Cryotherapy Guidelines

Developed by:
A. Hoens  Physical Therapy Knowledge Broker (UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Health Research Institute, Providence Health Care Research Institute)
M. Paul  Clinical Nurse Educator (OASIS Program, Vancouver Coastal Health)

When, Why, and How[edit | edit source]

Clinical Problem Signs & Symptoms Timing Clinical Objectives Intervention and Mechanism of Action


  • Pain

Acute Phase
(First 72 hours after a flare‐up or injury)

  • To reduce pain


  • Slows nerve conduction of pain message
  • More effective and appropriate for acute rather than chronic pain
  • Should NOT be used if suspected or confirmed Complex Regional Pain Syndrome (CRPS)


  • Heat
  • Redness
  • Swelling
  • Pain
  • Reduced function

Acute Phase
(First 72 hours after a flare‐up or injury)

  • To limit the extent of the inflammatory reaction


  • Decreases metabolic rate, and thus required blood flow, of the cells which were not originally involved in the injury; thereby controls the extent of the inflammatory reaction
  • Temporary vasoconstriction of superficial blood vessels only
  • The use of contrast baths to stimulate vasoconstriction and vasodilation is effective primarily in areas of ateriovenous anastamoses (ears, fingers, toes)

Combination of rest, cooling, compression and elevation (RICE)

  • Most effective in controlling inflammation when applied immediately post injury (<48‐72 hours)


  • No heat
  • No redness
  • Pitting edema (indicates presence of dead cells)
  • Swelling

72 hours ‐ 7 days

  • To assist in phagocytosis of the dead cell material
  • To control extraarticular swelling
  • To quickly resolve intraarticular swelling

Combination of eliciting muscle pump (active gentle muscle contractions), soft tissue massage, elevation and compression

  • Promotes movement of extracellular fluid into lymphatic drainage
  • Promotes circulation, which in turn promotes phagocytosis of dead cells

Swelling: Intraarticular

  • No heat
  • No redness
  • Possible pain and reduced muscle function/muscle atrophy (muscles surrounding the joint are typically inhibited by intraarticular swelling)

After 7‐10 days

  • To enhance exchange of fluid from intra‐ to extraarticular

ROM/Joint mobilization

  • Movement of fluid into and out of a joint does not occur primarily through blood vessels but rather through the bone‐cartilage interface and through the synovial membrane; this occurs during movement of the joint
  • Movement of the joint increases nutrition to the cartilage
  • Intraarticular swelling
    • Gentle short‐arc ROM
    • Gentle manual compression/traction
    • Grade 1‐2 joint mobilizations to create a pressure differential to assist in exchange of fluid intra‐ and extraarticular

Swelling: Extraarticular

  • No heat
  • No redness
  • An increase in tissue girth but no pitting edema

After 7‐10 days

  • To assist in resolution of swelling, normalization of movement and return of function (including strengthening)

Combination of eliciting muscle pump (active gentle muscle contractions), soft tissue massage, elevation and compression

Key Considerations[edit | edit source]

Inflammation, edema and swelling[edit | edit source]

These terms are NOT synonymous

  • Each symptom is associated with a different phase in the ‘continuum of resolving inflammation’
  • The specific clinical problem and the desired mechanism of action should guide the selection of the intervention

Is there an optimal ‘dosage of cryotherapy?’[edit | edit source]

There is no optimal dosage that is ideal for all body locations. Consider the nature of the tissue when icing:

  • The duration of icing for a small area with minimal fat and muscle, such as a finger, would be significantly less (~3‐5 minutes) than that for a larger area and deeper tissue such as at the hip (~20 minutes)
  • Intermittent icing (e.g., 10 minutes on: 10 minutes off) may be more effective for management of acute inflammation than icing for 20 consecutive minutes

Type/duration of cooling dependent upon the goal
[edit | edit source]

Cooling to reduce pain will likely require less intense (ice pack) and shorter durations (5 minutes)

  • Cooling to reduce metabolism of uninjured cells will likely require more intense cooling (ice bath or ice chips in a wet towel) for longer durations (10‐15 minutes)
  • The hierarchy of the efficiency of cooling from most to least: ice‐water immersion, crushed ice, frozen peas and gel pack

Possible Risks/Undesirable Effects[edit | edit source]

