Updated: Nov 19, 2020
One of the most common questions that patients ask me is “Should I use ice or heat for this injury?” It may seem like a simple question, but our answers vary depending upon whether it's an acute or chronic condition, whether or not the patient has any secondary conditions, and several other factors. So let's get into why we make the recommendations we do.
Inflammation Can be a Very Good Thing!
Yes, sometimes inflammation is a GOOD thing! Research has shown that when muscle fibers are damaged (as in an acute or strain/sprain injury), inflammatory cells (macrophages) stream into the injured area to remove damaged tissue, and to stimulate the muscle fibers to regenerate.
These macrophages are present in your blood stream at all times. When you injure your body, your body releases histamines that increase blood flow into the injured area; this increased blood flow releases additional macrophages into this area to digest the damaged tissue (a process known as phagocytosis). Fluid then rushes into the area from which the damaged tissue was removed (this is the swelling that occurs in the inflammatory process). Then about 24 hours later non- phagocytosing macrophages come in and fill the area with Insulin like Growth Factor (IGF-1). The IGF-1 spurs the damaged area to begin the formation of new tissue (precursor cells). (1) These precursor cells then join together to form the new tissue, replacing the old damaged tissue. (Image is 3D illustration macrophage cell)
Without this important inflammatory process, healing and regeneration of the injured area does not occur. As you can see, this process requires the body to be able to move fluids in and out of the injured or damaged tissue. Anything that blocks this movement can reduce the rate of healing.
ACUTE & CHRONIC INFLAMMATION
It is important to differentiate between normal (Acute Inflammation) and run- away or abnormal inflammation (Chronic Inflammation).
Acute Inflammation refers to the type of inflammation that happens right after you injure yourself. It could be caused by trauma, strain, sprain, infection, or even by hard physical exercise. This type of inflammation is usually short in duration, and acts to speed up the healing process. Inflammation immediately after an injury is a GOOD thing; it is an indication that your body has moved into an accelerated healing mode.
In comparison, Chronic Inflammation is an over-reaction, it is the body attacking its own tissues. This includes a number of autoimmune conditions such as rheumatoid arthritis, hay fever, asthma, celiac disease, and many others. The problem is that chronic inflammation is an out-of-control process. Unlike Acute Inflammation (which is short in duration), Chronic Inflammation just keeps going on and on. Even heart disease has been linked to chronic inflammation. The Chronic inflammatory process increases the production and availability of a substance called myostatin which hinders the regeneration of new tissue. (2)
Testing for Chronic Inflammation: If you suspect that you are dealing with chronic inflammation then you should be tested. There is a standard blood test that measures a protein produced by the liver called C-reactive protein (CRP). Another blood test called erythrocyte sedimentation rate is used to check for inflammatory conditions. (3) These tests can provide good information to your doctor.
Obviously, the type of inflammation that you are dealing with could alter our ice or heat recommendations.
Ice is a valuable tool as it definitely decreases pain, and it also reduces swelling after an acute injury (or surgery). On the other hand, icing can also slow the regeneration of new muscle tissue. Icing suppresses inflammation, and as soon as you suppress the inflammatory process, you slow down the healing process. (4,5,8)
Swelling causes pain (nociceptive pain) by increasing the pressure on nerve endings. Pain reduction is no small matter. If you are in acute pain you can’t sleep, you won’t do your exercises, and your level of functioning will be greatly diminished. Yet, ice could slow down the healing process, which is why I see using ice to reduce inflammation as a bit of a balancing act. (6,7,9)
If you are in severe pain, icing is a great way to reduce that pain and swelling (after an acute injury or surgery). I would recommend icing for no longer than the first 72 hours after an acute injury. If you feel that you don’t need the ice (no swelling not acute pain), then I recommend not using it.
This does not mean we are recommending that you heat the injured area right after an injury. Heat therapy does increase blood flow to an area, but this heat can cause an increase in inflammation, which in turn will cause an increase in pain. We need a certain amount of inflammation to heal, but too much inflammation will definitely be counter-productive.
When Not to Ice!
Do not use Cold Therapy if the person:
Is unconscious, unable to communicate, or has no sensation in the injured area. Crazy as it sounds yes people have used ice on unconscious people.
Tends to develop a rash or blisters when exposed to cold.
Has a circulatory problem.
How to Ice!
So, now that you know when to ice, and when to avoid icing, here are some tips on the best way to use cold therapy (icing) to reduce pain, and keep the healing pattern still going!
While icing, elevate the injured area – preferably to above the heart – to reduce swelling and move blood away from the affected area (use gravity as an aid).
Ice every two to three hours, but always make sure that the area being iced has warmed up, and is no longer numb.
Prevent frostbite by not allowing the ice pack to sit directly on your skin. Use a thin towel in-between.
Icing with an Ice-Pack: First place a thin cloth over the injured area so that the ice- pack is not in direct contact with the skin.
Apply the ice-pack to the injured area.
Keep the ice-pack against the affected area until it feels numb.
You should first feel cold, then a burning sensation, followed by aching, then numbness. If you don’t feel numb, then you haven’t iced for long enough. Allow the icing process to take a maximum of 15 to 20 minutes. Never longer! DO NOT allow the skin to freeze...you are not trying to get frost-bite.
Leave a minimum of one hour between each icing session to give your tissues sufficient time to warm-up.
Using Ice Massage: We have found that ice massage can be even more effective than regular icing (in many cases).
Fill small paper cups with water and keep them in your freezer till frozen.
Peel the top of the cup back to expose the ice.
Use the bottom of the cup, the paper covered part, as a handle.
Massage the ice over the injured area in small circular motions, allowing the ice to melt away. Use a towel to catch the melting water. To prevent tissue damage, only perform ice massage for a maximum of 7 to 9 minutes at a time.
Again you will first feel cold, then a burning sensation, followed by aching, then numbness.
WE ALL LOVE HEAT
Without a doubt, heat feels much better and more comforting than ice. But problems can arise when heat therapy is used too soon after an acute injury or trauma. In fact, the early use of heat therapy by our patients is often one reason for the increased time that is required to resolve their acute injuries.
Heat Therapy should only be used after the acute inflammatory response has subsided. Never use heat therapy within the first 72 hours of an acute injury (especially with tissue damage, and swelling). Applying heat to soft tissues (muscles, ligaments, and tendons) while the area is still inflamed and swollen will only aggravate the injured tissues. During the first 72 hours, cold therapy provides much more effective and appropriate relief (in most cases).
If the injury is NOT acute then heat can be used almost immediately.
Benefits of Heat
Once the inflammation has subsided, you can apply heat to the affected area to help restore flexibility, relieve muscle cramping, reduce arthritic symptoms, and most of all, to increase the rate of healing by increasing blood-flow to the area.
The power of heat therapy comes from its depth of penetration and its ability to increase circulatory and neurological function. Increasing circulation results in increased delivery of oxygen and nutrients to the affected area while at the same time displacing waste by-products. Heat affects the nervous system by stimulating the sensory receptors in the skin. This has the effect of decreasing the transmission of pain signals to the brain, thereby reducing muscle spasms and episodes of acute pain.
Application of Heat: For a minor, superficial injury you will want to use heat therapy for 10 to 20 minutes. For chronic injuries, you may need to apply heat therapy for 20 to 35 minutes.
MOIST HEAT OR DRY HEAT?
The effectiveness of heat therapy varies from individual to individual. Each person needs to experiment to determine which heat therapy is best suited to their condition. There are two primary types of heat therapy we recommend, moist heat and dry heat.
Moist heat therapy includes hot baths, heated whirlpools, hot packs, or hot moist towels. Many people feel they get better depth of penetration with moist heat.
The Moist Towel Treatment
Dampen an old, clean towel (towels may discolor with this process).
Heat the moist towel in a microwave for one minute. Then check the temperature of the towel and heat for another 30 seconds to a minute if necessary.
Carefully remove the moist towel (don't give yourself a steam burn) and wrap the hot towel with a dry towel (to prevent burns and to retain the heat), and then apply the towel to the affected area until the muscles relax.
Only apply the heat for 10 to 20 minutes.
Epsom Salt Bath
Soaking in an Epsom salt bath is one of the best things you can do for the body. Epsom salts (magnesium sulfate) have a high concentration of magnesium, which helps to reduce muscle cramps, ease joint pain, and increase circulatory function.
But, remember that Epsom salt baths are another form of Heat Therapy, and therefore all the rules that apply to Heat Therapy also apply to Epsom Salt Baths.
Mix 2 cups of Epsom salts in the hot water. Soak in the bath and let the Epsom Salts do their magic.
Using Epsom Salts Locally
Fill a bucket of hot water, add one cup of Epsom salts, and soak your sore feet.
Dip a wash-cloth in Epsom-salt-drenched water, and wrap it around your sore foot, hand, shoulder whatever the affected area.
Soak a cloth in Epsom salt water, wring it out, and place it over a sore or painful area. Now wrap a tensor bandage or towel around everything to keep the heat in, and to hold the Epsom-salt-soaked towel in place!
Heat, when used at the right time can be very effective!
Dry heat therapy includes dry saunas, electric heating pads, and heat lamps. These can be very effective forms of heat therapy but they can also dehydrate the individual, so remember to drink lots of fluids when you use dry heat therapy.
Only apply the heat for 10 to 20 minutes.
Be careful of dehydration in saunas. Staying too long in a sauna can increase the risks of dehydration, side-effects such as a drop in blood pressure and loss of consciousness can occur.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!
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What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?, Van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. J Athl Train. 2012;47:435–443. doi: 10.4085/1062-6050-47.4.14.
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DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.