Heat or Ice for Sore Muscles DOMS

Are you just starting a new workout plan or did you really push it during your last workout? Then you are probably preparing yourself all too familiar muscle soreness to kick in. So the question is should you use Ice or Heat for your sore muscles? Let’s dive in!

Muscle soreness is a familiar experience for both elite and novice athletes. Symptoms can range from mild muscle tenderness to severe pain. According to a review article in the Journal of Sports Medicine, Delayed Onset Muscle Soreness or “DOMS is most prevalent at the beginning of the sporting season when athletes are returning to training following a period of reduced activity. DOMS is also common when athletes are first introduced to certain types of activities regardless of the time of year.” (Cheung et al., 2003)

But what exactly is causing this pain to occur? That same review article in Sports Medicine states that “Up to six hypothesized theories have been proposed for the mechanism of DOMS, namely: lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation and the enzyme efflux theories. However, an integration of two or more theories is likely to explain muscle soreness.” (Cheung et al., 2003)

Generally, this muscle soreness occurs within 24 hours following exercise. It then reaches its highest levels between 24 and 72 hours then gradually decreases over the next 5 to 7 days.

Many different treatment strategies have been proposed to decrease the pain and the decrease in performance associated with DOMS. These include heat therapy, cryotherapy, massage, electrical stimulation, NSAIDs like ibuprofen, ultrasound, compression, and many more.

Today I want to focus on the 2 most common and easily accessible treatment strategies namely heat therapy and cryotherapy. Both heat and cold therapy are part of the standard of care when it comes to treating musculoskeletal pain.

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 contact area and adjacent tissues.” “Many devices are available for application of cold therapy, including bags of crushed ice, commercially available ice and gel packs, ice massage, cold compression units, and cold whirlpool.” (Malanga et al,. 2014)

The general idea as stated in this systematic review in the Journal of Athletic Training is, “Ice is used to limit the injury-induced damage by reducing the temperature of the tissues at the site of injury and consequently reducing metabolic demand, inducing vasoconstriction, and limiting the bleeding. It also can reduce pain by increasing threshold levels in the free nerve endings and at synapses and by increasing nerve conduction latency to promote analgesia.” (Bekerom et al., 2012)

More simply put, cryotherapy is thought to work through decreasing tissue temperature. This leads to decreased pain levels, lower rates of metabolism, less muscle spasm, and a minimization of the inflammatory processes which could aid in recovery following acute injury.

Heat therapy on the other hand “… is the application of heat to the body resulting in increased tissue temperature. Superficial modes of heat therapy include hot water bottles, heat 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.” (Malanga et al., 2014)

“Physiological effects of heat therapy include pain relief, increases in blood flow and metabolism, and increased elasticity of connective tissue.” “The rate of local tissue metabolism is also increased by warming, which may further promote healing.” (Malanga et al., 2014)

So how do these 2 therapies compare when we are talking about muscle soreness following a hard workout? Luckily there are some well-done studies looking at just this.

In one study posted in the Archives of Physical Medicine and Rehabilitation, participants performed a vigorous eccentric exercise to experimentally induce low back DOMS. They were then split into 2 groups. One group applied a continuous low-level heat wrap like one made by Thermacare to the low back region, 2 times for 8 hours each, beginning at hours 18 and 32 post-exercise. In the other group, participants applied a standard gel-filled, reusable cold pack to the low back for 15 to 20 minutes every 4 hours between hours 18 to 42 post-exercise.

The results were as follows, “At hour 24 post exercise, the mean pain relief score for the heat wrap group was 138% greater than for the cold pack group.” (Mayer et al., 2006)

They go on to say that “The finding in this study that the heat wrap provided superior pain relief at 24 hours postexercise compared with the cold pack treatment of low back DOMS appears to be contrary to the traditional practice of relieving acute muscular pain with cold pack therapy, a form of cryotherapy.” (Mayer et al., 2006)

Another study posted in the Journal of Strength and Conditioning looked at the difference between heat and cold therapy in 100 healthy individuals between the ages of 20 and 30. They performed squats for 5 minutes to induce DOMS. The participants were then split into 5 groups as follows; a control group, another group who used a cold pack immediately after exercise, cold packs applied 24 hours after exercise, heat packs applied immediately after exercise, and heat packs applied 24 hours after exercise.

The heat pack groups used Thermacare heat wraps for 8 hours and the cold group used a cold pack for 20 minutes.

The results were as follows; for strength testing “The heat immediate group recovered by the second day after exercise to the pre-exercise strength, whereas the cold immediate group still showed a significant loss in strength at 3 days after exercise (p < 0.05) compared to the pre-exercise strength.”

