Fire and Ice — Part I

Fire and Ice — Part I

Fire and Ice — Part I


Almost inevitably, the first question I am asked by any athlete (or non-athlete, for that matter) who has suffered a sprain or strain is, “Should I use heat or cold?” Given the ever-changing state of medical knowledge, it probably shouldn’t be a surprise that a great deal of confusion and/or ignorance persists about these most basic of all injury treatments, but I must say I am somewhat puzzled by the perpetuation of certain “myths” concerning the appropriate use of these physical modalities. As we get into the heart of the racing (muscle/tendon strains) and trail run (joint sprains) season, this might be a good time to clarify the issue.

First and foremost is the “rule” regarding treatment of sprains, particularly of the ankle. It seems most everyone seen in an Emergency Room is advised to “use ice the first 24 hours, then apply heat after that.” The fact is, if you have anything but a very mild sprain, the second part of this statement is the worst thing to do.

A joint sprain is an overstretch or tearing of ligaments, the structures that are primarily responsible for holding two separate bones together. But the ligaments aren’t the only tissues injured: blood vessels (capillaries) within and around the ligaments are also torn, in addition to supporting connective tissues. This causes bleeding into the surrounding areas (black and blue discoloration) as well as leakage of other fluids (plasma) which results in what we know as swelling of the joint. Application of cold (along with compression and elevation) arrests this process, thus limiting the amount of swelling, which is important since severe swelling in itself will stretch and damage the surrounding tissues. Use of heat (soaks, hot water bottles,etc.) will do just the opposite — it will cause the body to bring more fluid to the area, resulting in greater swelling. So how did the 24-hour rule come to be?

The thinking was that after 24 hours of cold treatment the blood and fluids that had leaked out was now starting to coagulate. Continued application of cold would inhibit circulation and prevent normal healing of the injured structures. Use of heat, on the other hand, would “flush out” the area by promoting circulation, which would also enhance healing by delivering oxygen and nutrients to the tissues.

This was a good theory but for one slight problem: with the exception of the mildest cases, the leakage of fluids continues well after the first 24 hours. Use of heat at that point in time will only reverse the process started by icing and accelerate the resumption of swelling. Unfortunately, this is something I have seen too often with patients who have followed the advice given to them in the ER or from books on athletic injuries that still tout the “24-hour rule.”

What rule should you follow? As always, listen to your body, not the clock! If the area is still warm-to-touch, red, and/or boggy swollen even one week after the injury, continue to use ice packs with compression and elevation, generally 15 minutes at a time. (If you’re still having these signs after one week, you should probably be seeing a professional anyway, and he/she will advise you on the proper treatment.) The same principle applies to muscle/tendon strains, although it’s not as easy to feel the physical signs described above. But we’ll take that up, along with when to use heat, in Part II next month.

Gabe Yankowitz

Gabe is a long-time runner and physical therapist currently practicing in Manlius. Gabe is a physical therapist in Central New York for the past 35 years, specializing in orthopedic treatment and rehabilitation. His website is

  • Physical therapy degree from Upstate Medical Center (1983)
  • Doctor of Physical Therapy degree from the Massachusetts General Hospital Institute of Health Professions  (2007)
  • Board-Certification as Clinical Specialist in Orthopedic Physical Therapy (2009).