Answering Your Questions about Heat vs. Ice Therapy

As you can imagine, I get asked a lot of questions about sports related injuries, “how do I treat” this and that injury and proper techniques for various forms of exercise.  The #1 question I get asked is “when do I use ice and when should I use heat for (injury)?”

This is a perfect example of why I created MikeRyanSportsMedicine.com.  The need for sports medicine advice for the non-professional athlete is very high.  Even for the most basic of questions on how to properly treat orthopedic injuries: Do I use ice or do I use heat?

The use of ice and heat is a key component to my approach to sports physical therapy.  When treating my athletes, my objectives are simple:

  1. Decrease Pain
  2. Decrease Swelling
  3. Increase Motion
  4. Increase Strength
  5. Enhance Function

When you think back to your last few injuries, would you have been happy if you achieve some if not all of these objectives within the first 2-3 days?

Let me show you how ice therapy and heat therapy can help you control your pain and supercharge your recovery to get back to a healthy and active lifestyle.

There are many sports medicine myths and questions in the battle of ice vs. heat.  I want to give you the truth about ice and heat…starting with ice.

Ice Therapy or Cryotherapy

Three Reasons to Use Ice

  1. It’s a lot easier to keep a joint from swelling than it is to get rid of swelling after the area is already inflamed.
  2. Icing an acute (new) or a chronic (old) injury after exercise or activity can reduce or prevent swelling.
  3. By using ice to reduce the swelling around an injury, you have the ability to literally cut your rehab time in half!

How Does Ice Impact an Injury?

  • Cryotherapy decreases inflammation.
  • Ice moderately reduces the circulation of blood in an area of the body so the soft tissue and joints have access to less fluid to create swelling.  Meanwhile, the application of HEAT to an area is like turning on a drippy faucet: It increases the blood flow and it will increase the swelling.
  • Ice slows down the injury site’s metabolism which will slow down the body’s inflammatory process….and that’s a good thing!
  • Ice decreases pain.

How Should I Use Ice?

  • Ice all the way around the joint–not just at the site of the injury.  For example, if your injury is on the right side of your ankle, ice all the way around the ankle instead of just on the right side.
  • Whenever possible, ice with elevation
  • Ideally ice with compression
  • RICE = Rest + Ice + Compression + Elevation

Methods of Icing:

  • Ice bucket or submerge the injured body part in ice water.  This is the best way to ice.
  • Ice bags with a thin paper towel or cloth to minimize the skin irritation. 
  • Ice massage is a great way to ice and it has been shown to be the best way to ice deeper tissue.

How Long Should I Ice?

  • For ice buckets and ice bags/frozen veggies, no more than 15 minutes.
  • Ice massage for 10 minutes.

Ice Massage Made Easy:

Fill a paper cup almost to the top with water and place in the freezer.  Once frozen, peel away most of the cup and massage with the exposed ice.

Common Myths About Cryotherapy:

“It’s uncomfortable when I ice.”  Toughen up–it’s not going to kill you.  Trust me when I say that you’ll get used to it after 4-5 icings and you’ll actually look forward to icing after you realize how much better it will make you feel.  To minimize your pain, keep your distal extremities in the area you’re icing warm such as your fingertips and toes.  By keeping these areas warm when icing, you’ll be removing much of the discomfort.  Cover the ends of your extremity with a non-sterile rubber glove with some air inside.  Put the gloves on your toes or fingertips when submerging in ice an ice bucket will keep them warm.

“I might get frostbite.”  The likelihood of frostbite is pretty rare, especially when you are only icing for a maximum of 15 minutes.  However, if you have any circulatory pathology like diabetes or are being medically treated for any chronically swollen extremities frostbite can occur.  Consult your physician prior to icing.

“It’s been more than 72 hours since my injury, so I should switch to heat.”    If the injured area feels warm, it needs ice regardless of the timeframe since the injury.  A warm and active injury rarely ever needs to be treated with heat, even if it’s been more than 72 hours since the onset of the injury.

Heat Therapy

When Do You Use Heat?

  • Generally speaking heat is used for chronic injuries or for injuries that have minimal inflammation or swelling.   The reason for this is the fact that heat speeds up circulation and it increases blood flow.
  • Heat therapy should only be used prior to a workout.  Never use heat after you workout.  For both acute and chronic pain, ice is a better choice after a workout.
  • Use heat to relieve sore, stiff, nagging muscle or joint discomfort.

The use of heat therapy before exercise will enhance the elasticity of both joints and connective tissue by stimulating an increase in blood flow.

How Should I Apply Heat?

Exercise – I tell my athletes this often: “Heat a joint or muscle from the inside out”.   Light exercise and flexibility exercises will warm up joints, muscle, fascia, tendons, ligaments, bursas, and, most importantly, your mind.
Hot Shower – A simple way to increase blood flow and prepare your body to move efficiently.
Hot Tub – Often referred to as Hydrotherapy, a hot tub is an easy way to enhance your ability to move.  Consume extra water and sports drink when getting in the hot tub due to the obvious dehydration concern with a hydrotherapy treatment.
Hot Pack – Be careful with hot packs do to the high incident of burns from heating pads.  Always make sure you have an additional layer of cloth between your skin and a heating pad.  Never leave a heating pad on for more than 15 minutes and never sleep with a heating pad on.

