Heat or Ice?

By: Dale J. Buchberger, PT, DC, CSCS, DACBSP

When to use heat or ice on an injury, ache or pain is as common a question in a healthcare office as you will find. While there are generalities that can be followed it can also be an extremely specific self-treatment. It is very difficult to go wrong with ice. On the contrary if you put heat on an inflamed body part there is potential to worsen a condition. So to start with a general rule of thumb in our office is to recommend ice for 20 minutes to the painful body part with at least 40 minutes off before the next ice application. A thin protective layer should be placed between the ice and the skin such as a paper towel or t-shirt. Always inspect the skin after the application. It should be pink and cool, returning to normal before the next ice application.

The majority of injuries or musculoskeletal ailments will respond to ice. Unfortunately most patients fail to ice frequently enough to be effective. For instance if you have an ankle sprain you may need to apply ice to the ankle four to five times a day for two or three days for the ice to be effective. If any body part swells, becomes discolored or causes a loss of function in this case the inability to bear weight you should see a healthcare provider and most likely have an x-ray to rule out a fracture or additional pathology. Applying ice in this case should be for comfort and swelling control while arranging to see a provider.

The best form of cold therapy is ice itself. Your relatives may recommend frozen peas, corn or other frozen produce. Frozen produce will not supply the same degree of cold as ice itself. Counter irritants such as rubs that produce a cold sensation do not reduce swelling or inflammation. They are designed to relieve pain by tricking your brain to focus on the cooling or heating sensation produced by the ingredients in the lotion or cream. This is where the term “counter-irritant” comes from. Remember the acronym PRICE therapy when applying ice: Protect, Rest, Ice, Compression and Elevation.

It is also common for patients to bring up the old adage of ice for the first 24-72 hours and then apply heat. This is a poor rule to follow because it negates the presence of pain and loss of function. If the condition is actively swelling or limiting function (weight bearing, sleep, work, etc.) it is appropriate to apply ice more than 72 hours after the onset of pain or injury.

Living in central New York I have come to think it is a natural reaction to prefer heat instead of ice. In general heat usually feels nice and comforting. Unfortunately, it is not the right thing to do more times than not when it comes to an injury or painful musculoskeletal condition. If you do apply heat it should be moist in nature. A hot shower or hot bath are good forms of home heat application. There are special heating pads available that are made with a moist sponge or there are also several microwavable devices available in your local pharmaceutical retailer. One thing that I would absolutely recommend you not use is a dry heating pad. As I tell my patients “if you own a dry heating pad give it to someone you don’t like”. Dry heat applications usually make the problem worse by creating local dehydration, edema and inflammation.

So when is heat the treatment of choice? Moist heat is very helpful when you have a chronic degenerative condition such as a noninflammatory arthropathy such as degenerative joint disease of the knee or back. Unfortunately these conditions usually are associated with some level of pain. In this case using “contrast therapy” may alleviate the stiffness and the pain. Applying moist heat for 15-20 minutes followed by and ice application for 15-20 minutes and then gentle movement such as walking is a form of contrast therapy that works well for patients with arthritis of a non-inflammatory type.

Never go to bed with an ice pack or heating device applied to a body part. There is a risk of falling asleep with the ice or heat in place and this can result in worsening of the condition or causing further injury or tissue damage. There are areas of the body where certain nerves are very superficial and at risk of injury from prolonged ice or heat application. The more common areas are the outside of the knee, inside of the elbow, the groin and lower abdomen. Lastly, if you are unsure or have a question about applying heat or ice to an injured area call a healthcare provider that knows your medical history and that you trust.