes
Topical cooling with a cold pack or ice is frequently used therapeutically to reduce acute pain and inflammation of injured tissues. Topical cooling has also been used in an effort to boost recovery after athletic exercise. But does ice help recovery?
Researchers at Duke University tested whether applications of ice were helpful in recovery after strength training- a type of eccentric exercise where muscle damage is induced as a result of the exercise. Eccentric training is defined as active contraction of a muscle occurring simultaneously with lengthening of the muscle.
- When the tissue is cooled through icing, peripheral blood perfusion can be reduced, in other words the blood vessels constrict and shut off the blood flow that brings in healing cells.
- After the ice is removed, the blood perfusion may then return, but the blood vessels may not open for many hours after the ice application.
This research team found that this fluctuation can cause the tissue to die due to lack of blood flow. It can also lead to temporary or permanent nerve damage and disability in the individual or athlete. Therefore, ice application does not boost recovery after exercise and can instead cause tissue and nerve damage.3
A study was performed in 2013 and published in the Journal of Strength Conditioning Research. The study involved eleven 20 year old male baseball players to examine the effects of topical cooling on recovery after eccentric exercise. Muscle damage markers and hemodynamic (the way blood moves) changes were checked.
- Topical cooling caused a significant increase in muscle damage markers (CK-MB and myoglobin) during recovery from eccentric exercise over the controls at 48 and 72 hours, as well as increased fatigue at 72 hours.
- “This data suggests that topical cooling, a commonly used clinical intervention appears to not improve but rather delay recovery from eccentric exercise-induced muscle damage.”4
Mirkin himself referenced a June 2013 study in The American Journal of Sports Medicine showing cooling did not hasten recovery from exercise induced muscle damage.
Ice applications can negatively affect athletic performance
Inflammation is necessary because it plays an important role in the healing and recovery of muscle cells and soft tissue regeneration. Tissue that is damaged through trauma or vigorous exercise requires inflammation. When muscles and other tissues are damaged, your body sends inflammatory cells to the damaged tissue to promote healing. Inflammatory cells rush to injured tissue to start the healing.5
Immune cells called macrophages release a hormone called insulin-like growth factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal.6
Mirkin states, “Applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1.”2
Another study done in 2009 looked into the effect of cold-pack application on hormones and inflammatory mediators on young elite handball players. Various anabolic hormones, catabolic hormones and anti-inflammatory cytokines were reviewed. The twelve male players performed 4 × 250 meter treadmill run, at 80% of each individual’s maximal speed, followed by a rest period with and without local cold-pack application. Pre, immediately post, and 60-min post-exercise blood samples were drawn.
The results? Local ice therapy immediately following sprint-interval training was associated with greater decreases in both pro- and anti-inflammatory cytokines and anabolic hormones supporting some clinical evidence for possible negative effects on athletic performance.7 Although these methods were developed to enhance the recovery of elite athletes after intense training or competition, utilizing cryotherapy such as cold packs and ice to treat sports associated injuries or as a method for recovery following training and competition may instead cause a level of traumatic muscle injury.
