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Heat vs. Ice


One thing you can count on: Most people, even if they know whether they should use heat or ice to treat a sports injury, will use whichever makes them feel good.

Another thing you can count on: They probably don't know which is better.

Alma Bethea, a 54-year-old teacher, has a personal trainer and works out four to five times a week.

"I can't remember," she says. "Is it heat or ice you're supposed to use first? I prefer heat. Physical therapists will tell you it will increase inflammation. But I like heat because it gives me that warm, fuzzy feeling."

Her friend Melissa Bryant, 37, a fitness instructor, likes ice for sports injuries. "It numbs the pain. Or else I worry about the cold so I forget the pain."

So who's right? Or in this high-tech age are therapeutic heat and cold hopelessly out of date?

Don't put away that hot-water bottle or ice pack yet, says Dr. Andrew Tucker, director of sports medicine at Union Memorial Hospital and head physician for the Ravens. Tucker believes both heat and cold are excellent ways for amateur athletes to treat pain.

After all, most of us are too busy or can't afford to go to a physical therapist a couple of times a week.

"The home remedies we're talking about have a significant role, both in ease of application and convenience," he says. You can put ice cubes in a plastic bag or use a bag of frozen peas when you need a cold pack.

You can apply dry heat with a heating pad or hot-water bottle, or you can zap a wet towel in the microwave for moist heat. You can step into the 21st century with chemical cold packs you keep in the freezer for emergencies, or hot packs that stay warm for eight hours. (Their only advantage over old-fashioned methods, say medical experts, is convenience.)

Heat and cold are low-risk remedies, unlike, say, anti-inflammatory drugs. Of course, there have been incidences of tissue damage with overzealous icing and burns from falling asleep with a heating pad on, but if you use a little common sense, there's not much risk of either happening.

Most health professionals agree about what to do for a sudden, or acute, injury such as a sprained ankle or a twisted knee. Applying a cold pack within the first 48 hours eases pain and may help reduce swelling and inflammation by constricting blood vessels and limiting blood flow in the injured area. They also agree that you don't apply ice to an injury before exercise, and you don't apply heat afterward.

A changing field

The confusion lies in what to do about injuries that aren't acute. Weekend warriors are also susceptible to chronic pain that comes and goes. It's often a dull ache, not a sharp pain. It may develop slowly, from overuse, and there is usually no visible swelling or redness. You want to relax and soothe stiffness and soreness, but you also want to treat lingering inflammation and pain.

Sean Dalton, 38, who works for an insurance company and in his spare time runs or plays golf, basketball or baseball every day, uses ice. "I think you're supposed to go heat-ice-heat-ice, but I don't know. Don't ask me the correct way. I just know what I do."

Of course, the best treatment is one few athletes will consider: rest. Most try to manage and minimize their discomfort while they continue running or playing racquetball or swimming.

Treating a nonacute injury, such as a sore back, used to be simple. You put heat on it. But these days, that might not be the answer.

"When I went to medical school, we understood [therapeutic heat and cold]," says Dr. Barbara de Lateur, a professor in the Johns Hopkins School of Medicine's Department of Physical Medicine and Rehabilitation, and an editor of the fourth edition of Therapeutic Heat and Cold (Williams and Wilkins, 1990). "Forty years later, it's much more complicated than we thought."

Some animal studies, for instance, have shown increased swelling with prolonged icing. And in certain situations, muscle spasms may decrease with cold therapy, although heat is the usual treatment.

The rule of thumb that Sandy Worth, an athletic trainer for 32 years at the University of Maryland, uses is that a chronic injury should be managed symptomatically. In other words, whatever works. "Heat or cold sometimes helps."

"It's sort of trial and error on the part of the patient," agrees Tucker.

Willie Rosen is a retired bartender who at age 86 works out at his gym five times a week. He used to run every day until he had a hip replacement. "I use mostly heat," he says. "I don't like to use ice."

Many pros like ice

Still, in recent years ice has become the treatment of choice for many health professionals, even when it's not the patient's favorite, because they feel it reduces inflammation.

Wendy Hoy, a physical therapist at Physiotherapy Associates in Lutherville, encourages her patients to continue to ice an acute injury even after the 48-hour period, especially if there's sharp pain.

"People say to me heat seems to relax [a chronic injury] like a sore back," she says. "That's OK. I tell them to follow up with ice. Heat aggravates inflammation." Her rule of thumb is heat for stiffness, cold for just about anything else.

If you have swelling, ice is most effective when you also wrap the area or otherwise compress it. In fact, research on laboratory animals suggests icing doesn't work very well to reduce swelling without compression, says de Lateur. So bind your ankle tightly in an elastic bandage before you apply a cold pack. Then elevate and rest it.

When applying ice, protect the skin with a paper towel or cloth. If you use a towel, it should be wet. Keep the cold pack on for 15 minutes or so, and let the skin warm up completely before reapplying. (If you don't have much body fat, you won't have to ice an injury as long as someone with more padding. Your 10 minutes may be someone else's 20.) You can ice several times a day, but keeping ice on for longer than 20 minutes at a time isn't a good idea, as it can damage skin. Continue to ice for the first 48 hours after an acute injury.

Some people respond better to ice massage, says Worth. You can be specific about where you're applying the cold, and the massaging motion is soothing. Fill paper cups three-quarters full of water and freeze them, she says. Then "tear the cup and pop the ice out." Rub your hand over the top in case of roughness, and massage the injured area until the skin is red and you get an analgesic effect.

Mark Coberley, a spokesman for the National Athletic Trainers Association, likes to use contrast treatment, a combination of heat and ice, as an athlete's acute injury gets better.

Four or five days after a sprained ankle, for instance, he'll have the athlete alternate between heat and an ice bath, each for about 3 minutes, for 30 minutes. "The cold water lets [the athlete] do something he might not be able to do with the pain" - in the case of an ankle, spelling out the alphabet with his foot as a stretching exercise.

If your treatment of choice is heat, don't worry about whether it's dry or moist heat. "Superficial heat is superficial heat," says de Lateur. "It all penetrates a few millimeters, regardless of what [anyone] tells you." For deeper heating, a physical therapist may use ultrasound, which provides more penetrating heat and allows for a greater range of motion when stretching.

Superficial cold can penetrate more deeply than superficial heat because it causes blood vessels to constrict, so the warmer blood flow is diminished. As the cold pack is left on, successive layers of tissue are cooled. The blood still flows to some extent, but not enough to stop the cooling. In contrast, heat causes blood vessels to dilate. The more rapid blood flow carries away the heat that was applied, so only the most superficial few millimeters are heated.

"If one tried to push it with higher and higher temperature hot packs, a burn would result," says de Lateur, "but the deeper layers would not be heated."

Getting relief

Ways to apply heat and ice:


Ice cubes or crushed ice in a plastic bag.

A bag of frozen corn or peas, which can mold well to the injured area.

A paper cup filled with water and frozen for ice massage.

A bucket filled with ice for an ice bath. Immerse injury for 5 to 10 minutes.

Commercial cold packs. Be careful - they can be colder than ice.


Heating pad.

Hot-water bottle.

Hot bath.


Wet towel heated in the microwave.

Commercial heat packs, which are convenient and can provide lengthy therapy.

Ultrasound, which uses high-frequency sound waves to provide deep warmth and promote circulation.

Sports creams (massaging them in may be as useful as their heat).

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