Ice or Heat

It can be difficult decide when to apply heat and when to apply ice to an injury or painful area. Certain injuries are usually more responsive to one than the other. Although research is still ongoing over the effectiveness of each, there have been some basic guidelines for their application which should be useful to know with the next bout of lower back pain or ankle sprain.

Ice application or cryotherapy decreases the temperature of the skin and muscles which decreases the blood flow and metabolism which in turn reduces the oedema (swelling), inflammation, pain, muscle spasm and elasticity of the tissues. This is ideal for injuries where the tissue is damaged, inflamed, red, hot and swollen. In many acute injuries, ice is part of the RICE protocol (Rest. Ice. Compression. Elevation) which is recommended for the first 48 hours after the initial injury. Examples of injuries that may benefit from ice are:

  • sprained ankle
  • a newly strained muscle
  • severe bruises
  • acute tennis elbow
  • supraspinatus tendonitis
  • shin splints

The tricky part comes when an injury has been present for some time. Should you apply ice to the tennis elbow that you’ve had for a few months or years? The pain from these chronic injuries are usually due to tissue degeneration rather than inflammation and will most likely not benefit from ice as much as they will from heat during this phase. It gets even trickier when it’s an acute on chronic injury which means that you’ve aggravated the old injury and it has become swollen and inflamed once again. The best in these situations is trial by error and see which one works the best for you.

There are different methods to ice an area. Ice packs are great when you need slow cooling to reach the deeper tissues. It’s important not to apply this directly to the skin as you may damage the skin. The recommended application for this method is 10 minutes of icing with 20 minutes rest and to repeat this as much as possible until the pain and swelling settles. Another way is to apply ice directly to the skin to rapidly cool the superficial layers for injuries such as shin splints. The area should be iced until numb which is usually around 1-3 minutes and then allowed to slightly warm up again before repeating the process. For this it’s best to use an ice cup or spray.

Heat application or thermotherapy is useful for longstanding injuries, joint aches and pains, muscle tension and lower back or neck pain. The effect of heat is the opposite to that of ice causing an increase in circulation, metabolism and tissue elasticity. The increase in blood flow brings oxygen and nutrients to the tissues and with the increased metabolism speeds up the healing process while the improved tissue elasticity can impact joint range of motion, making it easier to move. Injuries that may benefit from heat are:

  • lower back and neck pain
  • arthritis
  • most types of muscle cramps,tightness and spasms (not cramps from heat exhaustion such as after running a marathon)
  • fibromyalgia
  • muscle soreness from overexertion such as that after a week of hiking or skiing
  • posture related pain and stiffness

Heat is not ideal for acute flare-ups from arthritis where the joint once again becomes painful and swollen. Precaution should be taking with conditions such as rheumatoid arthritis, multiple sclerosis, diabetes mellitus poor circulation and spinal cord injuries. Heat can be applied with hot water bottle, microwaveable bean bags, hot bath or showers, adhesive heat pads, electric heat pads, hot towels or wraps etc. Care needs to be taking not to burn the skin. Heat is the most effective when combine with stretches and exercises.

To summarise, apply heat for muscle and joint aches and pains and ice for acute injuries where the tissue is swollen, red, hot and or inflamed. Heat therapy for acute back pain has been researched more extensively and therefore is most often recommended but if ice seems to help too then rather use the one that feels more effective. When in doubt, ask for a professional opinion from a physiotherapist.


  1. Malanga G, Yan N, Stark J, Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med, 2015
  2. Ingraham P, (Aug 19, 2016) Heat for Pain When and how to apply heat for therapy … and when not to! Retrieved from