Over the years in the medical arena Nonpharmacological treatment strategies such as cold and heat therapy have been used for musculoskeletal injury.
With the aim to help with pain management, swelling and promotion of healing in the affected body part. Despite prevalent confusion about which modality (heat vs cold) to use and when to use it
You may be wondering whether to apply heat or cold to your muscle /tendon pain or swollen injury.
I am reviewing the current scientific knowledge on the benefits of heat or cold therapy.
Happy reading!😀 and feel free to ask questions in the comments or share your own experience.🙏
Last updated: July, 2025. Written by Juliet Semakula, a diagnostic radiographer.
Disclaimer: Amazon affiliate links. Complete disclosure in legal notices.
Hot and cold therapy, also known as heat and ice therapy, involves using heat or cold to manage pain and inflammation
| Benefits! Heat therapy can help relax muscles and increase blood flow, while cold therapy can reduce swelling and numb pain. |
▶️There is no strong agreement on the benefits of heat versus cold.
While it’s commonly believed that heat and cold offer distinct benefits for pain and injuries, there’s no strong consensus on which is superior, and much depends on the individual and the specific situation.
Both heat and cold can be effective, but they work through different mechanisms and may be better suited for different types of conditions and stages of healing.
To understand the mechanisms by which cold and heat reduce acute musculoskeletal pain, it is first necessary to understand the mechanisms that cause the pain itself.
1️⃣Acute muscular injuries that occur because of either direct or indirect trauma include falls, sprains and collisions.
These can result in contusion at the point of contact, resulting in inflammation.
2️⃣Indirect trauma occurs because of excessive strain or force in the muscle without any direct contact, causing a disruption of myofibers.
In case you have an acute injury as an ankle sprain, it will lead to oedema, hyperalgesia, and erythema, which can potentially increase tissue damage, pain, swelling and delay healing.
Heat or cold therapy is sometimes recommended to help with the discomfort but there are some situations where you should not use it until you consult your doctor.
▶️ When should you not use cold or heat therapy at home before you speak to your doctor or therapist.
⚫A heart condition, such as angina
⚫Peripheral vascular disease
⚫Scar tissue
⚫High temperature or acute infection
⚫Heart disease
⚫Insensitivity to hot or cold
⚫Deep X-ray therapy as treatment
⚫Skin conditions such as: Dermatitis, eczema, broken skin.
⚫Cold sensitivity (rash / itching)
⚫Poor circulation
⚫History of cancer or tumour
There have been hundreds of academic publications on the subject for several years: And there is not a strong consensus in favour of heat or cold (Malanga 2015).
Here are the arguments put forward for applying heat rather than cold to tendon-related pain, and vice versa
▶️ What is the argument for applying a cold?
Cold therapy, also known as (cryotherapy) is the application of any substance or physical medium to the body that removes heat, decreasing the temperature of the affected area and adjacent tissues.
Many devices are available for application of cold and heat therapy, see on Amazon: bags of crushed ice, commercially available ice and gel packs, ice massage, cold compression units, and cold whirlpool.
| How it works! Cold causes blood vessels to constrict (narrow), reducing blood flow and helping to minimize swelling and inflammation. |
In return it:
🟠Reduces swelling which often causes pain.
🟠Cold acts as local anaesthesia, Numbs the affected area, hence reducing pain.
🟠Can be effective for recent injuries and acute pain be reducing muscle spasms:
🟠Cold can help to calm overactive muscles.
However cold therapy, if used inappropriately, can put you at risk for local cold-induced injuries, such as frostbite where the skin and underlying tissue freezes causing a cold feeling and numbness.
Some people who have used cold therapy inappropriately have reported complications such as:
🔴Allergic reactions.
🔴Burns.
🔴Intolerance/pain
🔴Cases of neuropathy of superficial nerves have been reported following ice application for muscle soreness (Moeller,1997)
▶️ What is the argument for applying heat?
Heat therapy is the application of heat to the body resulting in increased tissue temperature.
This can worsen inflammation by dilating blood vessels and increasing blood flow to the affected area which can increase heat and swelling.
It’s not certain that the effect of heat is sufficient to significantly increase inflammation, especially if applied for only a few tens of minutes per day.
Superficial modes of heat therapy include hot water bottles, heat and cold pads, electric heat pads, heat wraps, heated stones, soft heated packs filled with grain, poultices, hot towels, hot baths, sauna, paraffin, steam, and infrared heat lamps.
Most of these items can be bought in any local store or see on Amazon.
| How it works! Heat causes blood vessels to widen (dilate), increasing blood flow to the area and delivering oxygen and nutrients. |
▶️ Here are some of the advantages of heat therapy:
🟠Heat therapy can help relax muscles which helps reduce stiffness and discomfort
🟠Increase blood flow and metabolism which can help to speed up healing.
🟠Can be helpful for chronic pain and muscle spasms relief.
▶️What do clinical studies say about heat and cold?
Most recommendations for the use of heat and cold therapy are based on practical experience, with limited evidence to support the efficacy of heat or cold therapy.
