Should Athletes Return to Sport After Applying Ice?

A Systematic Review of the Effect of Local Cooling on Functional Performance


Applying ice or other forms of topical cooling is a popular method of treating sports injuries. It is commonplace for athletes to return to competitive activity, shortly or immediately after the application of a cold treatment.

In this article, we examine the effect of local tissue cooling on outcomes relating to functional performance and to discuss their relevance to the sporting environment. A computerized literature search, citation tracking and hand search was performed up to April, 2011. Eligible studies were trials involving healthy human participants, describing the effects of cooling on outcomes relating to functional performance. Two reviewers independently assessed the validity of included trials and calculated effect sizes. Thirty five trials met the inclusion criteria; all had a high risk of bias. The mean sample size was 19. Meta-analyses were not undertaken due to clinical heterogeneity. The majority of studies used cooling durations >20 minutes. Strength (peak torque/force) was reported by 25 studies with approximately 75% recording a decrease in strength immediately following cooling. There was evidence from six studies that cooling adversely affected speed, power and agility-based running tasks; two studies found this was negated with a short rewarming period. There was conflicting evidence on the effect of cooling on isolated muscular endurance. A small number of studies found that cooling decreased upper limb dexterity and accuracy. The current evidence base suggests that athletes will probably be at a performance disadvantage if they return to activity immediately after cooling. This is based on cooling for longer than 20 minutes, which may exceed the durations employed in some sporting environments. In addition, some of the reported changes were clinically small and may only be relevant in elite sport. Until better evidence is available, practitioners should use short cooling applications and/or undertake a progressive warm up prior to returning to play.

This is a preview of subscription content, access via your institution.

Fig. 1
Table I
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Bleakley CM, Glasgow PD, Philips P, et al. for the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). Guidelines for the management of acute soft tissue injury using protection, rest, ice, compression and elevation. London: ACPSM, 2011

    Google Scholar 

  2. 2.

    Costello JT, Donnelly AE. Cryotherapy and joint position sense in healthy participants: a systematic review. J Athl Train 2010; 45 (3): 306–16

    PubMed  Article  Google Scholar 

  3. 3.

    The Cochrane Collaboration. Assessing risk of bias in included studies. Section 8.5 of the Cochrane handbook for systematic reviews of interventions. Version 5.0.2 [updated September 2011]. Higgins JPT, Altman DG, editors. Chapter 8 [online]. Available from URL: [Accessed 2011 Oct 20]

  4. 4.

    Edwards RHT, Harris RC, Hultman E, et al. Effect of temperature on muscle energy metabolism and endurance during isometric contractions, sustained to fatigue in the quadriceps muscles in man. J Physiol 1972; 220: 335–52

    PubMed  CAS  Google Scholar 

  5. 5.

    Johnson DJ, Leider FE. Influence of cold bath on maximum handgrip strength. Percept Mot Skills 1977; 44 (1): 323–6

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Coppin EG, Livingstone SD, Kuehn LA. Effects on handgrip strength due to arm immersion in a 10 degree C water bath. Aviat Space Environ Med 1978; 49 (11): 1322–6

    PubMed  CAS  Google Scholar 

  7. 7.

    Bergh U, Ekblom B. Influence of muscle temperature on maximal muscle strength and power output in human skeletal muscles. Acta Physiol Scand 1979; 107 (1): 33–7

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Oliver R, Johnson D, Wheelhouse W, et al. Isometric muscle contraction response during recovery from reduced intramuscular temperature. Arch Phys Med Rehabil 1979; 60 (3): 126–9

    PubMed  CAS  Google Scholar 

  9. 9.

    Petrofsky JS, Lind AR. The influence of temperature on the amplitude and frequency components of the EMG during brief and sustained isometric contractions. Eur J Appl Physiol 1980; 44 (2): 189–200

    Article  CAS  Google Scholar 

  10. 10.

    Barter TJ, Freer PC. Effect of temperature on handgrip holding time. Br J Sports Med 1984; 18 (2): 91–5

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Ranatunga KW, Sharpe B, Turnbull B. Contractions of human skeletal muscle at different temperatures. J Physiol (London) 1987; 390: 383–95

    CAS  Google Scholar 

  12. 12.

    Sargeant AJ. Effect of muscle temperature on leg extension force and short-term power output in humans. Eur J Appl Physiol 1987; 56: 693–8

    Article  CAS  Google Scholar 

  13. 13.

    Vincent MJ, Tipton MJ. The effects of cold immersion and hand protection on grip strength. Aviat Space Environ Med 1988; 59 (8): 738–41

    PubMed  CAS  Google Scholar 

  14. 14.

    Mattacola CG, Perrin DH. Effects of cold water application on isokinetic strength of the plantar flexors. Isokinet Exerc Sci 1993; 3: 152–9

    Google Scholar 

  15. 15.

    Howard Jr RL, Kraemer WJ, Stanley DC, et al. The effects of cold immersion on muscle strength. J Strength Cond Res 1994; 8 (3): 129–33

    Google Scholar 

  16. 16.

