Ice or Heat? Which is better and when?

I thought I knew. I’d followed the research regarding ice and the negatives of using it at the wrong time for the wrong injury. I was definitely biased against ice for pain relief. So, for over 9 months, I used heat for my back and glute pain. Sometimes it helped, but sometimes I wasn’t sure. But my bias was strong, so I persevered with the heat.

It was not until I saw a new PT that she suggested icing my back and hip. “Light dawned on marble head” as the saying goes. The ice took my back pain down to almost zero. My sciatica also diminished.  Let’s say I was surprised at the least. I had been ASSUMING that my pain was mainly muscular as things felt “sore” and in need of relaxation, when, in reality, I had nerve involvement from the spine.  My nerve pain needed quick reduction of inflammation. Ice does that. Heat did the opposite for me, and increased the inflammation of nerves and the associated nerve pain.

I learned a big lesson about chronic pain. I had predetermined what I thought was the right thing to do, without more critical thinking.

And I began thinking about what others may or may not believe about the ice or heat debate. Are there any other therapies or techniques that are not useful for healing?  My story above actually illustrates the wrong application of a great tool. But many people still believe that ice is the only intervention when it comes to joint or muscular pain.  What is the truth?

The Sordid History of RICE

Most people are aware of the old RICE treatment protocol- Rest, Ice, Compression, Elevation- for healing of soft tissue injuries like sprains and strains. It’s what we’ve always been advised, and still is the most common injury intervention advised by doctors.

RICE was first mentioned in 1978 by Dr. Gabe Mirkin , author of “The Sports Medicine Book” and it quickly became an ingrained belief system.  Fast forward 40 years….a lot has changed. We have decades of updated research since 1978, and the overwhelming consensus is that ice, when used for the wrong reasons, impedes healing.  Yes. Impedes healing.

The research is quite clear. For example, there are over 220 studies on icing for ankle sprains alone. These studies refute the RICE protocol, especially the Rest and Ice part. A study published in 2014 by the European Society of Sports Traumatology, Knee Surgery & Arthroscopy, found that icing shuts off the blood supply that is essential for healing. The poor circulation created by icing diminishes the influx of healing macrophages which secrete necessary protein growth and repair factors.  And icing reduces blood flow for quite a while, even after it is removed, so the healing process can be delayed by hours if ice is over used.

As far back as 1986, a study published in the journal Sports Medicine showed that when ice is applied for a prolonged period, lymphatic vessels become more permeable, causing a backflow of fluid into the tissue. That means local swelling at an injury site will increase, not decrease, with the use of ice. Another piece of evidence to support NOT using ice for healing an injury.

Anti-inflammatories can also be problematic. You should avoid taking Alleve or Advil for extended periods of time, as these too can delay the natural healing process, Of course, you need pain relief for the first few days after an injury! And, if pain relief allows for better movement, that’s a win-win. But, long term, anything that prevents your immune system from beginning the healing process will only lengthen your return to sport or life.

One example of this NSAID problem was explored in the research paper  “NSAID therapy effects on healing of bone, tendon and enthesis” from The Journal of Applied Physiology:

    “NSAIDs are readily available, over-the-counter medications that are commonly used and prescribed to manage pain and swelling associated with skeletal injuries. Despite this, the available experimental and clinical evidence indicates that NSAID therapy can impair bone fracture healing and tendon-to-bone enthesis healing. The effects of NSAIDs on bone and enthesis healing is likely affected by the NSAID used, the initiation, and duration of therapy.” 

How many people do we know that pop a few Advil when they are in pain? It may be hurting more than helping. And, for some tendinous injuries like tennis and golfer’s elbow, healing may actually be significantly delayed by NSAIDs.

So, what does work for soft tissue injuries?

First of all, if you (or your doctor) are still not convinced, you can use ice for acute injuries. But it is no longer recommended after the first day, and even then, the protocol has changed. Dr. Mirkin himself now advises ice only if absolutely necessary, and then only 2-3 times for 10 minutes, with 20 minutes or more between each icing session. Mirkin does not advise using ice after more than 6 hours of the injury.

I love this ice pack. It stays cool for many hours.

But what else can you do?  With the advice of your doctor or PT, you should move as soon as possible.  Research supports early movement for common injuries like minor ankle, back, shoulder or knee strains/sprains.  I have seen way too many people develop “frozen shoulder” from immobilizing the shoulder after a mild injury. I can tell you that going to PT for a frozen shoulder is 10 times worse than the original injury itself.

Many research papers have focused on early movement for ankle sprains. Traditionally, this kind of injury was always treated with RICE, followed by a brace and even crutches for extended periods of time. But countless studies have shown that overly lengthy rest and immobilization slows healing. Instead, gentle movement within 48-72 hours of a soft tissue ankle injury increases blood flow and actually helps healing.

This is a nice soleus/calf stretch.

The trend towards less ice and more movement has even gained new acronyms. In 2011, Canadian exercise physiologist John Paul Catanzaro coined the term METH — Movement, Elevation, Traction, Heat — as an alternative to RICE. In April 2019, two British physical therapists proposed another acronym in the British Journal of Sports Medicine: PEACE — Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate — and LOVE — Load, Optimism, Vascularization, Exercise. Movement, not immobilization, may very well be the secret to less pain and swelling and most importantly, better healing!

While movement is essential to healing, this does not mean a quick return to exercise or sport. Just because you are not in pain does not mean you are fully healed. Use common sense.  For example, 48-72 hours after your ankle sprain, begin small ankle circles and gentle stretching. Try some cautious weight bearing. But don’t go out and run a 5K.

As far as using heat for soft tissue “issues”, I am a big fan.  Of course, I would not put heat on a new ankle sprain, but I certainly would heat a mild muscle pull or chronic muscle injury or muscle tightness. Heat can be a very useful tool for tense/tight or sore muscles. Heat breaks the pain cycle by relaxing tight muscles, relieving muscular compression of nerves and improving blood flow to injured tissue. ( Note- this is different from the kind of nerve pain related to nerve compression at the spine itself).

And that brings me back to my own pain story, where I used heat on my back rather than ice. It just felt better.  But, as I learned, I was wrong, because nerve issues are not soft tissue injuries. Pain coming from nerve entrapment will only be relieved when the inflammation of the nerve is lessened. And heat won’t do that.

The lesson? Understand the origin of your pain whenever possible, and collaborate with your MD or other health care professional about what tool is best for you and your injury.

Lastly, there is something to be said for common sense and individual variability around rethinking ice versus other interventions.

As Shane McLean of Balance Guy Training   explains:

” RICE is not completely useless when it comes to acute injuries. You need to reduce the pain and swelling the best way you can. But when it comes to chronic pain or injuries, I think RICE is useless. 

This type of pain or injury needs healing blood flow, whether it be through movement, targeted exercises or a heating pad or cream. Putting ice on your painful area numbs the area and reduces blood flow, which is what you don’t want. 

However, science only tells us so much. And what works in a lab or test may not work for you. You have to do what works best for you and if putting ice on an ouchy makes you feel better, then do it. But realize ice is a stop gap measure and not a long term solution.”

Seems like good advice to me.

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