Pain •Sensible advice for aches, pains & injuries

The Great Ice vs. Heat Confusion Debacle

A quick guide that explains when to ice, when to heat, when not to, and why

updated May 26 2015 (first published 2007)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful Vancouver, Canada. • full bioabout

There is sooooo much confusion about this issue. It’s a shame because icing and heating — cryotherapy and thermotherapy — are rational, cheap self-treatment options with minimal risks. This article gives you a concise, bird’s eye view of the issues, and links to other articles with as much detail as you could possibly want, especially the main icing article, the main heating article, and the please-beware-of-icing-back-pain article.

What ice and heat are for

Ice is for injuries, and heat is for muscles. Roughly.

Ice is for injuries — calming down damaged superficial tissues that are inflamed, red, hot and swollen. The inflammatory process is a healthy, normal, natural process … that also happens to be incredibly painful and more biologically stubborn than it needs to be. Icing is mostly just a mild, drugless way of dulling the pain of inflammation. Examples: a freshly pulled muscle or a new case of IT band syndrome (which is more likely to respond than the other kind of runner’s knee, patellofemoral pain, because ITBS is superficial and PFPS is often a problem with deeper tissues).

Heat is for muscles, chronic pain, and stress — taking the edge off the pain of whole muscle spasms and trigger points, or conditions that are often dominated by them, like back pain and neck pain), for soothing the nervous system and the mind (stress and fear are major factors in many chronic pain problems, of course).

What ice and heat are not for

Heat can make inflammation worse, and ice can make muscle tension and spasms worse, so they have the potential to do some mild harm when mixed up.

Both ice and heat are pointless or worse when unwanted: icing when you’re already shivering, or heating when you’re already sweating. The brain may interpret an excess of either one as a threat — and when brains think there’s a threat, they may also amp up the pain.

But heat and inflammation are a particularly bad combination. If you add heat to an fresh injury, watch out: it’s going to get worse! A physician once told my father to heat a freshly injured knee, and wow — it swelled up like a balloon, three times bigger than it had been before. And three times more painful. (That is a rare example of a particularly severe negative reaction to heat. Most cases are not going to be that bad!)

The lesser known threat is from icing at the wrong time, or when it’s unwanted.

If you ice painful muscles, watch out: it’s probably going to get worse! Ice can aggravate muscle spasms and trigger points, which are often present in low back and neck pain — the very condition people often try to treat with ice. Severe spasm and trigger points can be spectacularly painful, like knife wounds, and are easily mistaken for “iceable” injury and inflammation. But if you ice these tissues, woe is you — the muscles are likely to contract even harder, and the trigger points burn and ache even more acutely. This mistake is made particularly often with low back pain and neck pain. If in doubt, please see below in the “More information” section.

What about injured muscle?

If you’re supposed to ice injuries, but not muscles, what do you with injured muscles (a muscle tear or muscle strain)?

That can be a tough call, but ice usually wins — but only for the first few days at most, and only if it really is a true muscle injury. A true muscle injury almost always involves severe, sudden pain. If the muscle is truly torn, then use ice to bring down the inflammation. Once the worst is over, switch to heat.

Which is better?

Ice packs and heating pads are not especially powerful medicine: experiments have shown that both have only mild benefits, and those benefits are roughly equal.1

The bottom line

The bottom line is: use whatever feels best to you!

Your own preference is the tie-breaker and probably the most important consideration. For instance, heat cannot help if you already feel unpleasantly flushed and don’t want to be heated. And ice is unlikely to be effective if you have a chill and hate the idea of being iced!

If you start to use one and you don’t like the feel of it … just switch to the other.

More hot and cold information

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.


  1. Garra G, Singer AJ, Leno R, et al. Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Acad Emerg Med. 2010 May;17(5):484–9. PubMed #20536800.

    What’s better for neck and back pain — ice or heat? This experiment, conducted at a university-based emergency department, compared the effectiveness of these two common treatments. Everyone studied received 400mg of ibuprofen orally and then thirty patients were given a half hour of either a heating pad or a cold pack.

    The researchers concluded that adding heat or cold to ibuprofen therapy did not change the result. Both heat and cold resulted in “mild yet similar improvement in the pain severity.” They recommend that the “choice of heat or cold therapy should be based on patient and practitioner preferences and availability.”

page updated 2015-05-26