Ice Reduces Strength, Speed, Endurance and Coordination
Another study Mirkin cited was in Sports Med, Nov 28, 2011 which stated, “Ice is often used as short-term treatment to help injured athletes get back into a game. The cooling may help to decrease pain, but it interferes with the athlete’s strength, speed, endurance and coordination.” Mirkin goes on…”In this review, a search of the medical literature found 35 studies on the effects of cooling. Most of the studies used cooling for more than 20 minutes, and most reported that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. A short re-warming period returned the strength, speed and coordination. The authors recommend that if cooling is done at all to limit swelling, it should be done for less than five minutes, followed by progressive warming prior to returning to play.”2 This wasn’t the first study demonstrating that just 5 minutes of icing could be problematic. Ho et had already published articles in 1990 on the negative effects of ice, where they showed that as little as five minutes of icing a knee could decrease both blood flow to the soft tissues and skeletal metabolism. “This effect is time-dependent and can be enhanced three to four fold by increasing the ice application time to 25 minutes.”8
Ice hinders healing by decreasing blood flow
Healing is hindered by a decrease in blood flow and metabolism to the area. Icing increases the chance of incomplete healing by decreasing blood flow to the injured muscles, ligaments and tendons. This increases the chance of re-injury or the development of chronic pain. Did you ever wonder why almost all athletic trainers and therapists ice a limb for 20 minutes? In 1980, at the American Orthopedic Society meeting for Sports Medicine in Big Sky, Montana, and then again in 1981, physicians from the Louisiana State University School of Medicine reported on five athletes who obtained nerve palsies (nerve injuries usually to the peroneal nerve that moves the foot up) from too much ice around the knee. The conclusion of the article was, “Applying ice for more than 30 minutes, and preferably for not more than 20 minutes, should be strictly avoided.”9 They reported that one of the athletes still had nerve palsy at nine months. Here is our answer to the 20 minute question. You are iced for 20 minutes because the athletic trainer or therapist does not want to give you nerve palsy! The next time the trainer comes toward you with an ice pack, tell him, “Thanks, but no thanks. I want my injury to heal.” Interestingly Mirkin still recommends “ten minutes of ice application, removing it for 20 minutes, and repeating the 10 minute application once or twice.”2
Advising against RICE
We treat many types of musculoskeletal conditions in individual and athletes of all levels, every day. We recommend treating acute sports injuries, not with RICE, but with MEAT (Movement, Exercise, Analgesics and Treatment). We have already established that R.I.C.E. has been the conventional method of pain management and treatment of sports injuries for years, even decades. Even though the author of RICE has recanted its use, and research proves it can be injurious, you will most likely continue to see it utilized from the emergency room to the sports trainer. This is a good example of how something false can hold sway on even those who are considered professionals.
Anti-inflammatories delay healing
Mirkin states, “Anything that reduces inflammation or the immune response will also delay healing. This includes cortisone, NSAIDS, immune suppressants, and cold packs/ice.”2
We agree with this statement. Anti-inflammatory medications have been proven to be harmful. However, most people will continue to receive instructions to take anti-inflammatory medications after an injury or for musculoskeletal pain. “Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX) activity and are widely used as anti-arthritics, post-surgical analgesics, and for the relief of acute musculoskeletal pain.
Recent studies suggest that non-specific NSAIDs, which inhibit both COX-1 and COX-2 isoforms,10 delay bone healing. NSAIDS such as ketorolac and parecoxib delay fracture healing, but the daily administration of ketorolac, a non-selective COX inhibitor had a greater effect on this process.”
NSAIDS are commonly recommended because injuries such as ligament sprains are sometimes accompanied by quite a bit of inflammation and swelling, called edema. The premise is that the inflammation or swelling and edema are harmful to the tissue. Again, we have already established that inflammation is necessary for healing of the tissue. NSAIDS are used because they relieve pain; however they are also stopping the healing mechanisms of the body. Any technique or medication that stops the normal inflammatory process that helps heal the body must have a long-term detrimental effect on the body.
Muscles, unlike ligaments and tendons, are encapsulated within a tight, compartmental, special tissue called fascia. These fascial sheaths only have a limited amount of space and in high-energy trauma, as can occur in sports, this limited space can be encroached upon by a hematoma (blood clot in the muscle) or be externally compressed by a hematoma in another compartment (or broken bone, etc.).This increased tissue pressure within the fascial sheath that contains the muscle causes a decrease in the blood circulation (malperfusion), causing further tissue damage. This further tissue damage causes an increase in the edema, which increases the pressure in the space even more, causing even less oxygen to get to the injured tissues (hypoxia), which causes the pH in the tissue to be decreased (acidosis) and a vicious cycle is set up. This continued increase in a specific muscle facial sheath is called compartment syndrome. Compartment syndrome, if not immediately taken care of, quickly progresses to permanent muscle, nerve, or circulation damage. RICE treatment is very effective at eliminating edema, so it could, theoretically, prevent a compartment syndrome situation from occurring. Compartment syndrome only occurs in muscles (and only those with a lot of damage) and never occurs in ligaments. What happened in the 1970s, unfortunately for the athletes of the world, is that sports medicine doctors and trainers started treating every injury as if it was going to turn into compartment syndrome.
