Are Cold (Ice) Water Immersions Effective?

Picture from Scienceforsport

I used to have lots of ice packs in the freezer when I was still competing. The commercial ones plus bags of peas and mixed vegetables (pictured below). Used to put it on my shin or anywhere that hurts. However, I did not do the ice/cold water immersions. It was way too cold for me (since I had less body fat then) and I did not feel it helped. 

Good for icing

However, the more we know about cold water immersion (from research), the more it seems we (athletes and non athletes) have it wrong. Regular immersion in cold water significantly inhibits recovery from strenuous exercise. 

When our muscles feel sore after strenuous exercise, it is a consequence of doing physical activity to which we are unaccustomed or not used to. That can be a hard run, gym session, a few hours of golf or a repetitive household chore that took longer than you expected.

Here's an example of how our muscles get overloaded. If you continuously stretch a rubber band, the rubber band becomes frayed. Likewise your muscles sustain micro tears when you exert too hard. The damage causes a few hours to days of inflammation, swelling and soreness. When it's severe, you get delayed onset of muscle soreness or DOMs.

This is normal and also an essential part of muscular adaptation to exercise, also known as the overload principle. If the stress (exercise) is applied regularly, and you get enough recovery, the muscles adapt, get stronger and bigger by laying down new fibers. Just like a construction crew assembling steel beams to support the infrastructure of a building.

Ice immersion inhibits this process. Researchers (Roberts et al, 2015) have found that cold water immersion after hard exercise suppressed signaling pathways associated with recovery. This suppression lasted several days. Another group of researchers (Fuchs et al, 2020) showed that ice bathing reduced the body's muscles uptake of dietary proteins, which is important for growth and cell maintenance.

The conclusions of 2 recent meta-analyses support the suppressed signaling pathways and reduced dietary protein intake mentioned above. Grgic (2022) showed that cold water immersion reduced exercise related strength gains while (Pinero et al, 2024) showed that ice bathing immediately after weight training inhibited muscle growth.

So, whether you are strength training to improve athletic performance or just about anyone who needs to repair and rebuild your muscles after exercise, you need to reconsider if you should use cold water immersion after your exercise/ training.

Why are athletes and non athletes still doing cold water immersions? Social media is probably the cause. Wim Hof (the Dutch iceman) says that cold "activates" your metabolism and strengthens the body's immune response. Others on Tik Tok swears that ice baths improves alertness and concentration. Purveyors of commercial health and wellness have likely jumped on the same bandwagon.

Perhaps sports scientists and researchers have to share some of the 'blame'. These articles are written and published in scientific language, using unrelatable sequence and you have to pay to access them.

Possibly, only the articles with the most sensational findings/ conclusions make it out of academia. Since it is not communicated well with the public, there is a gulf between the lab and the average lay person. This gulf is then filled gleefully by fitness influencers and wellness 'gurus' who share their knowledge on unregulated social media platforms.

I ice my sore body parts still, because it does reduce muscle pain. I fell and bruised my elbow last week and the icing provided pain relief as the ice numbs the skin and blocks pain signals to the brain. 

Pain is subjective. To you it may be a 3/10 pain, to me, it may be 7/10 or vice versa. Pain cannot be studied objectively. Pain perception is definitely different to cellular recovery and to actually speed up recovery, you need to sleep well.

References

Fuschs CJ, Kouw IWK, Churchward-Venne TA et al (2020). Postexercise Cooling Impairs Muscle Protein Synthesis Rates In Recreational Athletes. J Physio. 598: 755-772. DOI: 1113/JP278996.

Grgic J. (2023). Effects Of post-exercise Cold-water Immersion On Resistance Training-Induced Gains In Muscular Strength: A Meta-analysis. Eur J Sp Sci. 23(3): 372-308. DOI: 10.1080/17461391.2022.2033851.

Roberts LA, Raastad T, Markworth et al (2015). Post-exercise Cold Water Immersion Attenuates Acute Anabolic Signaling And Long-term Adaptations In Muscle To Strength Training. J Physiol 593(18) : 4285-4301. DOI: 10.1113/JP270570.

