The Great Debate: Heat vs Ice

One of the most common questions I will get asked by patients is: Should I use ice or heat for my pain? There has been a lot of research and effort put in over the years to try and better answer this question. While there is no true consensus, there are some important takeaways that can help you make a decision that is best for you. While heat and cold therapy can help with your pain, it is first worth noting that they are best utilized in adjunct to other forms of recovery or therapy. Using ice or heat alone as a treatment to alleviate your pain is never the best option.

First and foremost, heating and cooling modalities should only be utilized as long as there are no contraindications present. If you are questioning if using heat or cold modalities is contraindicated for you, please consult a medical professional first.

Examples of contraindications for thermotherapy (heat): Impaired sensation, peripheral vascular disease, acute injury, impaired circulation, cancer in the area to be treated, active infections, poor thermal regulation

Examples of contraindications for cryotherapy (cold): Cold intolerance, cold hypersensitivity, Raynaud’s disease, open wound, impaired circulation

Heat therapy works as a vasodilator. This means that applying heat to a painful area will widen your blood vessels to allow for increased blood flow to the injured area. The increased blood flow allows for more nutrients and oxygen to be delivered to the area of discomfort. This is an inflammatory process. Inflammation is a word that often carries a negative connotation but it is not always a bad thing. Without an inflammatory response, our body would be unable to heal itself from injury. Cold therapy has the complete opposite mechanism. Applying ice for example will result in vasoconstriction of your blood vessels, meaning it will decrease blood flow. This is sometimes desirable as decreased blood flow will result in slowing down the breakdown of cells and decrease swelling.

For an acute injury, ice has been shown to be more beneficial than heat. A common acute injury we can all relate to is an ankle sprain. When the ligaments are injured in your ankle, the body will induce an inflammatory response which results in increased blood flow, thus swelling. In these instances, applying ice can help decrease the amount of blood flow and help limit the swelling. By limiting the swelling, we also help prevent the body from decreasing muscle activation. If we decrease muscle activation, we make the injured area even more unstable. The general rule of thumb is 48-72 hours after an acute injury, ice is the optimal decision. But then begs the question, what about after those 3 days are up? This is where there is more uncertainty. Once the body has done its job inducing the initial inflammatory response, the choice of heat or cold becomes less important. At this stage, heat and cold work similarly by becoming “pain gating” agents. The application of this temperature sensation then works to override the pain signals to the brain. Without going into too much detail, temperature sensation and pain sensation take the same pathway to the brain. If we can apply a temperature stimulus such as an ice pack or a hot pack to a painful area, it will compete with the pain pathways and hopefully inhibit the pain signals sent to the brain. It is certainly a confusing topic, and it is not really your job to understand the mechanism. For the sake of your pain, all you need to know is that heat and cold both play the same role in competing with the pain signals. At this point, it becomes a preference. If you feel you respond better to cold versus heat, use cold, it really is that simple. If putting a heat pack on your neck helps you feel like it relaxes the muscles in your neck, don’t overthink it, use heat. When using heat or cold, you should never exceed 20 minutes. There is some research indicating that alternating 20 minutes on, 20 minutes off, 20 minutes on, etc. is a preferred method. When using heat, I prefer a moist heat pack. Moist heat does a better job of penetrating the muscular tissue. When using cold, I prefer an ice massage. I do this by filling up a Dixie cup with water, freezing it, then ripping off the top and applying a simple massage technique to the painful area for 90-120 seconds.

Don’t worry about sounding professional. Sound like you. There are over 1.5 billion websites out there, but your story is what’s going to separate this one from the rest. If you read the words back and don’t hear your own voice in your head, that’s a good sign you still have more work to do.

Be clear, be confident and don’t overthink it. The beauty of your story is that it’s going to continue to evolve and your site can evolve with it. Your goal should be to make it feel right for right now. Later will take care of itself. It always does.

In summary, if it is an acute injury within 72 hours, apply cold therapy to the injured area to limit swelling and muscle inhibition. After that, it all becomes a preference. This concept remains the same even if it is an old injury, such as that low back pain you have been dealing with for the last 5 years. I personally have a bias to use heat if I feel like relaxing the area or if I am preparing to stretch and work the painful area. This all brings it full circle because as I stated at the top, heat alone to help my lower back will likely provide no long-term benefits and maybe very little in the short-term. However, if I am using heat to loosen my back up before stretching, or icing my back after exercise to improve recovery so I can work out again the next day, I am going to be able to maximize the use of cold and heat therapy.

Thanks for reading,

Dr. Ryan