Ice applications and ligaments
We have discussed how the fluctuation in blood supply from applications of ice can affect muscle recovery. Now let’s consider what it might do to ligaments. The main difference between muscles and ligaments is that muscles are massively strong structures with a tremendous blood supply, both outside and inside the muscle (this is why steak is red). Ligaments, on the other hand, are small tissues that have a poor blood supply both inside and outside of the ligament (why they appear white). Muscles, because of their good circulation, can heal more quickly, whereas ligaments, due to their poor blood supply, often heal incompletely. If muscles which have good circulation have healing issues due to the ice application causing a fluctuation in blood supply, it is understandable that it would be even more difficult for ligaments to recover or heal after ice applications. Ligament injuries are the cause of most chronic sports injuries and pain.
It is our opinion that non healing ligaments are the number one cause of early retirement in athletes.
The cells that make up ligaments, tendons, and organs are extremely temperature-sensitive. The metabolic rate at which these cells function is directly proportional to the temperature in their environment. For each 10 degree Celsius change in the temperature, there is a more than two-fold increase in the cell metabolism. In other words, in order to increase cell metabolic rate by more than 100 percent, the temperature of the tissue must increase by 10 degrees. Conversely, cooling tissue will decrease that cell’s metabolism. It is obvious that ligaments require improved circulation to the area in order to heal after an injury, since the blood supply to ligaments is normally so poor. Yet ice is arguably the most widely used therapeutic agent in medicine today, which most definitely decreases circulation. Ice has been shown to be one of the most efficient forms of cryotherapy, and is often the first line of treatment for traumatic injuries.
RICE treatment is totally inappropriate for healing ligaments
Exercise does not notably increase the blood supply to ligaments. This is probably because the ligament is not important in the fight-or-flight response. It is not involved in the defense of the body if attacked. Exercise does not have the profound stimulatory effect on ligaments that it has on muscles. Ligaments are made up primarily of type I collagen. This particular type of collagen is very resistant to stretching (has a high tensile strength). Collagen is a type of protein and is therefore made up of amino acids, building blocks of protein. What most people do not know is that the collagen in ligaments is thought to remain relatively metabolically inert, with a half-life on the order of 300 to 500 days. This means that the metabolism of collagen is very, very slow. It is a good thing this is true, because blood supply to ligaments is so poor. This is another reason ligaments heal so slowly and are so prone to injury. Anything that decreases the metabolic rate or blood supply to the ligaments will further promote the decline of the ligaments, and profoundly delay their healing.
Immobilization and rest delay soft tissue healing
Immobilization, also known as stress deprivation, is extremely detrimental to the joints and ligaments. Both intra-articular and extra-articular (inside and outside, respectively) ligaments and periarticular (joint soft tissue) connective tissue are brutalized by immobility. Gross inspection of the ligaments after stress deprivation shows them to be less glistening and more “woody” on palpation. Under a microscope the collagen of the ligament is very random. Chemically, the ligaments lose water and glycosaminoglycans (which help maintain structure) so there is a net loss of mass in the ligaments. There is also more degradation of the collagen with stress deprivation. These changes translate to a much weaker structure. In one study, knee ligaments immobilized for even a few weeks showed that the ultimate load, linear stiffness, and energy-absorbing capacity of a bone-medial collateral ligament-bone preparation is reduced to about one third of normal. In addition to weakening of the ligaments themselves, immobilization decreases the strength of the fibro-osseous junction where the ligament attaches to the bone. If rest and immobilization hinder ligament and tendon healing, then studies should show that early mobilization helps soft tissue healing. This is exactly what has been shown. Bekerom et al reviewed 11trials involving 868 ankle sprain patients.10 The results revealed those who included early mobilization compared to those following the standard RICE treatment reported a shorter sick leave with faster return to sport participation, less days missed from work with less visits to a clinic for follow-up, and improved range of motion with better functional scores.
1 Malanga G1, Nakamura R. The role of regenerative medicine in the treatment of sports injuries. Phys Med Rehabil Clin N Am. 2014 Nov;25(4):881-95.
2 Mirkin G. Why Ice Delays Recovery. March 16, 2014.
5. Tidball JG. Inflammatory processes in muscle injury and repair. Am J Physiol Regul Integr Comp Physiol. 2005;288:345-353.
6. Tidball JG, Wehling-Henricks M. Macrophages promote muscle membrane repair and muscle fibre growth and regeneration during modified muscle loading in mice in vivo. J Physiol. 2007; 578: 327-336.