    Evans TA, Ingersoll C, Knight KL, et al. Agility following the application of cold therapy. J Athl Train 1995; 30 (3): 231–4

    PubMed  CAS  Google Scholar 

  17. 17.

    Lakie M, Villagra F, Bowman I, et al. Shooting performance is related to forearm temperature and hand tremor size. J Sports Sci 1995; 13 (4): 313–20

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Catlaw K, Arnold BL, Perrin DH. Effect of cold treatments on concentric and eccentric force velocity relationship of the quadriceps. Isokinet Exerc Sci 1996; 5: 157–60

    Google Scholar 

  19. 19.

    Cross KM, Wilson RW, Perrin DH. Functional performance following an ice immersion to the lower extremity. J Athl Train 1996; 31 (2): 113–6

    PubMed  CAS  Google Scholar 

  20. 20.

    Kimura IF, Thompson GT, Gullick DT. The effect of cryotherapy on eccentric plantar flexion peak torque and endurance. J Athl Train 1997; 32 (2): 124–6

    PubMed  CAS  Google Scholar 

  21. 21.

    Zhou S, Carey MF, Snow RJ, et al. Effects of muscle fatigue and temperature on electromechanical delay. Electromyogr Clin Neurophysiol 1998; 38 (2): 67–73

    PubMed  CAS  Google Scholar 

  22. 22.

    Sanya A, Bello A. Effects of cold application on isometric strength and endurance of quadriceps femoris muscle. Afr J Med Med Sci 1999; 28 (3-4): 195–8

    PubMed  CAS  Google Scholar 

  23. 23.

    Hatzel BM, Kaminski TW. The effects of ice immersion on concentric and eccentric muscle performance in the ankle. Isokinet Exerc Sci 2000; 8: 103–7

    Google Scholar 

  24. 24.

    Hopkins JT, Stencil R. Ankle cryotherapy facilitates soleus function. J Orthop Sports Phys Ther 2002; 32 (12): 622–7

    PubMed  Google Scholar 

  25. 25.

    Cheung SS, Montie DL, White MD, et al. Changes in manual dexterity following short-term hand and forearm immersion in 10 degrees C water. Aviat Space Environ Med 2003; 74 (9): 990–3

    PubMed  Google Scholar 

  26. 26.

    Douris P, McKenna R, Madigan K, et al. Recovery of maximal isometric grip strength following cold immersion. J Strength Cond Res 2003; 17 (3): 509–13

    PubMed  Google Scholar 

  27. 27.

    Thornley LJ, Maxwell NS, Cheung SS. Local tissue temperature effects on peak torque and muscular endurance during isometric knee extension. Eur J Appl Physiol 2003; 90 (5-6): 588–94

    PubMed  Article  Google Scholar 

  28. 28.

    Borgmeyer JA, Scott BA, Mayhew JL. The effects of ice massage on maximum isokinetic-torque production. J Sports Rehabilitation 2004; 13: 1–8

    Google Scholar 

  29. 29.

    Hamzat TK, Fatudimu MB. Acute effects of cold and muscle vibration on maximal grip strength and muscle endurance in normal subjects. Afr J Med Med Sci 2005 Sep; 34 (3): 235–8

    PubMed  CAS  Google Scholar 

  30. 30.

    Kubo K, Kanehisa H, Fukunaga T. Effects of cold and hot water immersion on the mechanical properties of human muscle and tendon in vivo. Clin Biomech 2005; 20 (3): 291–300

    Article  Google Scholar 

  31. 31.

    Richendollar ML, Darby LA, Brown TM. Ice bag application, active warm-up, and 3 measures of maximal functional performance. J Athl Train 2006; 41 (4): 364–70

    PubMed  Google Scholar 

  32. 32.

    Wassinger CA, Myers JB, Gatti JM, et al. Proprioception and throwing accuracy in the dominant shoulder after cryotherapy. J Athl Train 2007; 42 (1): 84–9

    PubMed  Google Scholar 

  33. 33.

    Patterson SM, Udermann BE, Doberstein ST, et al. The effects of cold whirlpool on power, speed, agility, and range of motion. J Sports Sci Med 2008; 7: 387–94

    Google Scholar 

  34. 34.

    Fischer J, Van Lunen BL, Branch JD, et al. Functional performance following an ice bag application to the hamstrings. J Strength Cond Res 2009; 23 (1): 44–50

    PubMed  Article  Google Scholar 

  35. 35.

    Chen WL, Shih YC, Chi CF. Hand and finger dexterity as a function of skin temperature, EMG, and ambient condition. Hum Factors 2010; 52 (3): 426–40

    PubMed  Article  Google Scholar 

  36. 36.

    Dewhurst S, Macaluso A, Gizzi L, et al. Effects of altered muscle temperature on neuromuscular properties in young and older women. Eur J Appl Physiol 2010; 108 (3): 451–8

    PubMed  Article  Google Scholar 

  37. 37.

