To Cool or not to Cool, that is the Question: A Review of the Literature

Emma Mackie

MPhty (sports) Physiotherapy

Hobsonville Physiotherapy, Hobsonville, Auckland


As recently as March 2014 Gabe Mirkin, the doctor who coined the term RICE (Rest, Ice Compression, Elevation) in terms of managing soft tissue injury, has said he was wrong. “Coaches have used my “RICE” guideline for decades, but now it appears that both ice and complete rest may delay healing, instead of helping”. This profound and potentially game changing statement has gone almost unnoticed. It has as yet, had no effect on the management of acute soft tissue injury both pitch side and within clinic. Therefore clinicians may need to start considering what they aim to achieve from their chosen application modality for an acute muscle injury i.e. reduce pain, reduce swelling, strengthen and stabilise the affected area. Thus allowing the clinician to gain maximal clinical effectiveness and best outcome for the athlete.

The Science Bit:

The physiological and clinical effects of both hot and cold application, be it positive or negative, are vital to understand when it comes to implicating and justifying your chosen treatment modality be it hot or cold for the management of an acute soft tissue injury.

What I found:

Based on the literature available (37 suitable articles and reviews) the evidence suggests that the application of ice to an acute muscular injury can be potentially detrimental in terms of muscular repair and ultimately return to play. It has been shown that application of ice can delay healing times by as much as 24 hours while also exposing the athlete to risk of further injury should they return to play within 30 minutes of ice being applied. In comparison, heat application, therapeutically, has be seen to have an equally and in some situations grater analgesic effect, accelerate healing times and have even been proven to prevent injury if applied pre-sporting activity.

Q:  At what point / time post injury to apply the heat?

A:  Immediately post (immediate being up to 24 hours)

Thus it can be determined that ice is not the solitary or the superlative approach to the management of soft tissue healing post acute traumatic injury and that heat application, may actually be preferable in terms of healing times and return to play for the injured athlete.

Therefore physiotherapists should be aware of the desired outcome of their treatment methodologies and have a valid reason for choosing ice over any other treatment method.

More research needs to be conducted in terms how heat should be applied, establishing the frequency and duration of application of the modality along with whether other such accompaniments such as compression, loading or rest should be conducted adjacent to the application of heat to an acute traumatic soft tissue injury in order to maximise the best preferable outcome for the patient.

It is important to stress that this is the view of one person and more research does need to be completed prior to my findings becoming the status quo both clinically and within the population as a whole.

Q:  Any guidelines as to when heat could be applied post injury / duration and temp?-

A:  None as yet but my advice would be just like RICE, apply immediately 15-20min over the sight of injuy (34-37 degrees centigrade) – however people need to be aware of contraindications such as haemophilia or if they are on blood thinners etc so they don’t bleed too much!