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  • Writer's pictureCTPO Team

When to Ice + When to Heat

Top three questions physical therapists get asked:

  1. “How long will this take to go away?”

  2. “Are you going to give me a massage?”

  3. “Should I ice or should I heat?”

Well, friends, I am here to clear up number three! There has been some recent controversy on the use of ice and its possible role in delaying healing if used too often past the time when ice is indicated.

First, let’s go over a few foundational items…


When injuries happen, healing must occur to return tissues back to as much of their normal state as possible. Our bodies are designed to go through a cascade of events, known as phases of healing, that are necessary to ensure appropriate recovery. The time frame over which each phase occurs differs according to the type of tissue injured, increasing the complexity of the answer.

Let’s break down the healing stages.

Acute Inflammatory Phase

(Days 1-7)

Think of swelling, redness, bruising or bleeding, pain, and heat at the site of injury. This phase is vital to deliver the right nutrients to the injured area through increased blood flow and swelling, however, should not last too long as persistent inflammation can cause poor repair quality, muscle atrophy, and altered movement patterns.

Fibroblastic Repair/Subacute Phase

(Day 4 up to 6 weeks)

Think starting to feel better but tissues are still weak, healing, and prone to re-injury. Here your body is starting to generate progressive scaffolding for repair. Adequate blood flow at this stage is important to continue the healing process on a cellular level.

Remodeling Phase

(as early as 2-3 weeks extending up to months/years)

Think of that nagging stiffness from that old pickleball injury. The repair made in the previous phases will contract and tighten in an attempt to return to its original state allowing just the right amount of stretch or lengthening depending on the role of the tissue in the body.

Now, back to the main characters, let’s compare:


Icing an Injury

Ice causes blood vessels to vasoconstrict, decreasing circulation, metabolic activity, and inflammation while also temporarily numbing the area. This addresses the pain, swelling, inflammation, and muscle spasm/cramping.

Best used within the first 3 days after injury especially if noticeable swelling is present. Avoid using before activity as ice will stiffen tissues, increasing their risk for injury. Ice can continue to be used for pain after activity for up to 2 weeks. Avoid the use of ice over an area with decreased sensation, or open wounds, if you have cold sensitivity, vascular disease, or have injured a nerve.


Ice can be applied using an ice pack to large areas for 20 mins usually 3-4 times. Ice can also be applied to a small, focal area using ice massage directly to the skin for 3 minutes for rapid cooling 2-3 times a day.

Heating an Injury

Heat causes blood vessels to vasodilate, increasing circulation, metabolic activity, and inflammation, improving soft tissue compliance, and relieving pain and spasms.


Best used before the activity to warm up stiff or scarred soft tissue to reduce the risk of injury. If pain continues to occur after activity for more than the 2 weeks mentioned above for icing, a combination of alternating heat and ice can be used to improve circulation and restart the healing process.


Use moist heat, especially on tissues known to be chronically stiff, prior to a stretching session or prior to participation in an activity where a physical warm-up would be limited (even more important in cold weather).


Does Heat Make Inflammation Worse?

Avoid the use of heat on a fresh injury as this can increase swelling and delay healing. Avoid heat over an area that is numb, an open wound, or if experiencing a fever or heat stress.


How Often do you Alternate Between Ice and Heat?

Persistent pains are considered chronic when they have been present for 6 months and may benefit from alternating ice and heat. This is typically prescribed as 15-20 minutes of heat, then letting the skin return to its normal resting temperature, followed by applying ice for another 15-20 minutes.

This can be performed 2-3 times throughout the day. This acts as a circulation pump to improve healing while the benefits of one treatment counteract the negative side effects of the other.

That covered the details, now the big picture…

  • Both ice and heat have benefits when used at appropriate times.

  • If it feels like you have been icing something forever and it’s not getting better, time to add in heat.

  • Make sure to address stiff tissues by restoring flexibility, joint motion, strength, and/or sport-specific skills which can be determined by a physical therapist.

  • Every person is different with some preferences toward ice or heat that have little to do with what is most beneficial for healing

  • As the saying goes, there is too much of a good thing with icing, especially after the first couple of weeks. The body needs to respond to the injury with inflammation for repair however pain and swelling can be mitigated for comfort and to allow optimal loading with protection of the injured site as needed through bracing or immobilization.

Does your child or teen have an injury that might need to be evaluated? Feel free to make an appointment with one of our Physical Therapists by calling us at (512) 478-8116 or request online!

 

Resources

Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med. 2015;127(1):57-65. doi:10.1080/00325481.2015.992719


Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?. World J Clin Cases. 2021;9(17):4116-4122. doi:10.12998/wjcc.v9.i17.4116


American Academy of Pediatrics (2015, November 21). Treating Sports Injuries with Ice and Heat. Healthy Children. Retrieved January 27, 2023, from https://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Treating-Sports-Injuries-with-Ice-and-Heat.aspx


Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54(2):72-73. doi:10.1136/bjsports-2019-101253

https://bjsm.bmj.com/content/bjsports/54/2/72.full.pdf

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