6. Nemet D, Meckel Y, Bar-Sela S, Zaldivar F, Cooper D, Eliakim A. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. European Journal of Applied Physiology. November 2009, Volume 107, Issue 4, pp 411-417.
8. Drez D, Faust DC, Evans JP. Cryotherapy and nerve palsy. American Journal of Sports Medicine. 1981; 9:256-257.
10. Van den Bekerom M, Struijs P, Blankevoort L, Welling L, Van Dijk C, Kerkhoffs G. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train. 2012; 47(4): 435–443.
A: I asked an orthopedic surgeon friend of mine about your knee. He said there could be some torn cartilage, or your joint surface could be suffering from too much wear. If you have changed shoes (for runners, the cushioning wears out before the uppers even look blemished) that likely rules out worn shoes or patella tracking problems related to pronation (when your foot rotates inward and downward with each stride), but it is possible there is something structural about your gait that is putting excessive forces on your knees. Basically, he gave me the “could be anything, I’d have to see to know” response.
As for ice, 30 minutes is about all you should need to ice it, and all you would want to ice it. A half hour is enough to help reduce the circulation in the area and minimize swelling, but not so much that you start to see skin changes from the cold contact. If the pain persists, your choices are to take a break from running for a few months and switch over to some non-impact cardio, then try picking up running down the line. If the problem is still there, have it evaluated.
A physical therapist would have you do stretching and strengthening to help give the knee better support and function. If they couldn’t help you, an orthopedic surgeon could tell you if there were some underlying structural problems that focus undue stresses on the joint. I get knee pain that comes and goes. With running, it often means my shoes are shot. It started in my 20s, probably from too much basketball on ill-designed joints. Now when I walk up a quiet, carpeted staircase, it sounds like someone is wrinkling a candy wrapper inside my left knee. It’s very unnerving. I know that developing the supporting muscles helps, but I’m told I’ve done myself no favors with all my favorite climbing and squatting drills, so definitely have someone look at yours if it persists. You only have one pair, and it’s surprising how much you miss them when they’re gone.
Filed To: RunningRecovery
When and Why to Apply Cold to an Arthritic Joint
Painful arthritis inflammation can be treated with a cold compress. This is an inexpensive, effective treatment that can be used many times a day or occasionally, as needed.
See Understanding Joint Pain
Cold therapy can:
- Decrease inflammation. Cold causes the blood vessels of the muscles to constrict, and can therefore decrease the flow of blood and help reduce inflammation.
- Slow the production of joint fluid. Synovial joint fluid is essential to a healthy joint, but too much can contribute to swelling and discomfort. Applying a cold compress to a resting joint can slow the production of joint fluid.
- Distract the brain from the inflammation. Cooling an inflamed joint can stimulate sensory receptors in the skin and decrease the transmissions of pain signals to the brain.
Cold therapy constricts the blood vessels in the muscles. This constriction decreases blood flow
to the affected area and helps to reduce inflammation.
How long should cold be applied?
An ice or cold pack may be applied for no more than 20 minutes at a time, but this process can be repeated throughout the day—up to 8 or 10 times in a 24-hour period.
In This Article:
Cold application precautions
Applying ice or another cold source directly against the skin can injure the skin. To avoid skin damage, some precautions may be taken:
- Do not apply ice directly to the skin. A towel or other protective barrier can be used between the ice and skin. Cold therapy should not be painful to the skin.
- Limit the cold therapy to no more than 15 or 20 minutes at a time.
- People with certain conditions may be advised to avoid ice application, such as people who have:
- Raynaud’s Syndrome
- Cold allergic conditions
- Paralysis or areas of impaired sensation (i.e. nerve damage)
For some people, alternating heat therapy with cold application provides the most pain relief.
Article Featured on Knee Replacement Discovery
Icing the knee isn’t the best part about TKR recovery. Most people, even athletes, dislike icing because it’s cold and uncomfortable (numbness and pain). However icing your knee after replacement surgery can be an extremely beneficial way to reduce inflammation and aid in a quicker recovery.
How can icing my knee help my recovery? We’ll address that question in this article and I’ll share my experience as an athlete, coach, and someone who’s gone through TKR surgery.
We’ll also discuss the best ice packs for knees after knee replacement surgery, what to look for in a good ice pack, and how to make a homemade icepack that actually works.
