Expert: J.R. Strecker, B.S., D.C. - 5/19/2009

Question
I have a tear in my rotator cuff.  I went to physical therapy and felt better, but the pain has returned.  I cannot sleep at night and so I have been putting heat on it.  Am I making the injury worse?  Should I be icing it instead?

Answer
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Hello S.,

That’s a great question!  It’s almost controversial; you talk to 100 different doctors and you’re going to get a hundred different answers.  This is a big topic I bring up with a lot of my private patients because so many people really don’t know the answer.  And you’re right; it’s possible if you’re doing the wrong thing at the wrong time, it will make your condition worse.

First off, I have to say to never apply ice (or a strong heating pack) directly on the skin.  Your skin should be protected, so always wrap the ice (or heat pack) in a towel or cloth.  Also, never ice or heat an affected area for more than 15-20 minutes at a time, taking an hour break in between treatments.

Additionally, I always say, when in doubt, use ice.  Ice is anti-inflammatory and can never do any harm (if the skin is protected).  The worst that will happen is it just won’t help you, but at least it won’t harm you.  Heat can be pro-inflammatory, which can be bad or good, depending on its purpose.  If the injury is acutely inflamed, like when you sprain an ankle and it swells up, the heat will make it worse.  The confusing problem for so many people, however, is that the heat will actually feel good.  Your not going to notice the problem or have more pain until AFTER you’ve finished the heat therapy, such as two hours later, which is when people throw the heat back on to take away the pain again.  This can create a vicious cycle.  For example, if you sprained your ankle a minute ago, everyone knows to put ice on immediately after to get the swelling and inflammation down.  However, if you used heat during this time, it would help reduce the pain, but two hours later the pain will be back with a vengeance.  This is true for any area of the body.  So just because you don’t see the swelling in your rotator cuff just the same as you do in a sprained ankle does not mean there isn’t swelling in the shoulder.  

Many practitioners steer patients wrong after the initial injury.  They use a general rule that after the first few days of an injury, use only heat.  This is not necessarily true.  So I use a saying to help guide patients when to use the heat and ice: warm up, cool down.  What I mean by that is just like exercise; if you’re going to run, you shouldn’t just break out in a sprint after stepping onto the treadmill.  Rather, you should start walking and increase the speed gradually over time.  Then, you don’t just stop when you’re done.  You should gradually decelerate your speed over time until you’re finally walking again.  This is how the body works; it’s not just an on/off switch.  So in the morning, you might want to warm up (provided there is no re-injury to the shoulder).  To do that, you can use a hot pack or take a warm shower.  If you’re still injured, you can follow up with the ice after the hot shower; remember, warm up, cool down.  But if you’ve had a long day at work and you’ve used your shoulder a bunch during the day, your shoulder is already “warmed up” (rather, inflamed) so don’t even bother with the heat on a day like this.  Instead just do the ice before going to bed (cool down).  I would say more often than not, patients should be using ice.  And when patients need heat, they often should follow up with the ice after the heat.  When in doubt, use ice.  If the ice doesn’t help over a few days, then gradually throw in the heat with ice following the heat application, to where you can just use the heat when the injury starts to become more stable.