Should you use ice or heat to treat your Tennis Elbow? (Or Golfer's Elbow?) - Here's why you should consider using heat - Or at least stop the constant icing!
"What about the inflammation!?" you're probably wondering... All the medical websites and authorities say I should ice my Tennis Elbow to reduce inflammation! Could they all be wrong?
Podcast Version On Ice / Cryotherapy For Tendon Injuries
Here's an improved, better-sounding version of the "Should You Ice It?" podcast that you can download and keep by clicking the "download" link below:
And for an overview of the whole subject of treatment, comparing the standard medical approach to my contrarian approach, check out my page on the Tennis Elbow Classroom Treatment Strategy
Why Inflammation Is Not The Problem – And Ice Is Not The Solution
"Ice it" or "RICE it!" is certainly the #1 piece of advice that nearly everyone; Doctors, Physical Therapists, Coaches, Personal Trainers and your tennis-playing friends, seem to agree on!
Only, it’s wrong — At least, it’s wrong in the context of Tennis Elbow, because it’s based on two outdated, but VERY persistent medical myths:
- The false idea that Tennis or Golfer’s Elbow is an inflammatory condition (The same myth applies to most chronic tendon conditions)…
- And the false idea that you need to suppress, treat or “manage” this nonexistent inflammation supposedly in order to “help your tendons heal!”
"Numerous investigators worldwide have shown that the pathology underlying these conditions [Tennis Elbow, Rotator Cuff Tendinopathies, etc.] is Tendinosis or collagen degeneration."
'Overuse Tendinosis, Not Tendinitis Part 1: A new paradigm for a difficult clinical problem.' Phys Sportsmed. 2000 May;28(5):38–48.
Notice this quote is from the year 2000. This was known then, in fact, there are medical papers going back as fare as the 80's, saying that they were mistaken in classifying Tennis Elbow and similar tendon conditions as forms of 'Tendonitis.'
These conditions are not TendonITIS — (NOT inflammatory.) They are usually what's called 'TendinOSIS,' which is degenerative. So...
- Inflammation is NOT the real problem with Tennis Elbow,
- So, icing probably won’t help your elbow heal,
- And ice may actually slow your recovery instead...
Another reason why there's no benefit to icing Tennis or Golfer's Elbow, (as well as many other tendon problems) – OR using anti-inflammatories – or getting Cortisone shots...
Is because inflammation is actually part of your healing process...
What happens any time you injure something is that the healing process kicks in and inflammation is the first step in that process.
Now, sometimes when you have what they call an 'Acute Injury,' you get a lot of swelling, and in that case there MAY be some benefit to using ice, right after the injury to reduce the swelling
BUT, 'Acute Injuries' are almost always sudden, traumatic injuries, often involving some bruising or tearing – like a sprain or a strain.
And, although Tennis Elbow can sometimes start out this way – Most of the time it creeps up on you – It’s usually a sneaky, gradual breakdown.
For a good example of an 'Acute Injury' let’s take an ankle sprain…
Have you ever sprained your ankle badly – or seen someone who has?
You’re almost certain to see some swelling from the inflammation kicking in hard and fast, and putting some ice on that might make sense.
Let me emphasize that the appearance of swelling is what signifies that a significant inflammatory process is going on.
You can tell because it puffs up visibly and also feels kind of spongy when you press on the area. It's evidence of fluid building up in the area.
What’s Your Top Priority: Pain Relief — Or Healing?
So, should you stop icing your Tennis Elbow? (Or Golfer’s Elbow or similar painful tendon problem?) It really comes down to what your goal is:
- If your priority is simply short-term pain relief — then, maybe ice it,
- BUT if your priority is supporting your healing process — then, don't ice it!
- (I believe heat is a better choice, however — often for both goals)
If you really need some temporary relief from the pain, and the choice is between ice and taking anti-inflammatories…
Then putting a cold pack on the area from time to time is a healthier choice…
(Emphasis on ‘cold pack’ rather than an actual bag of ice, because an ice pack can introduce way too much cold to the area, too quickly.)
I would try heat first, however, and if it had the unfortunate effect of increasing the pain, I might try a cold pack at that point.
Inflammation Is NOT Your Mortal Enemy
The bottom line is, inflammation is part of your normal healing process — Not a terrible enemy to be treated and defeated.
Inflammation is 'Stage 1' — The first thing that happens when you injure something, whether you cut your finger or sprain your ankle.
And there's no going forward to stage 2 and 3 of that process if stage 1 fails or is completely suppressed.
But can’t inflammation sometimes get so “out of control” — so severe that it becomes a serious problem?
Sure, it can!
We all know how serious and potentially life-threatening the cytokine / histamine reaction can be to a serious peanut or bee sting allergy…
However, this not what you’re facing if you have Tennis Elbow.
You are most likely dealing with a FAILED healing process — An absence of a healthy, normal healing response and progression, certainly not an excess of inflammation. (In most cases there isn’t even any visible swelling.)
In many cases of Tennis and Golfer’s Elbow, there may be an initial inflammatory reaction, but this very often fails in the mid to long term.
(Could that be because of too much inflammation suppression with pills, ice and Cortisone Shots??)
And to be clear, swelling is NOT the feeling of tenderness, soreness or pain OR the presence of redness you can see in your skin – Although those symptoms often go along with it.
Swelling is really only the build up of fluid.
Some would argue that’s not a good situation because it means the area has gotten all clogged up and congested – and your circulation has slowed way down – And you need good circulation for healing!