    Dixon PG, Kraemer WJ, Volek JS, et al. The impact of coldwater immersion on power production in the vertical jump and the benefits of a dynamic exercise warm-up. J Strength Cond Res 2010; 24 (12): 3313–7

    PubMed  Article  Google Scholar 

  38. 38.

    Pereira LG, Pereira R, Pinto Neto O, et al. The short and long term effects of tibialis anterior local cooling on dorsiflexion force. J Hum Kinet 2010; 26: 65–71

    Article  Google Scholar 

  39. 39.

    Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med 2007; 41 (6): 365–9

    PubMed  Article  Google Scholar 

  40. 40.

    Knight KL. Cryotherapy in sports injury management. 1st ed. Champaign (IL): Human Kinetics, 1995

    Google Scholar 

  41. 41.

    Oksa J, Rintamaki H, Rissanen S, et al. Stretch andH-reflexes of the lower leg during whole body cooling and local warming. Aviat Space Environ Med 2000; 71 (2): 156–61

    PubMed  CAS  Google Scholar 

  42. 42.

    Rutkove SB. Effects of temperature on neuromuscular electrophysiology. Muscle Nerve 2001; 24: 867–82

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Ferretti G. Cold and muscle performance. Int J Sports Med 1992; 13 (Suppl.1): S185–7

    PubMed  Article  Google Scholar 

  44. 44.

    Krause AB, Hopkins JT, Ingersoll CD, et al. The relationships of ankle temperature during cooling and rewarming to the human soleus H reflex. J Sports Rehabil 2000; 9 (3): 253–92

    Google Scholar 

  45. 45.

    Pietrosimone BG, Ingersoll CD. Focal knee joint cooling increase the quadriceps central activation ratio. J Sports Sci 2009; 27 (8): 873–9

    PubMed  Article  Google Scholar 

  46. 46.

    Clarke DH Wojciechowicz. The effect of low environmental temperature on local muscular fatigue parameters. Am Corr Ther J 1978; 32: 35–40

    CAS  Google Scholar 

  47. 47.

    Ranalli GF, Demartini JK, Casa DJ, et al. Effect of body cooling on subsequent aerobic and anaerobic exercise performance: a systematic review. J Strength Cond Res 2010 Dec; 24 (12): 3488–96

    PubMed  Article  Google Scholar 

  48. 48.

    Palmieri RM, Garrison JC, Leonard JL, et al. Peripheral ankle cooling and core body temperature. J Athl Train 2006; 41 (2): 185–8

    PubMed  Google Scholar 

  49. 49.

    Myrer JW, Myrer KM, Measom GJ, et al. Muscle temperature is affected by overlying adipose when cryotherapy is administered. J Athl Train 2001; 36: 32–6

    PubMed  Google Scholar 

  50. 50.

    Myrer JW, Measom GJ, Fellingham GW. Exercise after cryotherapy greatly enhances intramuscular re-warming. J Athl Train 2000; 35 (4): 412–6

    PubMed  CAS  Google Scholar 

  51. 51.

    Bender AL, Kramer EE, Brucker JB, et al. Local ice-bag application and triceps surae muscle temperature during treadmill walking. J Athl Train 2005; 40 (4): 271–5

    PubMed  Google Scholar 

  52. 52.

    Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomised controlled trials. Am J Sports Med 2004 Jan-Feb; 32 (1): 251–61

    PubMed  Article  Google Scholar 

  53. 53.

    Quod MJ, Martin DT, Laursen PB. Cooling athletes before competition in the heat: comparison of techniques and practical considerations. Sports Med 2006; 36 (8): 671–82

    PubMed  Article  Google Scholar 

  54. 54.

    The Cochrane Collaboration. Special topics in statistics. Cochrane handbook for systematic reviews of interventions. Version 5.0.1 [updated 2008 Sep]. Higgins JPT, Deeks JJ, Altman DG, editors. Chapter 16 [online]. Available from URL: [Accessed 2011 Oct 20]

  55. 55.

    Friemert B, Franke S, Gollhofer A, et al. Group I afferent pathway contributes to functional knee stability. J Neurophysiol 2010; 103 (2): 616–22

    PubMed  Article  CAS  Google Scholar 

  56. 56.

    Uchio Y, Ochi M, Fujihara A, et al. Cryotherapy influences joint laxity and position sense of the healthy knee joint. Arch Phys Med Rehabil 2003; 84 (1): 131–5

    PubMed  Article  Google Scholar 

Download references


Part of this project was funded by the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). The authors declare no conflicts of interest that are directly relevant to the content of this review.

Author information



Corresponding author

Correspondence to Dr Chris M. Bleakley.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bleakley, C.M., Costello, J.T. & Glasgow, P.D. Should Athletes Return to Sport After Applying Ice?. Sports Med 42, 69–87 (2012).

Download citation


  • Grip Strength
  • Mean Difference
  • Knee Extension
  • Standardize Mean Difference
  • Vertical Jump