How long should I stay off it and will a post-exercise ice bath help me recover more quickly after an injury?
WHEN GREEK PHYSICIAN HERODIKOS of Selymbria, sometimes considered the father of sports medicine, got tuberculosis, he treated it with a vigorous program of massage, steam baths, and wrestling. We’ve come a long way in the 2,500 years since then (wrestling is out, massages are still in, and steam baths . . . well, it depends), but one principle hasn’t changed since Herodikos’s time: it’s better to prevent an injury, or at least nip it in the bud, than to treat it once it’s already full-blown.
Not surprisingly, contact sports like hockey and rugby cause the most injuries among adolescent boys (soccer and basketball lead the way for adolescent girls).
But non-contact sports are capable of producing overuse conditions like tennis elbow and runner’s knee. By some estimates, in fact, a staggering 70 percent of recreational runners get an injury in any given year. With that in mind, it’s important to understand that occasional injuries are an inescapable part of exercise—but with the right care, you can make a rapid return to full strength.
Ouch, I think I sprained something. How long should I stay off it?
When figure skater Anabelle Langlois fractured her fibula in a training accident just over a year before the 2010 Olympics, doctors pursued every possible avenue for her rehabilitation, including two surgeries. One thing they didn’t recommend, though, was a long period of complete rest for the injured leg.
In the past few decades, doctors have changed their thinking about the best treatment for sports injuries, ranging from sprained ankles and pulled muscles to, in some cases, broken bones. After the acute pain and swelling has passed—sometimes in as little as a few days—movement and gentle loading of the injured area seems to help muscles heal better, hasten return to full strength, and reduce the risk of recurrence. That advice remains little heeded, in part because of the very real risks of pushing too soon, and in part because of our natural caution. “In your head, you want to protect an injury,” says Langlois. But at the urging of her doctor, she was putting weight on her injured leg within two weeks of being operated on, with a still-broken bone and an open surgical scar. “That really surprised me,” she says.
The goal of early mobilization isn’t just to return an injured athlete to competition as quickly as possible. Favoring an injury for too long causes muscles to atrophy from disuse and affects the healing process. “If an injured muscle heals without any stress being put on it, it will generally heal in a shortened position, and the affected area will be a bit weaker and more fibrotic than the surrounding tissue,” says Shawn Thistle, a lecturer in the orthopedics department of the Canadian Memorial Chiropractic College. “It ends up being the weak link when you return to activity.”
A study published last year in Histology and Histopathology illustrates the process. Brazilian researchers compared the recovery of rats that rested against those that began moving their legs either an hour or three days after a muscle injury. Both mobilized groups were able to regenerate more muscle fibers than the rested controls, but only the early mobilization group also had a decrease in fibrotic scar tissue. Humans and rats recover at different rates, so it’s impossible to apply these findings directly to humans (and it’s equally difficult to find a group of human subjects with identical injuries to conduct a similar experiment), but the general principle of early mobilization is the same.
There are limits, though: before you start mobilizing the injured muscle, you have to give it a chance to form scar tissue strong enough to prevent re-tearing. During this period, which for mild injuries may last three to seven days, the “RICE” protocol of rest, ice, compression, and elevation helps speed recovery. Once the acute phase has passed, activity can progress in a sequence beginning with simply moving the affected muscle through its range of motion, then load-bearing exercises, and eventually functional activities, says Thistle. You can think of it as “MICE” rather than “RICE,” where movement replaces rest. Pain can serve as a useful guide to tell you when you’re pushing farther than you should.
Of course, elite athletes aside, most people won’t have a team of physicians carefully monitoring their progress, which makes it risky to push the pace of rehab too much. Any injury in which the initial pain and swelling persist for more than a day or two should be evaluated by a doctor or sports therapist. But for the milder tweaks that inevitably accompany many sports, it’s worth bearing the principle of “active rehab” in mind. Re-establish the full range of motion as soon as possible, and follow up by loading the muscle. Don’t push to the point of pain, but don’t hobble yourself by protecting an injury long after it’s healed, either.
Will a post-exercise ice bath help me recover more quickly?
As appealing as the prospect of a soak in the hot tub after a workout may sound, the consensus among elite athletes is that you’re better off doing the opposite. Ice baths at a chilly 50 to 59°F (10 to 15°C) have become the first line of defense for athletes dealing with everything from the heavy impact of bone-jarring tackles to the repetitive stress of a marathoner’s three-hour run. Two-time Olympic miler Kevin Sullivan, for example, soaks his legs in the cold tub several times a week, immediately after hard workouts. “And then if I’m feeling a little stiff or tired heading into a race,” he adds, “I’ll try to use them in the days immediately leading up to the race.”
The logic behind ice baths relates to the normal wear and tear of exercise. Hard exertion causes “microtears” in your muscles; these microtears stimulate new growth that makes you stronger, says University of Toronto exercise physiologist Greg Wells. But this damage can also cause soreness that interferes with the next day’s workout, so quick repair is essential. Ice baths cause blood vessels to constrict, forcing waste products out of the affected area. “It’s almost like wringing out a sponge,” Wells says. Then, when the area warms up again, fresh blood rushes in to help the healing process.