My Experience With Knee Pain, Inflammation, and Icing
I’ve had a knee pain since I injured my knee in college. That was decades ago and I’ve managed to live with the pain. Over the years I’ve made subtle life adjustments to make things less painful.
I’ve adjusted my exercise to include swimming instead of running and always getting an isle seat for flights. For many years I was able to do all the things I loved without too much pain. I’m a firm believer that icing helped me reduce pain and inflammation.
Pain, no matter where on the body, is usually accompanied by inflammation. Inflammation works well to fight damage and repair the body by increasing blood flow.
When this occurs capillaries become permeable so blood cells, hormones and nutrients can enter the area and repair damage.
Fluid is usually made up of dead white blood cells and other bodily waste after it has been used in the area. For people like me with knee problems, the inflammation and swelling can become chronic when the body doesn’t realize the problem is too serious to repair (in my case no meniscus). The inflammation is uncomfortable and creates more pain.
When I was younger the inflammation from strenuous activity was minimal but in recent years it was creating more pain. I’ve had my knee drained a few times because there was too much fluid in the joint.
Icing has always been a part of my routine post-exercise. I’ll admit that I don’t ice all the time, only when I know I’ve overworked the knee. I keep ice packs in the freezer and after a game or hike I’ll grab an ice pack and rest on the couch while I watch the news. I’ve found that icing my knee for 10-15 minutes after exercise noticeably reduces swelling, and thus speeds up recovery.
After my TKR surgery, I’ve been more consistent with icing. It’s understandable that my ligaments, muscles, and bones will take time to adjust to my new knee.
My body alignment has also changed due to the fact I’m no longer limping. The surgeon recommended that I ice daily after surgery, elevate my leg, and also ice after physical therapy sessions (any exercise). Eventually, the swelling will subside as my knee heals (given there aren’t complications).
Best Ice Pack After Knee Replacement Surgery
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How Long Should I Ice My Knee After Knee Replacement Surgery
One question you might be asking is “how long should I ice my knee after surgery”. If you’re like me, swelling will occur most within 2-3 weeks of surgery and less-so from 3-6 months. Early on, icing is a great way to reduce inflammation and pain.
Most doctors will recommend icing your knee 3-4 times a day. 3-4 times per day for the first 2-3 weeks should be relatively simple because your mobility will be limited. After a few weeks, inflammation will gradually reduce, but icing can still work great to naturally decrease inflammation and pain.
If possible, plan to ice your knee daily for months after TKR surgery. Icing will be of value years later too after exercising. If you can make it part of your daily routine it would be smart (for example, 10 minutes every night before bed).
How To Ice Your Knee After Knee Replacement Surgery
Icing your knee is simple and straightforward. The ice helps stop inflammation (associated with heat) in its tracks. Icing can be as simple as a zip-lock bag and ice cubes from the freezer or a specialized ice pack with a wrap to keep the ice secure to your knee.
If you’re using a homemade ice pack (zip-lock) make sure you have a layer of fabric between the bag and your skin. If the ice rests directly against the skin (or thin layer of plastic) it could cause burning.
Wrap the zip-lock bag in a cotton towel then apply to your knee. Zip-lock bags can also leak or perspire so check to make sure there isn’t water coming off the bag.
If you purchase an ice wrap it will be ready to go with fabric to protect your skin and it will likely have a strap to tie the ice to your knee. An ice wrap won’t leak or perspire and will be more user-friendly. Ice wraps are also reusable so you don’t have to worry about running out of ice (see options below).
When icing your knee it’s good practice to elevate it to heart level using a few pillows. Elevation will help reduce swelling and cycle fluid out of your leg where it can be processed by your body. You can elevate your leg while icing, but it is important to elevate your knee whenever you are sitting period.R
Best Knee Ice Wrap After Knee Replacement Surgery
What makes the best ice wrap for your knee? Early on I was using ice cubes and a zip-lock bag. Was it effective for icing? Yes, however, there were also problems.
The plastic bags occasionally leaked and they always perspired. They also fell off my knee again and again and I had to rearrange them or pick them up.
After a few days, we upgraded to an ice wrap to save the hassle of making ice cubes and cleaning up water leaks. The ice wrap was reusable so we saved water in the process. The wrap I use has reusable gels that are included with the wrap, they fit inside the wrap and it is applied around my knee with straps.
