Should I Ice or Should I Heat?

After posting about inflammation and swelling last week, I had a few questions about icing or heating muscle pains and injuries and how that interacts with the inflammatory process.

Unfortunately there does not seem to be a good answer.  Medical professionals seem quite divided on when to ice an injury and when to heat an injury.  PubMed, a repository of peer reviewed science journal articles, shows a significant number of published papers with the conclusion that icing helps, icing is detrimental, or that icing has no effect, along with heating an injury helps, heating an injury does not help, and that heating an injury has no effect.  So, at this point in time, it seems as though the jury is still deliberating on this case.  Personally, I am in the pro-icing camp for specific injuries and in the pro-heating camp for general aches and pains.  Basically my recommendation is to try something and see how your body reacts–icing, heating, or both.

Pros and Cons of Icing

  • Numbs the area
  • Reduces perception of pain
  • Reduces the swelling
  • Typically recommended in Western medicine
  • Slows inflammatory response

A recent 2017 study may have debunked the pro-ice camp.  The study [1] showed that icing after an injury was not beneficial to the tissues, for up to a month after the initial injury.  The study was done on multiple rats clamping their back leg in forceps creating a bruise.  Half the rats were massaged with ice and other half were massaged with the bottom of an empty beaker as the placebo.  The ice was only applied once, 5 min after injury, to the rat’s leg.  The ice massage or placebo beaker massage was applied for twenty minutes. Biopsies of the muscles were looked at varying times post injury.  While the biopsies do seem to suggest that healing was slowed because of the ice application, I personally won’t change my pro-icing stance because of this study.  For one, the ice was only applied one time, very close to the time of the injury.  Secondly, an ice application for that long of time on the small area which is the back leg of a rat was likely too long and past the point of numbness (as I will explain later in this post).  

Icing / Photo by Brett Warta

Pros and Cons of Heating

  • Promotes blood flow / increase circulation
  • Relaxes muscle tissue
  • Typically recommended in Eastern and ancient medicine

However, heating shouldn’t be used if it is a recent injury as the extra heat may cause an increased inflammatory response.  Generally, if the skin is hot to the touch, do not add more heat.  The hot skin indicates there is an active inflammatory reaction (remember that heat is one of the 5 signs of inflammation) and adding more heat may significantly increase the magnitude of that reaction.  

Heating tissues can have therapeutic benefit / Photo available via CC0

So do I need to ice or heat?

The answer to that question is “yes.”  There are a few rules of thumb to figure out which to do.

  • Heat the affected body part before activity (more often than daily routine usage of the body part in question) and ice after.  Heating before activity brings blood flow and awareness to the area allowing stiff muscles and joints to increase their general mobility and range of motion.  If you ice beforehand, the muscles will not contract well and will be somewhat numb which will decrease the proprioceptive response.
  • Ice chronic inflammation.  This helps reduce swelling in the area, which removes the cells associated with chronic inflammation, which will destroy both healthy and damaged tissue.  If the body swells the area again, the hope is that the swelling response has the cells associated with the acute response which are beneficial to healing.  Even if the cells that “re-swell” the joint after icing are the chronic inflammatory cells which destroy healthy tissue, there will be less of them because the “re-swell” response is usually smaller.
  • Ice the affected body part at least daily and you can ice multiple times in a day, as long as you allow the tissue to warm back up to body temperature between applications.  
  • Don’t apply heat to an area that is already hot from your body’s response.  Extra heat may accelerate and cause a more severe inflammatory reaction.  
  • Generally, heat both back pain and neck pain.   Pain in these areas is usually caused by muscles that are too tight and the heat will relax the muscles and restore range of motion with less pain.  Or get a therapeutic massage, which I have found to be one of the best solutions for my personal back pain.

Basically, the best recommendation I have is to do whatever feels right for your body.  If you aren’t sure, try each one and see what makes it feel better.  

Should I heat or ice? In the Jigokudani Monkey Park / Photo by Yosemite (Own work) and available via CC-BY-SA-3.0 via Wikimedia Commons

How to Ice

When you ice an area, it is prudent that you don’t ice for too long as you don’t want to damage the skin or underlying tissues.  Ideally, you want to ice until the area is numb.  Depending on what you are icing, this time frame ranges from about 5-20 minutes.  Thin skin and thinner body parts in the extremities cool faster than thicker skin and muscles towards the core.  If the ice is too cold on your skin, lay a towel between you and the ice.  The cold will still penetrate into your body, but at a slower rate which will make it tolerable for your skin.  

  • The frozen sponge in a baggie reminds me of summer camp.  This is a relatively inexpensive way to cool an injury.  However, this seems to be somewhat ineffective as the sponge heats up rapidly.  This is also probably what makes it such a good option for kiddos, as there is little risk of overcooling their skin with this technique.  
  • The frozen bag of peas (or other vegetables) is a personal favorite of mine.  The amount of peas contained in the bag gives the individual peas wiggle room and the ability to conform around my ankle, which is what I most commonly injure.  However, the peas heat up quicker than other options like regular ice or gel ice packs.  Also, I don’t recommend eating the bag of peas after multiple cycles of freezing and thawing, so make sure you know which bags of frozen vegetables are for eating and which ones are for icing.
  • Ice bags are inexpensive, fast to make, and effective.  The training room at college had a giant ice machine and a roll of bags next to it (the bags were the flimsy produce bags you would put your fruit in at a grocery store).  Daily, numerous athletes would grab a bag or two for various pain complaints.  As a varsity runner constantly spraining my ankles, I was a training room regular.  In order to make the best ice bag ever, follow these simple steps:

1)  Put ice in bag

2)  Suck air out of bag with mouth

3)  As you finishing sucking the air out seal the bag by twisting it.  

4)  Tie a knot a bit away from the blob of ice to allow some wiggle room and moldability of the ice cubes.

5)  Put fabric between your skin and the ice, sometimes tying it in place.  An old long sleeved t-shirt works great.

Now that my ice comes from my freezer as opposed to the fancy ice machine in the training room, the ice pieces are big and sometimes I use a baggie instead of a flimsy produce bag.  In that case, the above steps still apply, just instead of twisting the bag, you seal it with the zipper as you suck the air out.  Con: sometimes ice bags leak.

  • Gel ice packs are a leak proof option with similar effects of ice bags.  They are effective and usually come with a sleeve already on them.  They are soft and moldable and don’t have sharp edges like ice cubes have.  I really like this one.
  • Ice massage is a bit messier than ice bags but also more effective.  This is a common technique to use on shin splints, but can be used elsewhere, typically on wide flat surfaces.  Ice massage on joints and bony prominences can be a bit bumpy, and you will likely miss parts of the joint.  In order to do an ice massage, first you have to freeze small dixie cups that are half full of water.  After they are frozen, peel the paper back exposing the surface of the ice.  Leave some paper on the ice though, as that is where you can grip the ice.  Rub gently across the painful area until numb.  Have a towel handy though, as the ice melts it turns into water and runs everywhere–down your skin into your socks, onto the floor, up your leg and into your underwear, etc.  You will get the hang of it.  Dixie cup ice massage has its drawbacks that are solved by this fancy specialized ice cup massager called the CryoCup (affiliate).  When you use a dixie cup, the ice gradually melts away from the edges of the cup, making the chunk of ice harder to grasp and control.  The CryoCup grips the ice from the inside, which allows for more control of the ice block for longer.  Ice massage allows you to target the specific areas that need massaging, and allows for continuous application of ice.  When you use an ice bag, a layer of warmer water insulates you from the rest of the ice in the bag.  While the water is still cold, it isn’t as cold as the ice and reduces the effectiveness.  During ice massaging, there is a continual application of ice, as the melted water can’t create the insulated layer because it runs off and creates a soggy mess elsewhere.
  • A specialized form of ice massage comes from frozen water bottles and are excellent for foot pain, specifically plantar fasciitis.  Use the cheap plastic disposable water bottles.  Freeze one that is nearly full (but not totally full to allow for expansion of the water as it forms ice).  Once frozen, the water bottle can be rolled under your foot, back and forth repeatedly.  Usually the ice melts before my foot is totally numb, so I finish off with a regular ice pack or an ice bag.

Specialized ice massage with a water bottle / Photo by

  • There are fancy continuous cryotherapy units which do both compression and cryotherapy at the same time. You fill the machine with ice cold water and more ice, put on the attachment–they have specific ones for different body parts (knee, hip, shoulder, etc)–hook up the tubes and turn it on.  The machine then circulates water through the attachment.  By wearing the attachment, you are applying compression.  The circulating cool water applies the cryotherapy.  While extremely expensive, my personal experience with Game Ready (affiliate) has been top notch.  I highly recommend them (and other machines like them that are a bit less expensive).  I experienced significant, drastic, and immediate reductions in pain and swelling.  
  • Ice baths are the king of icing.  When afflicted with shin splints, I drained our house of ice daily.  Basically, you fill your bathtub with cold water and then add lots of ice.  My goal was to stay in 8 minutes, submerged over my hips.  We also used this technique in college when we had multi-day track meets.  After the first day, which was usually prelims, we would do an ice bath in preparation for finals the next day.  I found studies contradicting each other saying that icing and cold water immersion aided in recovery and not aiding in recovery.  The training room at college also had whirlpool ice baths.  The whirlpools prevented a warmer insulative layer of water forming next to your skin while sitting in still water.  To do this to myself while in the bathtub, I would swish the water around with my hands.  Ice baths are a great recovery tool after a long day on your legs.  

Ice bath, anyone? / Photo by Brett Warta

How to Heat

When you heat an area, it is prudent that you don’t heat for too long or with too much heat.  Also, in massage school, the teachers said never to rest your body weight on the heat source and to always have the heat source on top of you to minimize risk of burns.  Personally, I don’t follow that rule as long as I am aware of the heat (as opposed to putting it on and then falling asleep).  Also, make sure to have some sort of fabric between you and the source of heat to minimize damage to the skin.

  • Clay packs like this one (affiliate) do a dual purpose–they can be either hot or cold.  They mold easily but can become damaged if they are “cooked” too long.  
  • Hot water bottles are easy to store and make on demand.  Honestly though, the most common use of my hot water bottle was warming my feet at night. It was a little floppy and hard to mold onto a specific area that needed attention.   
  • Standard heating pads are a great choice.   Most have an automatic shut off function for safety.  I get impatient while mine heats up (it probably takes all of five minutes) and the heat seems to stay more superficial.  Other options (hydrocollators, showers, hot tubs) penetrate deeper into my muscles and joints.  
  • Some heating pad fans swear by infrared heating pads (affiliate).  Infrared heating pads theoretically penetrate deeper into the muscle tissue.  Another option could be a moist heating pad (affiliate).  I am not sure how moist heating pads work, especially if they are electric.  But if it does, in fact, produce moist heat, then that would solve the issue I have with my current heating pad.  I haven’t tried it out, but will update when I do.  
  • Paraffin dips are used in physical therapy settings to help alleviate arthritis pain and stiffness.  Basically, you dip your hand it hot wax and then leave it on for some time before peeling off the wax pieces.  Estheticians also use this to help promote healthier looking and softer skin.  And, dipping your hands in wax is also a fun way to make wax molds of your hands.  This method can be somewhat messy.
  • I love hydrocollators (affiliate).  The heat packs (affiliate) are nice and heavy which allows them to provide a degree of compression when applied.  Additionally, because it is moist heat, the heat penetrates further into the muscles.  The heat packs are also comforting and feel good on an affected injury.  However, these are messy.  The hydrocollator is basically a pot of hot water that the heat packs are soaked in.  When you want to use a heat pack, you use tongs and fish one out, then put it on a very thick towel (it is going to get pretty wet) and then apply to your affected area.  
  • A hot shower can be quite relaxing and beneficial.  Detachable shower heads allow you to target specific areas on your body that need a focused stream of hot (or cold) water.
  • Hot tubs are a great for many reasons.  They provide a general relaxation to all muscles of your body in an environment in which you don’t have to support much of your bodyweight.  Jets can provide targeted massage on an area of pain–I love love love hot tubs that have jets for your feet and ankles.  We recently purchased this hot tub and love it (yes, you can purchase hot tubs on Amazon!)!  There aren’t targeted jets, but it was inexpensive, has bubbles, and seems to be easy to set up and take down.  We have had it for 6 months now and it has been great!  

Full body heating in a hot tub / Photo by

My Conclusions

If you have pain in your body, try something.  Going to a doctor is always a good choice.  Try icing or heating and see which the pain responds to better.  You could also try getting a massage or foam rolling.  

References Cited

[1] Singh, Daniel P., Zohreh Barani Lonbani, Maria A. Woodruff, Tony J. Parker, Roland Steck, and Jonathan M. Peake. “Effects of Topical Icing on Inflammation, Angiogenesis, Revascularization, and Myofiber Regeneration in Skeletal Muscle Following Contusion Injury.” Frontiers in Physiology 8 (2017): 93. PubMed. US National Library of Medicine. Web. 14 Apr. 2017.


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