Do you have an injury? Should you reach for an ice pack or heating pad?

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If you are injured, should you apply ice or heat to treat the pain? An emergency room doctor explains.

There are as many as 35 million emergency room visits across the country for injuries. Most of these are musculoskeletal injuries that are treated with X-ray imaging, splints, and possible orthopedic surgery consultations. Most acute pain from stable fractures and sprains can be treated with standard medications such as acetaminophen, ibuprofen, and narcotics.

The larger debate between emergency physicians and orthopedic surgeon centers is about which complementary non-pharmacological treatment strategy is better for pain relief and healing – cold or heat therapy.

There is limited data comparing the two modalities in direct studies. Individually, both have shown a reduction in acute pain in small studies. I have found that most doctors will recommend patients use one or the other based on their own anecdotal experience.

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What is the science behind applying heat and cold for pain relief?

Application of cold therapy such as an ice pack signals the brain to trigger a complex physiological response. The muscle walls of blood vessels contracts in a process called vasoconstriction. This vasoconstriction reduces blood flow to the affected area, effectively limiting inflammation and suppressing pain.

Cold therapy options include:

• ice packs
• ice baths
• coolant spray
• ice massage

Heat therapy, on the other hand, relaxes the blood vessel wall muscles via vasodilation, increasing their diameter and increasing blood flow. Heat therapy improves circulation and the flow of healing nutrients to the injured area. As with cold therapy, it has also been shown to reduce pain. In fact, a systematic review of 32 randomized control trials involving more than 1,000 study participants showed that both cold and heat were effective at reducing pain.

Heat therapy options include both dry and moist heat options:

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General rule: 20 minutes on, 20 minutes off

As a rule of thumb, you should apply cold or heat therapy for 20 minutes and then take a 20 minute break.

In general, cold and warm therapy is a good option for many patients. However, never apply cold or hot directly to an open wound. Patients with chronic medical problems such as diabetes, dermatitis, multiple sclerosis and vascular diseases should exercise caution or consult their physician first.

The bottom line: both ice and heat are an option. Personally, I recommend using a 20-minute cold therapy session for acute injury pain. Ice works very well to reduce both pain and swelling. After 72 hours, switch to heat to increase blood flow, improve healing and reduce stiffness in the affected area.

Michael Daignault, MD, is a board-certified ER physician in Los Angeles. He studied Global Health at Georgetown University and received a medical degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps volunteer. Find him on Instagram @dr.daignault

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