Inhibit muscle function

  • Cooling can temporarily Inhibit muscle function with potential for increased risk of injury/re‐injury
  • Be cautious when having patients weight bear/undertake complex exercise after icing a lower extremity

Ice burn

  • Elderly patients with impaired sensation and/or circulation will be more vulnerable to an ice‐burn, therefore consider using less intense icing techniques (e.g., moderately cold ice pack wrapped in an insulating layer(s) of toweling)
  • Younger patients with intact sensation and circulation may benefit most from direct immersion of the limb in cold water then progressively adding ice cubes
  • Cold gel packs stored in a freezer have a surface temperature below 0°C (32°F) and thus an insulating layer should be used between the cold pack and the patient’s skin

Cryotherapy‐induced nerve injuries

  • Most common when cold is applied in combination with compression
  • Check capillary refill during application of ice combined with compression therapy to ensure adequate blood flow

Generalized cooling and decrease in core temperature

  • Shivering and piloerection are signs of decrease in core temperature which may compromise patient safety (especially in the elderly and those with fever)
  • The application of therapeutic cryotherapy should produce only local effects

Reduced ROM

  • Ice may contribute to shortening of collagen fibers in connective tissue
  • After gaining ROM by warming, stretching and then strengthening in the newest part of the ROM, it is likely counterproductive to cool the tissue in a shortened position
  • If one wishes to cool the tissue post stretch and exercise, it is best to do so with the tissue in a lengthened position
  • In patients with significantly restricted ROM due to scar tissue, it may be preferable not to use ice

Be aware of conditions in which icing is contraindicated

  • E.g. CRPS, hemoglobinuria, cryoglobinemia, Raynaud’s disease and cold uticaria

Links[edit | edit source]

For more information regarding cryotherapy and other electrophysical agents, check out Volume 62 Issue 5 of Physiotherapy Canada Journal (University of Toronto Press, Fall 2010):
Electrophysical Agents - Contraindications and Precautions: An Evidence-Based Approach to Clinical Decision Making in Physical Therapy.

References[edit | edit source]

  • Barlas D et al (1996). In vivo tissue temperature comparison of cryotherapy with and without external compression. Ann Emerg Med, 28, 436‐439.
  • Bleakley CM et al (2010). Is it possible to achieve optimal levels of tissue cooling in cryotherapy? Physical Therapy Reviews. 15(4): 344‐350.
  • Bleakley CM et al (2006). Icing protocols for acute ankle sprain. Br. J Sports Med, 40:700‐705.
  • Bleakley CM et al (2006). Cryotherapy for acute ankle sprains: a randomized controlled study of two different icing protocols. Br. J. Sports Med. 40, 700‐705.
  • Bleakley CM et al (2004). The use of ice in the treatment of acute soft tissue injury: a systematic review of RCTs. Am J Sports Med, 32:251‐61.
  • Chesterton L et al (2002). Skin temperature response to cryotherapy. Arch Phys Med Rehabil, 83, 543‐549.
  • Ernst E & Fralka V (1994). Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. J Pain Symptom Manage, 9: 56‐9.
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  • Ho S et al (1995). Comparison of various icing times in decreasing bone metabolism and blood flow in the knee. Am J Sports Med, 23, 74‐76.
  • Houghton PE, Nussbaum E, Hoens A (2010). Electrophysical Agents Contraindications and Precautions. An evidence‐based approach to clinical decision‐making in Physical Therapy. Physiotherapy Canada. Special Issue; 62(5).
  • Ivans D (2006). Acute ankle sprain: An update. Am Fam Physician, 74: 1714‐20, 1723‐4, 1725‐6.
  • Karonkkara RG et al (1999). Changes in forearm blood flow during single and intermittent cold application. J Orthop Sports Phys Ther, 29: 177‐80.
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  • Merrick MA et al (1999). A preliminary examination of cryotherapy and secondary injury in skeletal muscle. Med Sci Sports Exerc, 31, 1516‐1521.
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  • Oosterveld F et al (1992). The effect of local heat and cold therapy on the intraarticular and skin surface temp of the knee. Arth Rheum, 35, 146‐151.
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  • Tsang K et al (1997). The effect of cryotherapy applied through various barriers. J. Sports Rehabil, 6, 343‐354.