This past week I read an article recommending when to use ice versus when to use heat. I would like to give my thoughts and hopefully clarify what I have found works best.
For most of my career I recommended using ice for injury and for pain. I did this primarily because I personally liked ice and how it worked for me. I did it also because I was taught like most everyone else out there that ice helped with swelling. I no longer recommend ice the way I did in the past. I now recommend ice to prevent (or at least minimize) swelling initially, but no longer recommend it to reduce swelling.
Ice can help to delay or limit swelling and inflammation immediately after an injury, surgery or vigorous activity. Ice limits/prevents swelling by constricting blood vessels resulting in a slowing of blood flow. But that does not mean it can reduce swelling once the swelling has been established. This is why I use it immediately after an injury, surgery or vigorous activity. But after a period of time the fact that ice slows blood flow means that it is not helping to move the swelling, it’s not exactly stopping it from leaving the injured area but it certainly is not reducing the amount of swelling. In my opinion, ice is not the most effective way of dealing with swelling.
When you have an injury, the standard recommendation is to use the RICE protocol (Rest Ice Compress and Elevate.) Let’s say you sprained your ankle, the first step is to follow the RICE protocol.
Rest: (i.e. get off your sprained ankle)
Ice: (apply ice for 20 minutes then allow the tissue to warm, so you don’t freeze it or get frostbite and then ice again)
Compress: (use an elastic wrap or other means to compress the area)
Elevate: (above the heart is the MINIMUM elevation...I recommend people lift their foot to the highest level when they sprain their ankle)
I recommend the following: Use ice for the first 24 hours immediately after an injury to limit how much swelling you get, then switch to CHEM: Compress Heat Elevate and Move. (I made up the acronym CHEM.)
Compress: I have found compression to be far more effective at reducing swelling than any other method and it also works quickly. I have had several patients tell me the most effective advice I gave them was using compression to reduce the swelling. I like it so much that I typically say it at least 10 separate times during an evaluation to get the point across and follow up by wrapping my patients before they leave or suggesting where to find compression garments or compression tape that does the job.
Heat: I no longer recommend ice past 24 hours to help with swelling because it slows blood flow and I am trying to increase blood flow to get rid of the swelling. For muscle injuries I mostly recommend heat and IF I recommend ice, I only recommend it immediately after an event. So if one of my tri-athlete patients has an event and they are doing a big training session I don’t mind using ice to limit and/or hopefully prevent swelling immediately after the training or event, but then the next day I suggest heat and of course compression.
Elevate: I also like to recommend elevation and I teach my patients with lower extremity injuries to elevate their legs as high as they can. I recommend using the back of a couch for example or one of the big exercise balls. This is a perfect time to be compressing the area as well.
Often patients will tell me they elevate their legs on their recliner. I am sorry to tell you this is not elevation. This is better than putting your feet on the ground, but it is not the same as elevation and it is not effective for reducing swelling. It may help limit swelling and is better than nothing.
Move: The final thing I recommend is to move. I have a couple slogans I tell my patients: “when in doubt, move about” and “do a little bit a lot.” The two most common mistakes people make when moving are to do too much or to do too little. Finding what is just right sometimes requires trial and error so I recommend doing 10-15 minutes of some type of activity and then stopping to see what effect it has on the body. Then I recommend doing the same thing every hour. This is how you can do “a little bit a lot.”
It sometimes helps to have someone guide you through the type of movements that are most effective and most efficient, but it is absolutely not necessary to use the “no pain, no gain” philosophy, which applies specifically to building muscle and does NOT apply to joint issues or injured muscles. No purpose is served trying to force yourself to get better, often this slows the process.
I am sure there are people out there reading this that have heard their whole lives that ice is good for reducing swelling and although I also used to recommend that, I am more inclined to use compression before ice. Compression can be used 24 hours, 7 days a week, whereas ice should be used for 20 minutes and then there should be time to allow the tissue to warm up again before icing again.
Clearly compression has a bigger impact. Also due to the nature of most people’s lives, taking the time to ice more than a couple times a day is simply not practical, and yet compression is something you can have on and remain active. I often tell people that if you are only icing a couple times a day it is really not having the effects you think it is. The reduction in blood flow is temporary, so doing it once or twice a day is not very effective. Just another reason to use compression.
Compression prevents fluid from accumulating, it assists our blood flow and it can be used all day long. This is the way to go for sure.
Ice is effective when you use it a lot immediately after an injury to immediately after a big training event and ice is also a way to reduce pain. For the people that like how ice reduces the pain by numbing the area, then of course ice is an effective strategy. In this case it is not being used to reduce swelling, but rather for pain relief. If you are reducing pain with ice then you have chosen an effective method. If you are using ice to reduce swelling there are much more effective and efficient ways (i.e. compression).
I decided to write this because although it goes against things we have all learned, I have found the approach to be more effective and more efficient. I am a huge proponent of reducing swelling, and have found that by doing this, my patients are able to move more effectively and progress through rehabilitation faster. It is just not an effective strategy to rely on using ice. Heat is OK and I am not opposed to it, but in truth the most effective means I have found in reducing swelling is to use compression.
To summarize, use ice immediately after injury or very intense exercise and for up to the first 24 hours. Use compression immediately and persistently until the swelling is fully subsided. Use elevation, the higher the better, immediately after and until the swelling is fully subsided. Use heat, especially with muscular disorders after 24 hours. And finally, when in doubt move about, but make sure you start moving by doing a little bit, a lot.
If you have questions or are uncertain about what to do, feel free to contact me and I can guide you through the process. Good luck, and be well.
Matthew Goodemote can be contacted by calling (518) 306-6894. Goodemote Physical Therapy PLLC is located at 3 Maple Dell in Saratoga Springs.
