If you’re experiencing musculoskeletal (MSK) pain, you may be wondering: Should I use heat therapy or cold therapy?

Generally speaking, ice is the best choice when you have an acute (or new) injury and want to reduce excessive swelling and pain at the site. Meanwhile, heat loosens stiff or sore tissues, and is the better option for chronic pain due to arthritis or old injuries.

Let’s get into the details of when and how to use ice vs. heat as an MSK pain treatment.

When to Use Cold Therapy

Ice should be applied only if you are experiencing a lot of swelling, or after you have surgery. Ice helps to reduce inflammation when there is too much of it.

You may have heard the popular acronym RICE as a method for treating soft tissue injuries at home. RICE stands for: Rest, Ice, Compression, Elevation. But this is no longer considered the most effective protocol to facilitate healing.

Instead, experts recommend using the PEACE & LOVE method to treat acute MSK injuries at home. The PEACE part of the protocol explains how to optimize soft tissue recovery during the first few days post-injury:

• Protect the injury by avoiding activities that aggravate it.
• Elevate the injury higher than the heart when possible.
• Avoid anti-inflammatory medications and cold therapy.
• Compress the injury using tape or an elastic bandage.
• Educate yourself on your condition, and trust that your body knows best.

The LOVE part of the protocol refers to the management of the injury after the first few days, which is the second stage of the rehabilitation continuum. During this stage, you should focus on providing LOVE to your soft tissues:

• Load
• Optimism
• Vascularization (blood flow)
• Exercise

Load, blood flow, and exercise are all intimately connected, as they refer to the critical importance of remaining active when recovering from an injury. This includes both cardiovascular physical activity to increase blood flow to injured structure, and appropriate load-bearing exercises (such as walking, doing squats, and climbing stairs) to repair tissues, tendons, muscles, and ligaments. While prolonged rest may be tempting when you are in pain, it is far better for healing to implement gentle exercises that do not aggravate your pain.

You may have noticed that, unlike the RICE method, the PEACE & LOVE method discourages icing, as well as non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Why? Because ice and NSAIDs block inflammation, and acute inflammation (i.e., inflammation that occurs as a direct result of injury) is actually a natural and necessary part of healing. You don’t want to discourage it completely.

Acute inflammation post-injury means that your body’s immune system has swung into action, sending inflammatory cells to the injury site to repair damaged tissue, clear away dead cells, and fight infections. Swelling at the site is a result of your blood vessels dilating to accommodate this rush of fluids, proteins, and white blood cells to the area. These are positive signals that your body’s natural healing system is working as it should.

That being said, too much swelling and pain can be counterproductive to healing. When the body’s inflammatory response is excessive, icing and NSAIDs can serve an important analgesic, or pain-relieving, purpose.

How to Use Cold Therapy

Apply ice—this could be an ice pack, a bag of frozen vegetables, an instant ice pack, or a frozen wet towel—to your injury for 10 to 15 minutes at a time. Repeat every few hours (or as needed) during the first 24-48 hours post-injury. Place a light towel or plastic bag around the ice to protect your skin from ice burn.

When to Use Heat Therapy

While ice causes blood vessels to constrict, heat causes blood vessels to widen. Therefore, applying heat to an area stimulates blood flow to it, which allows for the delivery of nutrients and oxygen that help injured tissues recover. In other words, heat therapy actually promotes inflammation and the processes associated with it. While heat is not a long-term cure for MSK pain, it can provide short-term comfort.

Heat is a great option for:

• Relaxing stiff muscles
• Relieving sore muscles
• Reducing arthritis pain
• Limbering up prior to exercise
• Decreasing pain before bed to improve sleep quality
• Preventing muscle stiffness and spasms

Heat should not be used when there is swelling or bruising because, by encouraging even more blood flow to the area, it can exacerbate inflammation and delay healing. This is why heat is not used in the immediate after-care of acute MSK injuries.

How to Use Heat Therapy

Apply heat—this could be a heating pad, hot water bottle, or hot compress—for 15 minutes at a time as needed. Place a barrier, such as a light towel, between your skin and the heat source to prevent burns.

Frequently Asked Questions About Ice vs. Heat

• Should I use ice or heat for back pain? Back pain is best treated using heat, which encourages blood flow to the area to increase mobility.

• Should I use ice or heat for nerve pain? For nerve pain, it is best to apply heat. This promotes increased nerve conduction and stimulates healing.

• Should I use ice or heat for a pulled muscle? For muscle strains, apply heat during the first 24-48 hours. This will facilitate the flow of blood and oxygen to the injured tissue.

• Should I use ice or heat for knee pain? For knee pain, the decision to use ice vs. heat is more dependent on what has occurred than where the pain is located. If your knee pain is because you’ve just had surgery or experienced an acute injury, applying ice within 24-48 hours could be beneficial. If your knee pain is chronic, or if your injury occurred more than 48 hours ago, heat would be the better choice.

• Should I use ice or heat for a sprained ankle? If the injury occurred within the last 48 hours and there is visible swelling, apply ice as mentioned above. This will help reduce excess swelling.

If you have questions, or you’re unsure how to properly use heat or ice, please contact your healthcare provider for guidance.

Interested in how Sword Health can help you find freedom from MSK pain? Check if you're eligible through your employer or health plan.