With regards to pain “The least pain was felt 1 day after exercise and was in the heat immediate and cold immediate groups; there was no statistical difference between the hot and cold groups 24 hours after exercise.”

They discuss their results as follows “For some reason in athletics, it is believed that cold after exercise is the best modality to prevent swelling and damage to muscle. At least for this age group, this is not true. There is a definite advantage of heat after exercise, if applied or used immediately. Cold and heat both prevent muscle damage, but on balance, heat actually has small advantages over cold in increasing healing after a heavy workout.” (Petrofsky et al., 2015)

So heat is looking like it has some advantages over cold when it comes to improving recovery following a hard workout. But when should you apply the heat? Should you use it right after exercise or wait until the pain and stiffness kicks in?

One study compared the use of heat wraps either immediately after an exercise designed to produce DOMS or they waited for 24 hours after the exercise to begin the heat therapy. They noted that “The best use of heat was for 8 hours after exercise because soreness was less, as was the apparent muscle and tendon damage.” (Petrofsky et al., 2017) Meaning that earlier use of heat therapy produced better results with regards to pain reduction, strength production, and reduction in blood markers for muscle damage.

In most of these studies, the researchers used continuous low-level heat wraps like the ones made by ThermaCare. This is a much different therapy then using something like a heating pad, moist heat from a hydrocollator, or infrared heating lamps for 15 minutes multiple times a day.

The researchers in the above study state that “The advantage of ThermaCare heat wraps is that they slowly raise internal tissue temperatures and maintain the temperature for hours. This is especially important because if individuals have thick subcutaneous fat, a 20-minute heat modality may not even penetrate the skin and get into fascia and muscle.” (Petrofsky et al., 2017)

This is one reason why I believe that these studies above show advantages of heat therapy over cold which is contrary to previous work which shows conflicting information comparing the 2 modalities.

For example, a large Cochran Systematic Review n 2006 looked at nine clinical trials involving 1117 participants comparing heat or cold for low back pain. They summarize their findings as follows; “In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days compared to oral placebo.”

They go on to say “There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain.” (French et al., 2006)

So as summarized by the Sports Medicine review article, “Thus, cold application, other than its analgesic effect, provides little benefit.” (Cheung et al., 2003)

By contrast according to a review article in Postgraduate Medicine, “Heat therapy has demonstrated therapeutic benefit for both analgesia and promoting healing in certain injuries. Thermotherapy can be used as monotherapy or in combination with oral analgesics to relieve acute low back pain and muscle soreness.” (Malanga et al., 2014)

I want to point out that this information should not be taken as specific medical advice. If you have an injury or musculoskeletal condition I highly recommend that you seek out a medical professional for accurate diagnosis and the creation of a treatment plan to get you better faster.

I hope that you have found this helpful. If you have any questions or comments please leave them in the comments below. And make sure that you are subscribing and following for more great content.

Again this is Floyd Meyer reminding you to Recover Better so you can Do More!




Bieuzen, F., Bleakley, C. M., & Costello, J. T. (2013). Contrast Water Therapy and Exercise Induced Muscle Damage: A Systematic Review and Meta-Analysis. PLoS ONE, 8(4), e62356. doi:10.1371/journal.pone.0062356 

Bleakley CM, Glasgow PD, Philips P, et al. for the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). Guidelines for the management of acute soft tissue injury using protection, rest, ice, compression and elevation. London: ACPSM, 2011

Bleakley, C. M., Costello, J. T., & Glasgow, P. D. (2012). Should Athletes Return to Sport After Applying Ice? Sports Medicine, 42(1), 69–87. doi:10.2165/11595970-000000000-00000  

Bleakley, C., McDonough, S., & MacAuley, D. (2004). The Use of Ice in the Treatment of Acute Soft-Tissue Injury. The American Journal of Sports Medicine, 32(1), 251–261. doi:10.1177/0363546503260757

Cheung, K., Hume, P. A., & Maxwell, L. (2003). Delayed Onset Muscle Soreness. Sports Medicine, 33(2), 145–164. doi:10.2165/00007256-200333020-00005 

Daniel, D. M., Stone, M. L., & Arendt, D. L. (1994). The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 10(5), 530–533. doi:10.1016/s0749-8063(05)80008-8 

Engelhard, D., Hofer, P., & Annaheim, S. (2019). Evaluation of the effect of cooling strategies on recovery after surgical intervention. BMJ Open Sport & Exercise Medicine, 5(1), e000527. doi:10.1136/bmjsem-2019-000527 