Contrast Therapy

Contrast therapy is the application of both heat and ice to enhance performance.  The alternating of the two forms of thermal therapy can produce wonderful results if performed properly.

Always remember the basic premise of the two:  ICE decreases blood flow and slows down the activity in an area while HEAT increases blood flow and speeds up the activity in an area.

When and how do you use Contrast Therapy?

When – Once an inflammatory process is minimized and the swelling is controlled, the application of contrast therapy can be very effective.
How – Pick your methods of heat and cold to improve circulation and increase motion.  Alternating between either hot water/cold water, heat pack/ice bag, active exercise/ice massage or even a hot shower/cold shower are great ways to increase your ability to move pain-free!
How Often – Alternate form of heat/cold every 2 minutes for 3-5 revolutions of each.

Take Home Tip:

If you’re ever uncertain whether to use heat or ice, ICE is always your safest option.

10 replies
  1. Gordon Clark
    Gordon Clark says:

    As an Orthopedic and Sports Massage Therapist, I’m using ice and heat quite often. I’m always asked by my clients and athletes whether to use ice or heat. My education tells me the same as you have outline in the article, however sometimes convincing folks one way or the other may be a bit difficult. I’m going print this article and keep it in my library to give to my clients!
    Thank you, Gordon Clark http://www.linkedin.com/pub/gordon-clark/16/b50/471

    Reply
    • Mike Ryan
      Mike Ryan says:

      Great point, Gordon. Convincing an athlete is not always easy. I had an orthopedic doctor at one of my talks in Barcelona, Spain tell me that he only uses heat on himself and his patients b/c it’s much more comfortable than ice! If you can focus on the reward of less pain, less swelling and a faster recovery, smart athletes will quickly embrace to the use of ice.

      Reply
  2. Andy Cunningham
    Andy Cunningham says:

    Mike
    Great article! I’m not sure though that there is any evidence of the effectiveness of contrast bathing in reducing swelling. You might get some changes in superficial blood flow but that does not mean edema is affected. The only way to get rid of edema is change fluid filtration pressures through gentle exercise, elevation or compression. It is difficult to find any evidence to support its use over cold or heat applied independently.
    Knights and Draper’s book ‘ Therapeutic Modalities the Art and Science ‘ is by far the best book on the use of cryotherapy in acute injuries and they do not support its use.
    Any thoughts? Best regards, Andy

    Reply
    • Mike Ryan
      Mike Ryan says:

      I thank you for the interesting insight and intriguing perspective. (Those that know me will agree that I’m offended by those that disagree in an effor to make us all smarter) Your point on the need for exercise, gravity assistance and compression is strong. Simple temperature changes alone via contrast bath will do little. Knowing which type of “swelling” is the first step and addressing that problem may very well dictate if contrast is needed. As with an acute injury, a contrast might be the last form of treatment to implement. As for the various forms of inflammation, I’d love to get your thoughts on this article: http://www.mikeryansportsmedicine.com/sports-medicine-article/5-tips-to-improve-your-swollen-knee/ Thanks, Andy

      Reply
  3. Ralph
    Ralph says:

    Do you have any thoughts on timings? Does icing immediately retard any of the healing process? Does waiting a brief period of time (20mins?) to allow cellular healing mechinisms to enact before restricting them with ice or compression or NSAI meds? Have you seen any evidence of this??

    Reply
    • Mike Ryan
      Mike Ryan says:

      There is no strong evidence that rapid icing immediately post-injury slows the healing process.
      For what it’s worth, here’s my theory: How can the magical “cellular healing mechanism” be enhanced if acidic blood and injury waste products are allowed to bleed into the damaged cells while waiting 20 minutes? ICE will immediately slow the uncontrolled blood flow into a wound, thermally reduce the metabolism at the injury site and allow the body to do what it does: Heal Thy Self with much less “bad stuff” flooding into the area.
      If you want to test my theory, the next time you have a significant injury, immediately put HEAT on it. It will be much more comfortable than ice but your healing time will be at least 50% longer.
      My Approach on Acute Injury Management to Get Back in the Game: IF I CONTROL THE SWELLING, I CUT THE RECOVERY TIME IN HALF!!

      Reply
    • Mike Ryan
      Mike Ryan says:

      How cool is that?! I’m very impressed and you inspire me to continue to help others for decades to follow. Congrats, Dr. Max Morton. Stay strong & sharp.

      Reply
  4. Derek Dewitt
    Derek Dewitt says:

    I get sore muscles almost every time I workout, so I’ve been looking for ways to help that. I like your point about how, with heat therapy, you should heat a joint of muscle from the inside out. I’ll have to focus on warming my joints and muscles with a shower or something to see if it helps the stiffness afterward.

    Reply
    • Mike Ryan
      Mike Ryan says:

      #Smart, Derek. Add aggressive roller work both before and after workouts, stretching before bedtime, massage therapy, and proper hydration to reduce your soreness.

      Reply

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