Ice or Heat: What does the science say about their use for acute injury?
By Dr. John Mishock, PT, DPT, DC
Approximately 70-90% of people use ice or cryotherapy (ice packs, ice towels, ice massage, gel packs, refrigerant gases, ice baths) following an injury or to enhance recovery. Dr. Gabe Mirkin first coined the term “RICE” (Rest, Ice, Compression, and Elevation) in 1978, a snappy 4-letter acronym that quickly gathered momentum and popularity throughout the 80s and 90s, which has now become the standard of care for acute musculoskeletal injuries. (Hubbard et al. J Athl Train. 2004, Horsching et al. CDT 2024) In this article, I will review the use of ice, heat, ice baths, and active recovery in their role in acute musculoskeletal injury.
What happens to muscles and ligaments during an acute injury?
Following an injury, like an ankle sprain, the damaged tissue sends chemical signals (neutrophils, macrophages) to the body to create inflammation, redness, heat, and pain. The early inflammation protects the area and begins the healing process. During this inflammatory phase, damaged or dead cells are removed, oxygen and nutrients enter the injured soft tissue, and clotting proteins enter, beginning the scar formation. Keep in mind that this process is essential to optimizing the three phases of healing: inflammation (swelling), proliferation (scar tissue elements), and remodeling (scar tissue strengthening) of the damaged soft tissue. (Serhan C, Ward P, Gilroy D. Fundamentals of Inflammation. Cambridge University Press; 2009.)
How does ice or cryotherapy work?
Ice slows inflammation by constricting blood vessels, reducing inflammation and pain. The pain is decreased due to reduced pain receptor activity. According to existing scientific research, the main advantage of using cryotherapy is a transient decrease in pain.
When should I use ice or cryotherapy?
Recent studies have demonstrated that ice should be used in the 1st 6 hours following an injury to reduce pain and inflammation. However, ice should be used with caution beyond that due to slowed tissue healing and regeneration. (Racinais et al. Brit J of Spor Med 2024)
How long should I use ice for?
During an acute injury, ice should not be used for more than 10 minutes with at least 60 minutes off. Excessive use of ice causes reduced blood supply and oxygen (hypoxia) to the muscle, reducing healing and possibly damaging tissue (frostbite). (Jinnah et al. J of ISAKOS 2019)
How long should I use water immersion baths?
Cold water immersion (ice baths) of 11-15 minutes may benefit muscle and body recovery. More extended periods may reduce therapeutic benefits. (Fonseca et al. J Athl Train 2016)
When should I use moist heat?
Moist heat opens up blood vessels, increasing circulation. The increased circulation can improve tissue healing by bringing in new oxygenated blood with healing elements. Moist head can be used any time following the first 6 hours for no more than 20 minutes per use.
Is active recovery better than ice and heat?
Active recovery uses muscle contraction, range of motion, or stretching for therapeutic gain following injury. These activities increase circulation, eliminate toxins (metabolites like H+, substance P), and maintain joint range of motion and muscle flexibility. Active recovery can speed up healing while reducing the adverse effects of immobility, such as muscle atrophy and weakness, limited joint range of motion, and reduced function. Active recovery should begin within the 1st 6-24 hours following injury in a pain-free manner.
Should I use ice, heat, and active recovery?
After the first 6 hours following injury, heat, active recovery, and ice should be done to accelerate the three phases of tissue healing, all three modalities should be used in order 3-5 times daily.
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Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, and “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon and train2playsports.com.
