3 Easy Rules When Choosing Heat or Ice For Chronic Pain Relief

One of the most common questions I get as a physical therapist is, “Should I use hot or cold to help manage my pain?” Heating pads and ice packs are simple and accessible pain management tools that should be included in the treatment arsenal of anyone living with a chronic pain. Many people tend to prefer to utilize heat, because they find it to be more comfortable and relaxing. Luckily, for many chronic pain sufferers, heat is in fact the better choice, but there are specific circumstances when ice should be used.

Outlined below are three easy to follow rules on how to choose between ice or heat when you have a pain flare.

  1. If your pain is “acute” use ice, if your pain is “chronic” use heat

An acute injury, means an injury that is new or has just recently occurred. An example of this would be a recent ankle sprain. Unfortunately, those with chronic pain are not immune to new injuries, and ice would be the best choice in this case.

Here’s why: When an injury occurs a natural inflammatory cascade floods the injured area to initiate the healing response. The area swells as a result of the increased blood flow and local soft tissue damage and causes compression on the nerves in the immediate area. The result is a red, hot, painful blob where you ankle used to be.

This inflammatory process is important but should not be allowed to go on too long. The application of ice causes local vasoconstriction or reduction in the size of blood vessels. This will help to reduce the risk of the area swelling more and will also allow the excess fluid to return to circulatory system once the healing molecules have done their job. Ice can additionally help to reduce pain by numbing the area and reducing sensation from the aggravated nerve endings.

The application of heat at this point in the healing process would cause further vasodilation, or widening of the blood vessels, bringing more blood to the area causing increased and excess inflammation. In other words, your ankle would become more of a red, hot, swollen blob—not good. Wait about 2 weeks, or until the swelling is gone, to apply heat to the area.

When an injury is chronic, the natural inflammatory reaction as described above has completed or the pain is occurring in an area where an acute injury has never occurred. The application of heat can be safe and effective in this case, as you do not need to worry about worsening swelling.

  1. Choose ice or heat based on your medical history or diagnosis

When diagnosed with a chronic health condition that results in pain, ensure that you discuss all possible pain management strategies with your doctor. Make sure that you know which of your diagnoses could cause heat or cold sensitivity or intolerance- a possibility with some autoimmune diseases. In your quest to reduce your pain, the last thing you need is to stress your system or cause a new injury.

Here are examples of some chronic illnesses that could result in heat sensitivity/intolerance:

  • Diabetes – be very cautious with application of heat if you have decreased sensation in your hands and feet as you could burn yourself
  • Multiple sclerosis – heat is known to worsen symptoms in those with MS and therefore should be avoided

Here are some examples of medical conditions that could result in cold sensitivity/intolerance:

  • Raynaud’s Syndrome – avoid completely in affected areas due to circulatory concerns
  • Fibromyalgia – may be okay depending on the person, but some find cold too uncomfortable or report that it increases their pain
  1. Identify the type of pain you are having and choose accordingly

Here are guidelines for type of pain and recommendations for use of heat/ice:


  • Muscle pain/spasm
  • Tension headache
  • Abdominal cramps
  • Arthritic joints


  • Tendonitis
  • Migraine headache
  • Burning pain
  • Nerve pain
  • Swollen joints

I hope these guidelines are helpful if choosing between ice and heat during a pain flare. Please feel free to leave any questions or comments below!

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