Pinero A, Burke R, Augustin F et al (2024). Throwing Cold Water On Muscle Growth: A Systematic Review With Meta-analysis Of The Effects Of Postexercise Cold Water Immersion On Resistance Training-induced Hypertrophy. Eur J Sp Sci. 24: 177-189. DOI: 10.1002/ejsc.12074

Shouder Keeps Clicking But No Pain

I had a patient come in to our clinic this week complaining that his shoulder keeps clicking and popping with occasional discomfort (but not pain).

I shared with him an article published earlier this month where 100 patients with suspected rotator cuff tendinopathy and/ or tearing underwent MRI investigation. 

Indication for MRI was when the patients had weakness on testing of the rotator cuff muscle(s) or symptoms resistant to conservative treatment . This is inclusive of at least a 6-week course of physiotherapy. The presence of subjective mechanical symptoms, including clicking or popping was recorded prior to MRI.What the researchers were looking for was the presence of full or partial thickness rotator cuff tearing and biceps long head subluxation.

Results showed that 60 percent of the patients reported subjective mechanical symptoms in their affected shoulder. However only 42 percent of patients had full thickness rotator cuff tearing, 69 percent had partial tears while only 14 percent had biceps long head subluxation.

The authors concluded that subjective mechanical symptoms were not associated with any rotator cuff tearing, biceps long head subluxation. 

However, older age was associated with partial and full thickness rotator cuff tearing. Subjective shoulder mechanical symptoms has the ability of only 44 percent in predicting partial and full thickness rotator cuff tears. Patients may be reassured that clicking or popping sensations alone does not necessarily mean structural shoulder damage.

This article highlights the difficulty of diagnosing shoulder pain/ disorders based solely on symptoms like clicking and/ or popping. I have previously written and explained about this before. The clicking and popping sounds do not really matter, especially when there is no pain. Plus abnormal MRI findings happen in patients with no pain as well.

Reference

Zhang D, Dyer GSM and Carp BE (2024). The Significance Of Subjective Mechanical Symptoms In Rotator Cuff Pathology. J Shd Elbow Surg. 3: S1058-2746(24)000227-1

Help! My child Is Pigeon Toed

I saw a concerned parent this week who brought her child in to our clinic. She was told that her child had her feet pointing inwards while walking. This is also called in-toe or pigeon-toed walking. (If a child walks with their feet pointing onwards it is called out-toe walking or duck-footed).

These childrens' walking patterns are often termed "rotational deformities" which often cause parents to seek the opinion of podiatrists, physiotherapists or an orthopaedic surgeon for more specialized assessments and treatments.

Often when a baby is born, bowed or curved legs are normal due to the position they may be inside the mother's womb. This sort of bowed or curved legs can remain for a while and seem more obvious when the child starts to walk. It may appear that their feet face inwards (or outwards). Often the child may even trip or fall over their own feet while walking.

There may be different reasons why the child's leg or foot faces inwards or outwards while walking. When a child's leg or foot faces inwards or outwards during walking, it can be due to a number of changes in the leg or foot. If the foot is curved in ('banana' shaped feet ), or when there an inward twisting of the shin or thigh bone (tibial or femoral torsion), in-toe walking can occur.

Tibial torsion occurs when the shin (tibia) bone turns in or outwards. An inward-turned tibia is common in children under the age of 3. It almost always straightens after this age after this age (3) with NO treatment. Sometimes the shin bone even turns slighly outwards as the child grows order. This is perfectly normal. These changes occur in children up to the age of 8.

The are health professionals who will recommend that children with in-toe walking wear a type of orthotics called gait plates. While gait plates may provide some cosmetic effect when worn, there is insufficient evidence they will result in long term change. 

Parents please be very cautious about claims that such devices will fix your child's in-toe walking. Please consider if the expense, time, and your child's well being is worth it for something that will naturally get better on it's own. Do not let these health professionals prey on your fear.

Femoral torsion is when the femur (thigh bone) is turned in or outwards. Children may appear to walk with their feet tuning inwards or outwards. It then looks like their knees point inwards or outwards. 

The femur goes through many changes up to the age of 12 and this inward turn of the of the femur is more commonly seen in girls than boys. Please note that this rotational changes in the femur are a very normal part of growth.

