Should I Use Heat or Cold For Injuries?

A friend posted something on Facebook from 180 Degree Health, which was cool, I got to take a look at some ‘interesting’ weight loss and metabolism theories, but it also took took me to this post.

I got so caught up in a comment, I decided it would be best just to take the time to put a post on my own blog.

Most people are taught RICE or PRICE in first aid settings, this has become the norm.

P – protect

R – rest

I – ice

C – compress

E – elevate

What few people are aware of, is that this recommendation is completely based on the context of the injury. This can often be dictated by the severity of the pain, and should be diagnosed by a medical or rehab professional.

This recommendation is often made for immediate or ‘acute’ injury, not necessarily ‘chronic injury.’ So ice may not be appropriate if you suffer from something like arthritis or tendonosis.

The reason?

In acute injury, more or less in the first 72 hours of a injury, we want to limit inflammation a little bit.

Now inflammation a good thing, which is why your body naturally does it when injured, in an attempt to shuttle nutrients for repair to the affected area, but your body tends to over-react.

If too much inflammation reaches the area, here’s what will happen:

1. Too much inflammation can make it difficult to read an X-Ray, particularly for ankle and hand injuries, but it will alter the images on other joints too.

This makes it very difficult to determine what happened, and particularly if there is a break or fracture to the bone, which may require being set.

I can’t tell you how many times I’ve worked with someone with a negative X-Ray, only to go back 3-7 days later and discover a break, which wasn’t properly set (because you couldn’t see it on the original X-Ray), and this can create problems down the road in your recovery.

2. Too much inflammation will take longer to eventually clear the area, no matter what the injury.

This means (particularly joint injuries), that depending on the severity of the issue — resist the temptation to self-diagnose, unless absolutely certain, severity should be determined by a medical professional in some cases —  at about the 72 hour mark, we typically want to start mobilizing the area again — massage, laser, ultrasound, etc… are often used to break up or limit any potential scar tissue formation, which can set us back in our recovery.

Cyromassage is often used within the 72 hour window anyway, when dealing with rehab professionals, provided pain is at a minimum during the treatment. Massage combined with cold, can be especially useful for controlling inflammation and breaking up scar tissue formation if you’re dealing with a fascial or muscle related issue.

By re-gaining mobility we can speed up the process of healing, so the act of icing and elevation can usually be forgotten at this point, but I would recommend at this point you see a rehab professional to really boost your recovery time. Rehab professionals are trained in mobilizing joints post-injury, and sometimes this requires new proprioception patterns, and exercise therapy as well.

Compression can be used to enhance proprioception in some instances during a rehab process.

Protection by way to limit activity that would affect the joint, or in some cases taking precautionary methods, like braces, might be helpful in returning to activities. The objective is to eventually get back to the activity without the use of a brace.

3. Inflammation will obviously immobilize a joint.

Which to a certain extent we want, but like I mention above, it can slow recovery time. We want to start mobilizing the joint as soon as we can in order to speed up recovery.

4. Inflammation does not always get to the source of the problem in less vascular tissues, like ligaments or tendons.

In many cases, it is more appropriate to use cold in conjunction with heat (or room temperature), in order to create a fluid-like pump on the cellular level and assist with shuttling nutrients in and out of the cell for recovery.

It’s Cold In Here

O.K. so there are certain instances when I want to use cold right?

Yep, but it’s much shorter duration than you might think, so use it appropriately, please don’t go icing something for 20 or 25 minutes straight.

Second, ice should never be applied directly to the skin. Ice on the skin can cause frost-bite in longer-duration, so choose something above 0 degrees, or insulate an icepack with paper towel, or a towel, or something.

Third, you should probably never ‘ice’ more than 8 minutes, typically only 5, or until the area starts to feel a little numb and the skin cold to the touch. Then remove the pack, until the skin feels warm to the touch again, or at least as long as you had the ice pack on for. Repeat.

This altering between cold and room-temperature (which is heat relative to ice) creates that pump I was talking about earlier, allowing some inflammation into the area, but ideally not too much, all the while, making sure the tissues that need the inflammation to heal are getting more of the good stuff.

Cold baths are an alternative to ice packs, but should only be used for 1-2 minutes, and ideally used in a contrast setting, alternating between cold and warm baths. This is more a recommendation for aiding in recovery from training, or minor injuries.

Likewise, you may see greater benefit alternating between a cold pack, and a heat pack, than either on their own — in my experience and there is some research out there to support this.

Ice can numb an area, providing relief, which some people worry about, as in creating a false sense of security — like being able to walk on a joint before you are capable.

The Skinny on Heat

Some people argue that heat is more appropriate for injuries because inflammation is the bodies ‘natural’ reaction anyway, why not encourage it?

A cat will lick an open wound out of ‘instinct’ or natural reaction too, often leading to infection.

‘Natural’ does not always mean ‘good.’ 

Sometimes we would be wise to outwit our bodies’ natural tendencies, like using corrective exercise to assist in maintaining good movement patterns and consequently prevent injury, even though it is not apparently natural to wrap an elastic band around our knees and train our hips this way.

Heat increases blood flow — but as ligaments and tendons are not particularly ‘vascular’ in nature, where would this additional inflammation/blood flow go?

Heat can also aid in mobilizing tissues, once you are ready to start moving again, which can be important.

Heat will also signal muscle relaxation too, which can just as easily (comparable to ice) create a false sense of security. The relaxation effects of heat can destabilize a freshly injured joint (providing it’s a joint injury) that should be stabilized immediately after injury.

Heat should be probably be used more for chronic injuries. It would probably be inappropriate to ice a chronic injury between games at an athletic tournament for instance.

Pain Relief and Temperature Variance

Heat and Cold actually produce similar pain relief benefits, albeit from opposite ends of the spectrum from your temperature receptors.

Your temperature receptors in communication with your nervous system, over-ride the neural pathway, giving you temporary pain-relief.

Your nervous system has a a bit of a one track mind, which makes it very difficult to feel pain when you’re too hot, or cold, and why you may not be able to feel the pain and pressure at the same time.

The sensation of warm or cold, can help reduce or eliminate the sensation of low level pain or throbbing, by over-riding them as sensations.

The cold sensation is much more dramatic because once you hit about 60 degrees celsius your skin will burn in a matter of a few seconds — generally safety devices will limit tap water to about 49 degrees celsius, and most hot tubs are not recommended past 104 F, or about 40 C.

So you would definitely have less than a 20 degree variance, probably not much more than a few degrees (not much more than 10), as far as temperature manipulation goes — assuming your skin has a variability of between 34-38 degrees on average, depending on the location — through a shallow heat treatment like a pack, jacuzzi or hot tub.

Therefore the upper limit applicability of heat as a treatment modality is limited — but does have it’s place, particularly deep heat treatments like ultrasound or laser.

The change then when applying ice is much more drastic (and more tolerable by comparison) but we more easily manage a drop of 30 degrees in the opposite direction, than an increase of 30 degrees.

This variance alone, makes ice a more effective treatment modality for acute musculoskeletal issues.