Farahbod, F. (2014). The Efficacy of Thermotherapy and Cryotherapy on Pain Relief in Patients with Acute Low Back Pain, a Clinical Trial Study. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. doi:10.7860/jcdr/2014/7404.4818 

French, S. D., Cameron, M., Walker, B. F., Reggars, J. W., & Esterman, A. J. (2006). A Cochrane Review of Superficial Heat or Cold for Low Back Pain. Spine, 31(9), 998–1006. doi:10.1097/01.brs.0000214881.10814.64 

Howatson, G., Goodall, S., & van Someren, K. A. (2008). The influence of cold water immersions on adaptation following a single bout of damaging exercise. European Journal of Applied Physiology, 105(4), 615–621. doi:10.1007/s00421-008-0941-1 

Hsu, J. R., Mir, H., Wally, M. K., & Seymour, R. B. (2019). Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of Orthopaedic Trauma, 1. doi:10.1097/bot.0000000000001430 

Hubbard TJ, Aronson SL, Denegar CR. Does cryotherapy hasten return to participation? A systematic review. J Athl Train. 2004;39(1):88–94.

Johar, P., Grover, V., Topp, R., & Behm, D. G. (2012). A comparison of topical menthol to ice on pain, evoked tetanic and voluntary force during delayed onset muscle soreness. International journal of sports physical therapy, 7(3), 314–322.

Kuo, C.-C., Lin, C.-C., Lee, W.-J., & Huang, W.-T. (2013). Comparing the Antiswelling and Analgesic Effects of Three Different Ice Pack Therapy Durations. Journal of Nursing Research, 21(3), 186–193. doi:10.1097/jnr.0b013e3182a0af12 

Malanga, G. A., Yan, N., & Stark, J. (2014). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine, 127(1), 57–65. doi:10.1080/00325481.2015.992719 

Mayer, J. M., Mooney, V., Matheson, L. N., Erasala, G. N., Verna, J. L., Udermann, B. E., & Leggett, S. (2006). Continuous Low-Level Heat Wrap Therapy for the Prevention and Early Phase Treatment of Delayed-Onset Muscle Soreness of the Low Back: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 87(10), 1310–1317. doi:10.1016/j.apmr.2006.07.259 

Meeusen, R., & Lievens, P. (1986). The Use of Cryotherapy in Sports Injuries. Sports Medicine, 3(6), 398–414. doi:10.2165/00007256-198603060-00002 

Nadler, S. F., Steiner, D. J., Erasala, G. N., Hengehold, D. A., Hinkle, R. T., Beth Goodale, M., … Weingand, K. W. (2002). Continuous Low-Level Heat Wrap Therapy Provides More Efficacy Than Ibuprofen and Acetaminophen for Acute Low Back Pain. Spine, 27(10), 1012–1017. doi:10.1097/00007632-200205150-00003 

Petrofsky, J. S., Khowailed, I. A., Lee, H., Berk, L., Bains, G. S., Akerkar, S., … Laymon, M. S. (2015). Cold Vs. Heat After Exercise—Is There a Clear Winner for Muscle Soreness. Journal of Strength and Conditioning Research, 29(11), 3245–3252. doi:10.1519/jsc.0000000000001127 

Petrofsky, J., Berk, L., Bains, G., Khowailed, I. A., Lee, H., & Laymon, M. (2017). The Efficacy of Sustained Heat Treatment on Delayed-Onset Muscle Soreness. Clinical Journal of Sport Medicine, 27(4), 329–337. doi:10.1097/jsm.0000000000000375

Qaseem A, Wilt TJ, McLean RM, et al, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514–530. doi: https://doi.org/10.7326/M16-2367

Stöckle, U., Hoffmann, R., Schütz, M., von Fournier, C., Südkamp, N. P., & Haas, N. (1997). Fastest Reduction of Posttraumatic Edema: Continuous Cryotherapy or Intermittent Impulse Compression? Foot & Ankle International, 18(7), 432–438. doi:10.1177/107110079701800711 

Torres, R., Ribeiro, F., Alberto Duarte, J., & Cabri, J. M. H. (2012). Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: Systematic review and meta-analysis. Physical Therapy in Sport, 13(2), 101–114. doi:10.1016/j.ptsp.2011.07.005

Van den Bekerom, M. P. J., Struijs, P. A. A., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. M. J. (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Journal of Athletic Training, 47(4), 435–443. doi:10.4085/1062-6050-47.4.14


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