But that simply raises the question:
Can you see any swelling around your elbow?
Does it feel significantly puffy to your touch in that area?
Now, I’m not trying to diagnose you here, but if you don’t see it, there’s probably no significant swelling you need to be worried about.
And icing won’t do a thing for you except make your pain feel a little better for a little while.
Of course, once again, that’s better than popping anti-inflammatories.
As a side note, I’ve been focusing on treating Tennis Elbow, as a specialty, for over a decade in my practice, and I can’t remember ever seeing one person who had any significant swelling around their elbow.
Is RICE Wrong? Questioning The Whole Protocol
Word seems to finally be spreading and prominent trainers and other sports, rehab and therapy professionals are recognizing that the RICE protocol is not only useless for chronic conditions, (like Tennis Elbow) which aren't even inflammatory...
But that RICE and especially the ice part is also potentially counterproductive for mild-to-moderate Acute injuries!
(At least beyond the initial minutes following a significant, traumatic injury.)
One of the most visible (and quoted) sources is the Doctor who coined the RICE acronym in the first place, who has since radically changed his position on it.
The Doctor Who Coined The Term RICE Has Reversed His Position
Dr. Gabe Mirkin, co author of 'The Sports Medicine Book' from 1978, now says that:
Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping. And he points out that:
- Healing Requires Inflammation - And
- Anything that reduces it also delays healing!
- Gabe Mirkin, MD Why Ice Delays Recovery
Joshua Stone, a heavily-credentialed Athletic Trainer has an excellent series on RICE and icing on his blog at StoneAthleticmedicine.com
Most of it is not specific to Tennis Elbow treatment but the same principles apply for the most part. He tells us in '10 Reasons – Icing Injuries is Wrong' that:
- "You cannot have tissue repair or remodeling without inflammation,"
- "Ice constricts blood flow and impedes the inflammatory cells from reaching injured tissue."
- "Inflammatory cells are designed to release a hormone known as Insulin-like Growth Factor (IGF-1)" [But ice inhibits this essential healing component]
- Joshua Stone, Stone Athletic Medicine - 10 Reasons – Icing Injuries is Wrong
Video On Icing Muscles | Gary Reinl Interview
In this video Kelly Starrett (of MobilityWOD on YouTube, and author of 'Becoming a Supple Leopard') interviews Gary Reinl (Author of 'ICED! The Illusionary Treatment Option')
At one point, Gary, describing a conversation he had with a pro football trainer about ice and the “goal” of reducing inflammation, asks:
“Are you under the belief that your body doesn't know how to regulate that?... You think you need to 'regulate' the body's inflammation response? You're better at it than the body is?”
And later on he poses the rhetorical question:
“Could the body's natural inflammatory response actually be a mistake!?... If it's not a mistake, and it's right, then why are you preventing it?”
I was also delighted to see that Gale Bernhardt, the U.S. Triathlon team coach at the 2004 Athens Olympic Games, seems to have also "switched sides" and now plays for the "RICE is wrong" team, according to her article on Active.com, where she references both Gary Reinl's and Dr. Gabe Mirkin's books.
OK, let’s quickly sum it up now:
- Don’t assume your Tennis Elbow pain is the result of inflammation — (Be aware that after a few weeks — especially after a few months, it’s more likely to be painful because of degeneration / Tendinosis — NOT inflammation / Tendonitis.)…
- RE-think trying to suppress any inflammation that MAY be present — with pills and especially Cortisone shots (because inflammation is a healthy part of the healing process)…
- Ice (or better yet, use a cold pack) only if you're desperate for pain relief — (If the choice is between that and drugs, but maybe try some heat first!)
- And do what you can to encourage healing and regeneration — Try to break the vicious cycle of stagnation and degeneration rather than inadvertently contributing to it by following “the conventional wisdom.”
Your Allies In That Mission To Support Your Healing Process Are:
► Encouraging and increasing circulation — (Heat is often very helpful!)
► Keeping it moving with gentle movement — (NOT immobilization with a brace, which is more bad “conventional wisdom.”)
► AND other forms of mobilization — (Since a large part of the dysfunction involves tight, ‘shortened’ and ahesion-restricted muscle and tendon tissues.)
My primary tools for mobilizing and releasing all that tension and “stuckness” are advanced massage (and self-massage) techniques.
As well as, stretching and exercise (although, I’m a believer that rehab exercises are often better deferred until ones symptoms have decreased significantly.)
If you’re tired of chasing your Tennis Elbow symptoms around in a vicious circle following the latest remedy, trick or cure...
You’re in the right place to get the big picture, to understand how your healing process really works, and learn how to help your injury finally heal.
Learn How To Treat Your Own Tennis Or Golfer’s Elbow At Home:
You’ll get instant access to a complete program designed by a professional therapist who specializes in treating these vexing injuries daily (me)
Just watch the videos, follow along, and I'll show you how to break your vicious elbow pain and injury cycle, whether you have Tennis or Golfer's Elbow from tennis, golf, using your computer doing construction for a living, swimming, playing your guitar or just working around your house or gardening...
You’ll learn all the therapy techniques, key stretches AND essential exercises you need to treat and recover from your injury at home.
A Complete Self-Treatment Program For Tennis Elbow
Learn more about the Tennis Elbow self-help treatment program - Including what's in all the video lessons, what the bonuses are and the success stories:
A Comprehensive Golfer's Elbow Self-Help Program
Learn more about the self-help home treatment program for Golfer's Elbow - Including what' in the video lessons, the bonuses and more: