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ICE vs HEAT for acute injuries – What does the evidence tell us?

When it comes to managing acute injuries, the age-old question persists: Should you reach
for ice or a heat pack? Is R.I.C.E. still relevant, or should we be looking more towards the
L.O.V.E. and P.E.A.C.E approach? Recent research sheds light on this debate, providing
valuable insights into the effectiveness of ice versus heat therapy.

Ice Therapy:
Ice therapy, also known as cryotherapy, has long been a go-to treatment for reducing
inflammation and pain in acute injuries. However, recent studies have raised questions
about its efficacy in certain scenarios. A 2021 systematic review published in the British
Journal of Sports Medicine found limited evidence supporting the use of ice therapy for
improving outcomes in acute soft tissue injuries.
While ice may provide temporary relief by numbing the area and constricting blood vessels,
its ability to accelerate healing or reduce pain beyond the initial stages of injury appears to
be less significant than previously thought.

What are the potential issues with using ice therapy?
Using ice therapy on an acute musculoskeletal injury (ie. ankle sprain) is a common practice
to reduce inflammation and pain. However, it’s important to recognise that while ice
therapy can provide benefits, there are also potential negative physiological impacts to

  1. Vasoconstriction: Ice therapy causes blood vessels to constrict, reducing blood flow to the
    injured area. While this can help decrease inflammation initially, prolonged vasoconstriction
    may impact the delivery of oxygen and nutrients necessary for tissue repair and healing.
  2. Delayed Healing: Some research suggests that excessive or prolonged application of ice
    may slow down the body’s natural healing process. By restricting blood flow, ice therapy
    may delay the removal of cellular debris and reduce the influx of immune cells and growth
    factors essential for tissue regeneration.
  3. Nerve Damage: Excessive cold exposure can potentially damage nerves in the affected
    area, leading to numbness, tingling, or heightened sensitivity. It’s essential to use ice
    therapy cautiously and avoid prolonged direct contact with the skin to minimise the risk of
    nerve injury.
  4. Muscle Stiffness: While ice therapy can help reduce muscle spasms and pain, it may also
    contribute to temporary stiffness or tightness in the muscles. This can impair mobility and
    range of motion, especially if ice therapy is applied excessively or for an extended period.
  5. Skin Irritation: Direct contact with ice packs or ice baths may cause skin irritation,
    redness, or frostbite, particularly if applied for too long or if the skin is sensitive. It’s essential to use a barrier such as a towel between the ice and the skin and to limit the duration of ice therapy sessions to prevent skin damage.
  6. Potential for Rebound Inflammation: After the initial vasoconstriction caused by ice
    therapy, there is a risk of rebound vasodilation once the ice is removed. This sudden
    increase in blood flow can lead to a surge in inflammation, exacerbating pain and swelling in
    some cases.


Heat Therapy:
In contrast, heat therapy, or thermotherapy, has been shown to increase blood flow, relax
muscles, and alleviate stiffness, making it a promising option for managing acute injuries.
While traditionally recommended for chronic conditions, recent research suggests that heat
therapy may also play a beneficial role in the acute phase of injury. Heat application can
promote tissue flexibility and enhance the delivery of oxygen and nutrients to the injured
area, potentially speeding up the healing process. However, its efficacy in the acute phase of
injury remains debated.

What are the potential issues with using heat therapy?
While heat therapy can offer numerous benefits for musculoskeletal injuries, it’s essential to
be aware of potential negative impacts:

  1. Increased Inflammation: Applying heat to an acute injury or during the initial
    inflammatory phase can exacerbate inflammation, leading to increased pain and swelling.
    Heat dilates blood vessels, which can potentially worsen tissue damage and delay healing.
  2. Delayed Healing: Excessive heat application can impede the body’s natural healing
    process by increasing metabolic activity and promoting fluid accumulation in the injured
    area. This may prolong recovery time and hinder tissue repair.
  3. Risk of Burns: Prolonged or excessive heat therapy can cause burns or tissue damage,
    particularly if the heat source is too hot or if applied directly to the skin without a barrier.
    It’s crucial to use caution and monitor the skin closely during heat therapy sessions.
  4. Masking Pain: Heat therapy can temporarily mask pain sensations, making it difficult to
    gauge the severity of the injury or identify warning signs of further damage. This may lead to
    overuse or inappropriate activity, potentially worsening the injury.
  5. Aggravation of Pre-existing Conditions: Heat therapy may exacerbate symptoms in
    individuals with certain pre-existing conditions, such as inflammatory arthritis or circulatory
    disorders. It’s important to consult with a healthcare professional before using heat therapy
    if you have any underlying health concerns.
  6. Potential for Rebound Symptoms: After the initial relief provided by heat therapy, there is
    a risk of rebound symptoms, including increased pain and stiffness once the heat is removed. This can occur due to the temporary vasodilation and subsequent vasospasm response.
  7. Nerve Sensitivity: Heat therapy may exacerbate nerve sensitivity or irritation in some
    individuals, leading to increased pain or discomfort. It’s essential to use heat therapy
    cautiously, especially around areas of nerve compression or injury.
  8. Increased Swelling: In some cases, heat therapy can exacerbate swelling, particularly if
    applied for an extended period or if combined with factors that promote fluid retention,
    such as immobility or inadequate elevation of the injured area.

Choosing the Right Therapy:
So, how do you decide between ice and heat therapy for your acute injury?
In general, ice therapy may be more appropriate for acute injuries characterised by
inflammation, excessive swelling, and intense pain, such as sprains, strains, and bruises.
On the other hand, heat therapy may be beneficial for acute injuries involving muscle
tightness, stiffness, and reduced range of motion, such as muscle spasms or minor muscle

In the realm of acute injury management, the debate between ice and heat therapy
continues to evolve with the latest research findings. While ice therapy remains a valuable
tool for reducing inflammation and pain in certain cases, heat therapy is emerging as a
promising alternative for promoting tissue flexibility and enhancing healing.
Ultimately, the key is to assess your injury’s specific characteristics and choose the therapy
that best suits your needs and preferences. By staying informed and seeking professional
guidance when needed, you can navigate your recovery with confidence and improve your
chances of a speedy and successful outcome. Physiotherapists may consider using a
combination of modalities, including ice, heat, manual therapy, and exercise, to optimise
outcomes and promote recovery in acute injury cases. Additionally, further research is
warranted to better understand the optimal use of ice and heat therapy in different clinical

But wait….. what about ice baths for recovery?
Many sports people and teams are incorporating whole-body cold therapy into their recovery sessions. This practice involves submerging the body, typically after intense exercise, in water chilled to temperatures ranging from 10 to 15 degrees Celcius for a duration of about 10 to 20 minutes. The recent research shows that this is different to cold therapies for injuries and as such, ice baths/cryotherapy chambers could be beneficial when. used immediately after exercise to effectively reduce muscle soreness and accelerate fatigue recovery.

We will delve into this subject in more detail in future blogs….

Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med . 2020;54:72–73.
Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?
World J Clin Cases. 2021 Jun 16;9(17):4116-4122.
Petrofsky et al. Cold Vs. Heat After Exercise-Is There a Clear Winner for Muscle Soreness. J Strength Cond Res.
2015 Nov;29(11):3245-52.

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