Alexander, Jill

May, Karen Alison

Richards, Jim

Selfe, James

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BackgroundThe effect of cryotherapy on joint position sense (JPS)presents conflicting debates (1,2) as to whether individualsare at an increased risk of injury when returning to playfollowing cryotherapy application at the lower limb.Commonly applied for the acute management of soft tissueinjuries (1,3), crushed ice as a form of cryotherapy inducesanalgesia due to physiological changes when skin surfacetemperature (Tsk) reaches between 10-15°C (1,4,5,6).Anecdotal evidence suggests crushed ice is applied for thefacilitation of joint movement during rehabilitation thereforesubjecting athletes to exercise immediately aftercryotherapeutic exposures. Furthermore many athletes incontact and non-contact sports return to the field of playpost exposure to cryotherapy modalities. Although, minimalconsensus can be derived from the literature (2,7) as towhether joint stability and position sense is affected bycryotherapy.PurposeIt is undecided in the literature as to the immediate affecton JPS cryotherapy application induces. If JPS is affected,particularly at the knee this has implications on theapplication and exposure of players to bouts of cryotherapyduring competitive play. Therefore this study investigatedthe effects of a 20 minute application of crushed ice at theknee on knee JPS immediately post removal, during asmall knee bend.Materials and MethodThis study followed a single group, pre-test-post-testdesign with 11 healthy male participants. Average age21.3±1.7 years, body mass 83.5±32.5 kg and height182±12.8 cm. Using three-dimensional motion analysis(Qualisys Medical AB Gothenburg, Sweden), kinematics ofthe knee was measured during a weight bearing functionaltask (small knee bend) pre and immediately postcryotherapy intervention. The target angle of 45° was heldfor 5s supporting previous methodologies (3,8,9) and limbposition awareness (3). Testing was carried out on theparticipants non-dominant limb, known to be the most likelyfor knee injury to occur (10). Anatomical markers wereapplied (Figure 1.) Two anatomical markers were removedat the lateral and medial epicondyles of the knee prior to800g of crushed ice was applied to the anterior aspect ofthe knee for the clinically relevant time of 20 minutes (11).Tsk cooling was measured via a digital thermometer overthe anterior and medial aspect of the knee pre andimmediately post.ResultsSignificant reduction in the ability to accurately replicateknee joint flexion in the sagittal plane (P=.035) (Figure 2)and an increase in valgus shift in the coronal (P=.011)plane during the descent eccentric loading phase of asmall knee bend following intervention was noted,supporting earlier research (12,13,14). Tsk demonstratedsignificant reduction post cryotherapy intervention(P=.001). Immediately post cryotherapy applicationaverage Tsk was recorded at 13.4°C ±2.9 reflecting a Tskresponse to within the desired therapeutic range.References1. Bleakley, et al (2012). 2. Costello & Donnelly (2010).3. Costello & Donelly (2011). 4. Knight & Draper (2013). 5. Jutte et al, (2001). 6. Bugaj (1975). 7. Bleakley & Costello (2013). 8. Costello,Algar & Donnelly (2012). 9. Olsson et al, (2004). 10. Krajnc, et al (2010). 11. Janwantakul (2009). 12. Ribeiro et al (2013). 13. Surenkok et al (2008). 14. Uchio et al (2003).Jill Alexander, Karen May, Prof. James Selfe, Prof. Jim Richards.Allied Health Professions Research Unit, Division of Physiotherapy and Sports Therapy, University of Central Lancashire, Preston, UK.  Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK.THE IMMEDIATE EFFECTS OF A 20 MINUTE CRUSHED ICE APPLICATION ON KNEE JOINT POSITION SENSE DURING A SMALL KNEE BENDFigure 1. Anatomical landmarks for marker placement (a) anterior view and (b) posteriorview.ConclusionA 20-minute application of crushed ice to the non-dominant knee has an adverse effect on knee joint repositioning. In particularthe accurate reproduction of knee flexion and reduced varus control during eccentric loading of an SKB following ice application.This may be due to reduced sensitivity of JPS, with the assumption of a reduced discharge rate of slow adaptingmechanoreceptors during exposure to cryotherapy or an increase in joint stiffness. Team doctors, clinicians, and therapists shouldconsider these findings when deciding to return an athlete to functional weight bearing tasks immediately following ice applicationat the knee, due to the potential increase risk of injury. Consideration should address potential risk of ACL or medial complex injuryin sport. Further research is required however to understand any potential delayed effects on JPS after a period of time postcryotherapy removal. At what period of time JPS returns to baseline levels remains to be investigated.Figure 2. knee joint flexion during a SKB (sagittal plane), pre and immediately postintervention.

The immediate effects of a 20 minute crushed ice application on knee joint position sense during a small knee bend

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