The Question: Ice or Heat?
At my clinic a common question arises time and time again. Should I ice it or put heat on it? Great question! Depends on what type of condition or injury you have and when you sustained it.
Many people have heard the term R.I.C.E. or Rest, Ice, Compression, Elevation. R.I.C.E. is used primarily after an acute injury or within 48 hours after an injury has happened. For example, if a runner has a significant ankle sprain, he/she will want to ice the ankle to decrease the “carpet bombing” effect of multiple red and white blood cells scrambling to the site of injury for repair. This is the time to put ice on the ankle to decrease the inflammation in the area. The same goes for most acute injuries.
Ice may also be used when an injury is constant in nature. Sometimes we experience intractable pain. This can be from something in the body not sitting where it’s supposed to be sitting (mechanical pain) or it can be from an inflammatory response from, perhaps, an overuse injury that causes tendonitis. Tendonitis is inflammation of a tendon that has been and continues to be irritated. For the most part, if you have been diagnosed with tendonitis or anything musculoskeletal in nature that ends in “itis,” put ice on it. If you have not been diagnosed with an “itis” the pain may be mechanical. In this case use ice or heat or both. Find out what alleviates your discomfort.
Ice packs can be purchased in gel wraps or perhaps you would prefer to make your own. A bag of pees out of the freezer or ice in a bag placed in a pillow case will suffice. Other alternatives include making your own ice pack by mixing 1 part isopropyl alcohol and 2 parts water in a zip-lock bag. Put it in the freezer, and like magic, you have your own gel pack. You may also apply ice directly to the skin but should continuously move it around the site of inflammation so you don’t damage the tissue. This can be done by taking a Dixie cup and filling it 3/4 full of water, freeze it solid, tear off the top edge so some of the ice is exposed, grab the Dixie cup with the ice still in it and with a circular motion, rub it on the site of inflammation for no longer than 4 minutes. After you are done, it might look like a “bulls-eye.” Another technique used primarily for athletes after ankle or knee injuries is immersion directly in an ice bath for a short period of time. After an ankle injury putting an athlete’s foot in a bucket of ice water for a few minutes can really help. If the coach is feeling kind enough, he/she may wrap your ankle with an ace bandage or have you keep your sock on prior to immersion.
How long do I keep the ice pack on? Unlike heat, you should only have an ice pack on for no greater than 15-20 minutes to decrease inflammation. Take it off for an hour or so and repeat. Heat can be placed on area until you have a relief of discomfort. Just don’t burn yourself. Caution should be taken when placing heat in areas where numbness is present to prevent burns.
Heat is often used to help decrease tightness felt in the joints and muscles. Heat helps to increase the extensibility of tissues which allows them to stretch further prior to an exercise. Sometimes a warm shower really helps prior to doing an exercise when you have multiple joint pain. Heat is also used to decrease muscle guarding and allows your muscles to relax which can help to decrease your pain.
Heat should never be used directly after an acute injury, trauma, or orchestrated trauma such as surgery secondary to increasing inflammation. If you have had a total joint surgery, do not place heat directly on the joint that has been operated on. You may place it on the muscles adjacent to the joint especially when trying to gain range of motion during exercises and/or in PT.
Sometimes people use both heat and ice in contrast. This helps to desensitize the injured or affected area by putting the affected area in cold water then into warm water and continue to alternate. This can be effective with chronic pain, nerve pain such as a condition called Complex Regional Pain Syndrome.
If a patient does have a chronic condition; pain that has persisted for greater than 6 months with insidious onset and is mechanical in nature; I advise them to use whatever feels better.
To help prevent patients from getting worse after exercise, I typically recommend ice following some guidelines. This is not the case for all exercises but just another rule of thumb to help prevent further injury. For example, If I provide an exercise to a patient and prior to the exercise their pain is 2/10 on a scale of o-10 with 0 being no pain and 10 being the worst pain imaginable; I have them follow this guideline: Generally speaking, if your pain is produced during the exercise but no worse after doing them (still 2/10) then no worries. If pain increases after exercises and does not decrease back to a 2/10 after 10 minutes following the exercise then ice for 10-15 min 1-2 times within a 2 hour period. If after 2 hours you still have pain greater than 2/10, stop doing the exercise and report back to me. However, your therapist may have a different guideline, so follow their plan of care.
Hope this helps,
Brett Jenks, PT, DPT, Cert. MDT