W sitting

This inward turning at the top of the femur and hip sometimes appear in children who W-sit (pictured above) as well. There is however, no research proving that W-sitting is harmful.

There are no shoes, orthotics, garments, stretches etc that have evidence showing them being effective to change in-toe or out-toe walking associated with these rotational changes. Children walk in-toe or out-toe for many reasons. 

Unless your child is tripping often because of the leg position at the ages past 8 years of age, or if one leg turns significantly more in or outwards than the other. Unless one leg seems a lot longer or looks very different compared to the other, there is no reason to be worried. For the majority of children, in-toe or out-toe walking is just part of growing.

Actually, famous athletes like Michael Jordan, Bjorn Borg, Andre Agassi, Andy Murray, Vera Zvonareva, Zinadine Zidane and Ronaldinho are all pigeon toed. There is some anecdotal evidence and indirect research evidence to support that pigeon toed athletes have faster feet reaction times. And that will have to be in another post.

Reference

Mudge AJ, Bau KV, Purcell LN et al (2014). Normative Reference Values For Lower Limb Joint Range, Bone Torsion, And Alignment IN chldren Aged 4-16 Years. J Ped Orthop. 23(1) : 15-25. DOI: 10.1097/BPB.0b013e328364220a

Tight Or Just Tired?

Who says my hamstrings are tight?

I always hear my patients telling me that their muscles are feeling 'tight' or tense. Does this mean that their muscles are 'short' or have poor range of motion? Or is it that the area that they complain about is tight and does not feel relaxed or 'loose'. Perhaps there is a vague sense of discomfort, not pain, just an unpleasant feeling, but too mild to be painful.

I always explain that when I put both my hands on their e.g. trapezius muscles that they feel the same, one side is not 'tighter' than the other. 

If I get a dollar each time my patients tell me how tight they feel when they come and see me I will have many extra dollars for sure.

A patient ran a very hard 21 km road race recently and complained of 'tightness' in his hamstrings for the past 5 days came to see me in our clinic this week. He said his hamstrings felt very hard, achy and 'tight' of course. They even threaten to cramp when he tried running or doing some strengthening exercises. 

However, he can easily put his palms on the floor in a forward bend. (Note: there are other patients whose hamstrings do not feel 'tight' but they can barely get their hands past their knees while bending forward).

He tried stretching but other then feeling a little better for less than a minute the 'tightness' came back quickly. Upon assessment he definitely had some delayed onset of muscle soreness (DOMs). I told him his 'tightness' was actually fatigue from his training and racing.

I suggested resting and focusing on his recovery. Definitely decrease his intensity and mileage. My personal experience after a hard race would be doing any of the 2 aerobic exercses outlined below at reduced intensity and low volume.

These low intensity exercises will increase blood flow to the affected muscles and often reduce pain. Pedaling at low resistance on a stationary bike is ideal as you don't have to worry about traffic (if you ride on the roads). An easy swim or just walking in waist or chest high water works well too. Wearing compression garments will help reduce DOMs as well. These above mentioned strategies do have some support in the research.

After he recovers fully, I suggested testing for strength imbalances and deficits as weaker muscles do tend to fatigue more rapidly. Specific strength training will address that.

In most other cases of patients feeling 'tight', the reason is obvious. If the stay in the same position/ posture for too long, their muscles need a rest or change of position to reduce the lack of blood flow or metabolic stress that is causing the noxious stimuli. Think of the last time when you spent hours in a car, plane or behind your computer, after you move/ stretch, the symptoms of stiffness/ tightness will be alleviated.

Remember this, when you feel stiff and 'tight', it is just a feeling and not necessarily a physical shortening that needs you to structurally change it. Like other things that you feel, you may feel it more sometimes compared to others. Like other forms of sensitivity, those feelings will change if you improve your overall fitness, strength and health.

Reference

Stanton TR, Moseley GL, Wong AYL et al (2017). Feeling Stiffness In The Back: A Protective Perceptual Inference In Chronic Back Pain. Sci Rep. 791): 968. DOI: 10.1038/s41598-017-09429-1