I can adjust the straps on the wrap to compress the ice against my knee. It’s easy and when I’m finished I throw in the freezer for a few hours until I’m ready to use again.
It helps to have 2 wraps to make sure one is always frozen. Below are a few knee ice wraps that I like. Any of these would be useful after TKR surgery and they will last forever.
#1 Elasto-Gel Ice Wrap
When I came home after my TKR surgery I began icing with the Cryo Cuff (you can read about the Cryo Cuff here). The Cryo Cuff saved me time and money on ice. I filled up the cooler once a day and kept the device near my recliner. I used the same water/ice all day and didn’t have to worry about fetching it from the freezer.
When I began my physical therapy, the therapist mentioned the Elasto-Gel Ice Wrap. I was told that it was the ice wrap preferred by physical therapists because it didn’t leak, was comfortable and easily conforms to the knee.
>> check Elasto-Gel price on amazon
When I tried their Elasto-Gel Wrap I wasn’t disappointed and decided to purchase one for myself. Transitioning from the Cryo Cuff to the Elsasto-Gel was a good decision when I became more mobile because I had to keep it cold in the freezer.
The Elasto-Gel is soft and uses velcro to tighten the wrap. It’s also oversized so it fits all knee sizes. This was a great investment for me and I plan to continue using it throughout my first year of recovery.
#2 Knee Support Brace Wrap with Ice Gel Pack – Adalid Gear
Adalid makes a nice quality wrap specifically for the knee and elbow. This product only uses 1 gel pack but it’s a large pack (7.3 x 8.5 inches). The pack fits in an inside pocket on top of the knee and is strapped on securely by an upper and lower strap. Similar to other wraps on this list, the pack can also be heated for heat therapy.
The brace is an adjustable stretch-type material made from neoprene, nylon, and polyester. The gel pack is leak-proof and reusable in nylon (heated and cooled). The ice pack can be used for 20 minutes at a time then refrozen. It can also be hand washed if needed.
>> check Adalid Knee Wrap price on Amazon
The ice wrap weighs 1.1 lbs and is guaranteed for one year with a no hassle replacement. Because it uses 1 ice pack, it will not be able to ice the back of the knee. If you’re creative you might be able to make it work for the back of the knee but the main downside to this wrap is only 1 ice pack (but it’s big).
In some ways, one large ice pack will be easier to manage than having to arrange multiple smaller ice packs – your call.
#3 Shock Doctor Ice Recovery Compression Knee Wrap
The Shock Doctor is a perfect ice wrap for knees. It is contoured to fit any knee at a slight bend. It uses adjustable straps and gel ice packs. Although it’s advertised for tendonitis, knee bruises, and strains, it is perfect for people like me recovering from knee replacement surgery.
This compression wrap comes in 2 sizes (S/M or L/XL). In the smaller sizes there are 3 ice packs while the larger have 4 ice packs. All ice packs are removable and reusable.
The wrap uses kycra pockets for the ice packs and N-Tex neoprene for the wrap material. It is latex free. The wrap only weighs 1 pound so it’s lightweight too.
>> check Shock Doctor Knee Wrap on Amazon
I like the fact it adds a compression component to the icing and the adjustable straps allow the user to tighten to comfort without worrying about the ice falling off. Reviews say that patients love it for their knee replacement and that it stays cold longer than your typical ice pack. It can also be used for heating!
#4 Ubertherm Compression Ice Wrap
Ubertherm is a popular ice wrap made for reducing inflammation and knee pain. It uses 1 large ice pack that covers the knee. The ice pack can also be adjusted (reversed) to ice the back of the knee as well.
The cold pack uses multiple chambers of gel that doesn’t freeze (never below 34 degrees F) into an ice block. Rather, it gets cold and holds some flexibility. The gel will stay cold up to an hour and refreezes in an hour – longer than others on our list.
Ubertherm markets their product as providing a longer icing time, comfortable, with good strap support. The gel can be removed as packets so the wrap can be washed. It weighs 1.8 lbs and measures 12.2 x 5.2 x 4 inches. Ubertherm is a U.S. company based in Maryland.
>> check Ubertherm Ice Wrap price on Amazon
Reviews mention it works great without the hassle of ice. Others mention the quality is superb but they must keep the leg straight while icing (should be expected right). I like the appearance and the fact its gel never freezes too much – it remains at the perfect temperature for icing.
#5 TheraPAQ Large Reusable Gel Ice Pack w/ Wrap
The TheraPAQ is the simplest product on our list, but its simplicity also makes it a good option for post-TKR surgery. The ice pack comes as a gel pack that is a large rectangle. The gel pack fits inside a rectangle pack that can be strapped to the leg.
The straps are made with elastic and Velcro. Its design is functional and it doesn’t offer the knee contouring that other ice wraps on our list offer. The pack can be taken out of its sleeve and put in the freezer or heated.
I like the product and the price – and so do other customers. It comes with a money back guarantee if you aren’t 100% satisfied (any time). TheraPAQ weighs 2 lbs and measures 11 x 14 inches, making it one of the larger ice packs on our list.
>> check TheraPaq price and reviews on Amazon
Due to its large flat design, it might work better on flat body parts (like the back) than it does for rounded areas of the body like the knee. However, it has good enough reviews to be an option to ice my knee after knee replacement.
Ice Pack For Knee: Homemade Options (How To Make A Cold Homemade Ice Pack For Your TKR)
If you’re a true do-it-yourselfer (DIY) I’m also including an option to make your own ice pack. I mentioned earlier that adding ice cubes to a zip-lock bag is the simplest solution and as long as you’re not worried about excess moisture or leakage then you can go with it – I’ve done it before and it works.
If you’re willing to give a little more effort you can make your own gel-like ice pack. It won’t cost much but it will take you some time. If you make multiple homemade ice packs then you can always have one frozen ready to use while the other is refreezing. Below are a few options. Let us know what DIY ice pack works best for your TKR recovery.
Homemade gel ice pack
The homemade gel ice pack requires three items. First, you’ll need a few gallon-sized zip-lock bags (the big ones). Second, you’ll need 2 cups of water, and finally 1 cup of rubbing alcohol. The rubbing alcohol will keep the water from completely freezing and it will be more malleable to fit around your knee.
Mix the 2 cups of water and 1 cup of rubbing alcohol in a zip-lock bag and seal. When you seal it, make sure all of the air can escape.
Now, put the first bag into another zip-lock bag. You can even use a third zip-lock bag to ensure there isn’t a leak.
Put all the bags into the freezer for 1 hour and the contents should result in a gel-like substance perfect for icing. If you need some extra help, check out the video below.
Homemade ice pack salt
A homemade ice pack with salt results in a slush-like substance that can be effective for icing after knee replacement surgery. Salt decreases the temperature needed to freeze water and adding a few tablespoons to water will make the perfect ice pack that can be used again and again.
To make the salt ice pack add 2 tablespoons of salt to 2 cups of water. For a gallon sized zip-lock use 3 cups water and 3 tablespoons of salt. Place the zip-lock bag inside another zip-lock bag to make sure nothing will leak and you’ve got a DIY ice pack for knee replacement rehab.
Homemade ice pack with dish soap or corn syrup
Another option is to use dish soap or corn syrup as your liquid instead of water. You can dump a whole container of dish soap in a zip-lock bag and you don’t need any other ingredients. The same goes for corn syrup.
While writing this I wondered, “why use dish soap or corn syrup – it’s wasteful” then I remembered you can always use the dish soap later after you’ve stopped icing (just refill the container it came in. I like this idea.
A corn syrup or dish soap leak would be horrible to clean so do the same as recommended above and use a few zip-lock bags to make sure there’s a seal.
Homemade ice pack rice, coins, or frozen vegetables
Use these only in case of emergency! These are options, but honestly, they won’t work as good as ice or homemade gel. Rice, coins, and vegetables can be frozen and they will retain the cold long enough to ice your knee, but there are better options above.
Homemade ice packs are not created equal. if I had to choose one, I’d go with the water + alcohol or water + salt. Try these out and let us know which one is best for you.
Can You Ice Too Much After Knee Replacement
I’ve been asked if there is such a thing as “icing too much”. Generally, you don’t want ice on your knee all day. Exercise and movement is an important part of healing so don’t remain in one position and ice your knee constantly.
In my experience, icing should be done alternatively with movement. Early after TKR surgery, you’ll be icing more often. After a few months, you’ll likely ice less often.
The length of time you ice matters and you won’t want to ice for longer than 15-20 minutes at a time. Longer icing might damage skin or cause localized frostbite.
Excessive Swelling After Knee Replacement Surgery
Swelling should be expected after knee replacement surgery so there’s no cause for alarm. Swelling can remain for 3-4 months after surgery and that’s why icing is so important.
In addition to ice, there are a few recommendations that medical professionals say should be followed. These good practices are:
Compression can be applied to the knee to reduce swelling and pooling of fluid in the leg. Compression stockings go on the leg and are tight against the skin (think of a tight sock).
They are also used when we are standing for long periods of time or exercising. Standing activities will increase blood flow and swelling to the area.
In the section above I mentioned how to incorporate elevation with icing. Elevation can also be done on its own while watching television.
Elevation also reduces swelling and promotes proper blood flow throughout the body. When using elevation to reduce fluid in the leg, try to elevate the leg to the same level as the heart. This can be done for 20-30 minutes and be used in combination with ice.
Most importantly, exercise. Exercise can promote swelling if strenuous but it also increases blood flow and helps to reduce blood clots in the leg after surgery.
Exercise post-knee replacement should be low-impact and short (start slow and consult your doctor). Getting the blood pumping through the body is great for circulation and you can follow up the exercise with ice and elevation.
What About Heating My Knee
Heating your knee is something you’ll probably do after knee replacement surgery. I use heat the opposite way than I use ice. Before physical therapy, exercise, or stretching, I use heat to warm up the knee and attract blood and improve elasticity.
Heating can help loosen the joint and attract blood – we’re going for the opposite effect with icing which usually occurs after activity or during recovery.
In this article, we discussed icing after knee replacement surgery. I discussed my experience icing my knee and the relief I received when icing to reduce inflammation.
We also discussed how inflammation works, the length of time to ice and how long you should be icing your knee after surgery. There were 3 other activities to remember in addition to icing that will help reduce inflammation and pain.
1) Elevation will help reduce fluid build up in the leg.
2) Compression will discourage swelling and the risk of blood clots after surgery.
3) Exercise – although it might not sound like a good idea right after TKR surgery, exercise is important for blood circulation and helps flush out toxins while strengthening the muscles and ligaments around the knee.
There are many different knee ice wraps on the market that make icing an easier task. While you can create your own ice packs, sometimes buying an ice wrap is more effective and less of a hassle in the long run. We really like the Uberthereum Compression Wrap because it’s functional and has been well reviewed.
If a DIY project is in order, try out the variety of homemade ice packs that can be made using just a few ingredients and handy zip-lock bags. Multiple homemade ice packs can be made and rotated to use as another refreezes. Just remember to use multiple bags to reduce leakage and wrap the ice pack in cloth to avoid freezer burn of the skin.
I hope you enjoyed this article and my experience recovering from total knee replacement surgery. It’s been a long road, with preparation, surgery, and recovery but the result is worth it. I hope you regain your health and mobility just like I did.
How-To Guide: RICE Treatment
After an accident, such as an ankle sprain or knee injury, you can relieve pain, reduce swelling, and counteract the body’s initial response to injury with the RICE Treatment. It’s important to perform this protocol as soon as possible after an injury to promote flexibility and healing.
What does RICE mean?
RICE stands for rest, ice, compression, and elevation.
Stop using the injured body part! Protect the area, and avoid any activity that is painful or may have caused the injury. Continued activity could cause further damage.
Use ice for the first 48-72 hours after an injury. Apply ice several times a day for 20 minutes at a time, followed by one hour “off.” The cold will contract injured capillaries and blood vessels to help stop internal bleeding. Do not apply ice directly to the skin.
Wrap the injured body part firmly with an elasticized bandage, compression sleeve, or cloth – especially when you are more active. This will help speed up healing time by reducing swelling around the injury.
Elevate the injured body part above the level of your heart to decrease swelling and joint pain.
Non-steroidal anti-inflammatory drugs (NSAIDs) are over-the-counter pain relievers, such as ibuprofen and aspirin. They may also help reduce your pain and swelling, and are popular treatments for muscular aches and pains, arthritis, and joint stiffness.
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