Using Cold therapy to musculoskeletal injuries such as pain in the lower back and neck.
Here are some of the physiological effects noted by people who have used cold and heat therapy on musculoskeletal injuries such as pain in the lower back and neck pain.
🟠Reductions in pain.
🟠Cold therapy decreasing temperatures of skin and muscle which reduces blood flow to the cooled tissues, reducing the metabolic demand of hypoxic tissues, potentially preventing secondary hypoxic damage in injured tissue
🟠Cold therapy decreases in blood flow reducing edema and slows the delivery of inflammatory mediators (e.g., leukocytes), reducing inflammation of the affected area
Malanga,2015
A figure showing the physiological effects of cold and heat therapies (Image source Malange,2015)
Caution!⚠️ Cold therapy should be used with caution in patients with hypertension, mental impairment, or decreased sensation.
Cold therapy should not be used in patients with cold hypersensitivity, cold intolerance, or Raynaud’s disease, or over areas of vascular compromise (Malanga,2015)
There is limited evidence from randomized clinical trials supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness
Randomized clinical trials supporting the use of heat therapy have shown that:
🟠Heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of delayed-onset muscle soreness
Malanga,2015
A Chinese research team synthesized the results of 59 clinical studies involving 1367 individuals suffering from muscle soreness (Wang 2022).
Their conclusions:
🟣Within 48 hours following exercise, the use of warm compresses resulted in the best pain relief.
🟣More than 48 hours after exercise, cryotherapy (cold) was the optimal intervention for pain relief.
🟣The level of evidence remains low.
However, it is important to note that these recommendations should be treated with caution. Because different factors such as sex, reason for therapy should be put in play.
▶️ Conclusion should you alternate ice and heat therapy, and for how long.
Alternating between hot and cold can create a pumping action that improves circulation and lymphatic drainage, aiding in healing and reducing inflammation.
| The heat dilates blood vessels, and the cold constricts them, creating a cycle that helps flush out waste products and bring nutrients to the injured area. |
Yes, alternating between ice and heat therapy can be beneficial for certain injuries and conditions.
The initial cold application helps reduce inflammation, while the subsequent heat application helps to improve circulation and flexibility.
This can be particularly useful for injuries that are no longer in the acute phase but still require pain management and improved healing.
The general recommendation is normally to start with cold therapy for acute injuries because this will help reduce inflammation. And swelling.
✅If you find relief immediately after applying cold therapy, then you can continue.
❌But if you do not feel relief then you can try the heat therapy.
My personal experience: Usually when I have stomach pain, I normally prefer to use a warm hot water bottle to rub my stomach which helps with pain and helps me relax.
And when I burnt my finger one day, cold water helped me ease the pain.
I have also seen some people alternate between 1-2 minutes of cold and 3-4 minutes of heat for a total of 15-20 minutes, repeating the cycle 1-2 times per day.
The decision will be yours to decide which of the two provide more relief, then you can stick to one or if you try alternating and it works for you, then continue.
▶️How to do hot and cold therapy at home safely?
Protect your skin:
⚪Always use a barrier, like a towel, between your skin and the heat or ice source to prevent burns or frostbite.
⚪For ice cubes in a plastic bag or a packet of frozen peas, wrap them in a towel or pillowcase to protect your skin.
⚪Place the pack over the injured area. Leave it on for 10-15 minutes until the ice starts to melt and then remove.
⚪Never leave the pack on for more than 20 minutes.
⚪This treatment may be repeated every 2 to 3 hours, if your skin temperature has returned to normal.
Never use boiling water and make sure the hot water bottle is wrapped in a towel and has enough layers to avoid burn.
⚪Do not over do: Limit heat or cold application to 15-20 minutes at a time, with breaks in between.
⚪Do not go to sleep whilst using heat treatment.
⚪Leave on for 10 to 15 minutes and then remove.
⚪This treatment may be repeated up to 3 times a day
Listen to your body: If you experience discomfort or pain, stop the therapy.
Remember: whether you use heat or cold for your muscle and tendon pain, you’re not exposing yourself to a risk of complications!
Here’s what I wanted to tell you about this! I wish you a very quick recovery! 🙋
Do you have any comments or questions? Your comments are welcome!
📚Source:
Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med. 2015 Jan;127(1):57-65. doi: 10.1080/00325481.2015.992719. Epub 2014 Dec 15. PMID: 25526231.
Moeller JL, Monroe J, McKeag DB. Cryotherapy-induced common peroneal nerve palsy. Clin J Sport Med. 1997 Jul;7(3):212-6. doi: 10.1097/00042752-199707000-00011. PMID: 9262890.
Wang Y, Lu H, Li S, Zhang Y, Yan F, Huang Y, Chen X, Yang A, Han L, Ma Y. Effect of cold and heat therapies on pain relief in patients with delayed onset muscle soreness: A network meta-analysis. J Rehabil Med. 2022 Feb 8;54:jrm00258. doi: 10.2340/jrm.v53.331. PMID: 34636405; PMCID: PMC8862647.