At least, that’s the theory. But scientists putting ice baths to the test under laboratory conditions have produced mixed results. One problem is that different studies have used different protocols for their cold baths, making it hard to compare. For example:
• A 2007 study in the British Journal of Sports Medicine tried using three one-minute dunks in 41°F (5°C) water, with one minute between dunks. They found no benefits in perceived soreness, swelling, or blood markers of muscle damage after a leg workout compared to room-temperature water or no bath at all.
• A 2009 study of Australian soccer players tried five one-minute immersions in 50°F (10°C) water, again with one minute off between dunks. This time, the soccer players felt less sore and less tired a day later (compared to a body-temperature bath), but there was no change in how quickly their strength returned or in blood markers of damage.
• Another Australian study in 2009 tried two five-minute sessions in 50°F water, separated by a 2.5-minute break. This time, they observed decreased soreness and quicker recovery of strength and speed, though the changes still weren’t reflected in blood markers of muscle damage.
The latter study, by researchers at the University of Western Australia, also compared their protocol with the results from another popular technique called “contrast therapy,” which involved six alternating two-minute bouts of cold (41°F) water with warm (104°F/40°C) water. The goal of contrast therapy is to “squeeze the sponge” several times instead of just once, but the results were significantly worse than cold alone. The problem may be that the two-minute bouts don’t allow enough time for the deep muscle tissue to actually change temperature, the researchers suggest—which may also explain why the ice-bath tests that dunk their subjects for only one minute at a time have produced disappointing results.
Despite the difficulties in determining exactly how and why ice baths work, most researchers—even University of Melbourne professor Peter Brukner, one of the authors of the British Journal of Sports Medicine study that found no benefits—are cautiously optimistic that the baths offer real therapeutic value. “Even though our research was unconvincing, I still encourage their use,” Brukner says.
You can make your own ice bath in the bathtub or in a (clean) garbage bin, with a few trays of ice or a reusable ice pack. Better yet, take advantage of a cold river or lake to soak your legs after a hard workout. Given the studies described above, you should aim for 5 to 10 minutes to allow the cooling effect to penetrate. (Keeping a pair of socks on can make your feet more comfortable; don’t soak in temperatures below 41°F, as there’s a risk of tissue damage.)
Will a heat pack or hot bath soothe my aching body?
Nowhere are the healing powers of a hot bath more respected than in Japan. Researchers there have found, for example, that levels of the stress hormone cortisol drop after a relaxing soak in the tub. Heat is also prescribed for conditions ranging from arthritis to chronic pain. But when it comes to exercise and athletic injuries, heat isn’t always the right choice.
The traditional advice has been to apply cold to acute injuries—a sprain or a bruise, for example—and reserve heat for nagging pains that persist for weeks or months. The reason is that new injuries are often accompanied by swelling. Cold constricts your blood vessels to limit swelling, while heat can have the opposite—undesirable—effect. Chronic injuries, on the other hand, are often tight and surrounded by scar tissue, so heat can help soften and loosen the muscles around the injury, allowing them to move more freely.
Researchers believe that to have a significant loosening effect on muscle, the heat needs to increase skin temperature by 5 to 7°F (3 to 4°C) for about five minutes. The problem is that when you put a heat pack next to your skin, the greatest heating effect is limited to the outer quarter-inch of your body. Even just an inch below the surface, a heat pack generally elevates muscle temperature by less than 2°F.
Electric blankets, hot water bottles, saunas, and even hot baths also qualify as “superficial” heat sources that don’t penetrate far into your muscles. (Heating deeper tissue generally requires machines using, for example, ultrasound, shortwave, or microwave energy. Several studies have found that shortwave machines can produce muscle temperature changes of over 7°F at a depth of greater than an inch.)
So does heat work? According to a 2010 literature review by the Cochrane Collaboration, there is “moderate evidence in a small number of trials” that heat wraps can reduce lower-back pain. For example, a pair of studies found that after five days of using a heat wrap, subjects reduced their back pain by 17 percent compared to subjects who were given a placebo pill instead. This gives some credence to the idea that you might get some relief from nagging aches throughout the body by applying a heat pack, or even by soaking in the tub.
But the more common and well-supported use for heat is immediately before exercise, to help prepare an injured or (preferably) recovering muscle for further exertion. Just as a proper warm-up helps to ensure that your muscles and tendons are loose and supple, focused heat at the site of a nagging injury can make sure the affected muscles are as warm as possible before you start using them.
A 2005 study in the Archives of Physical Medicine and Rehabilitation found that pre-heating calf muscles with a heat pack allowed greater ankle flexion, even without any additional stretching. The heat pack in this case started at about 175°F (80°C) and was applied for 15 minutes; towels between the pack and the subject’s skin ensured that it didn’t exceed “comfortably warm.” As expected, deep heating using a shortwave machine produced even greater increases in flexibility.
Overall, the clinical evidence on the use of heat suggests a few guidelines: use it before exercise rather than after, and don’t use it on a fresh injury. Beyond that, the evidence is thin enough that it comes down to personal preference. It won’t hurt you, and—as the Japanese researchers have shown—it might make you feel better.
