Heat or Cold for Joint Pain: Which and When

How heat and cold work

Heat widens blood vessels, increases blood flow, relaxes tight muscles and eases stiffness. It may make joints feel looser and prepare them for movement. It can also soothe aching.

Cold narrows blood vessels, reduces swelling and numbs pain signals. It can calm an inflamed, hot joint and dull sharp pain.

Both give temporary relief and do not change the underlying disease. Evidence for either in chronic arthritis is limited, but many people find them helpful, and they carry few risks if used carefully. They work best alongside exercise, pacing and medicines advised by the doctor; see exercise with arthritis and arthritis home care guide.

A simple guide: which to use

Rather than a fixed rule, use these rules of thumb.

Heat is often better for:

• Stiffness and chronic aching in osteoarthritis, particularly in the morning or before activity.
• Tight, sore muscles around a joint, in the back, neck and shoulders.
• Cold, stiff hands and feet, in cool weather.
• Before exercise or stretching, to loosen up.

Cold is often better for:

• A flare with heat, redness and swelling, such as a hot, swollen knee, or an acute injury within the first couple of days.
• Pain after exercise or activity, when a joint feels sore and inflamed.
• Gout flares, where cold packs may ease pain; see gout in older adults.
• Sharp, localized pain, such as after a strain.

Either may work, or alternate (contrast) for some people, for example for hands or feet, but follow your own response. Some people find that heat in the morning and cold in the evening works best. If one makes pain worse, stop and try the other, or neither.

Neither, or only with advice, when there is a suspected fracture, infection, clot, unknown cause of swelling, or when skin sensation is reduced.

Ways to apply heat

Warm bath or shower. The easiest. Warm, not hot, water for 10 to 20 minutes eases stiffness all over. Take care getting in and out; hot baths may cause dizziness in people with low blood pressure or heart problems. Use a shower seat and a non-slip mat; see bathing safely with a shower chair. Check the water with a thermometer or elbow; see hot water and scald safety for older skin.

Warm towel or damp heat. A towel soaked in warm water and wrung out, placed on the joint for 10 to 15 minutes, covered with a dry towel. Re-heat as it cools.

Hot water bottle. A rubber bottle filled with hot, not boiling, water, in a thick cover. Never use boiling water, never lie on it, and never use a damaged or old bottle. Replace bottles every year or two. Do not fall asleep with it. Check the skin often.

Electric heating pad or blanket. Convenient but can burn if left on, particularly on someone who is asleep or insensitive. Use a low setting, with a cloth between pad and skin, an automatic shut-off, and never lie on it or use while sleeping. Do not use if cords are frayed.

Microwavable gel or grain packs. Heat as directed, test the temperature on your wrist, cover with a cloth. Do not overheat; they may burn. Do not use on skin with reduced feeling.

Paraffin wax baths for hands. Soothing for stiff hands, but wax is hot and should only be used with a therapist's advice and proper equipment.

Warm water exercise or soaking. Gentle exercises in warm water help, if available and safe.

Heat creams and rubs. Products that warm the skin by irritating it. They can burn or blister, particularly if used with heat packs. Check with a pharmacist before use. Do not apply with a heating pad. See painkillers and older adults.

See hot pack safety for older skin for a full guide to using hot packs.

Ways to apply cold

Ice pack or bag of frozen peas. Wrap in a thin, damp cloth or towel. Never place ice directly on the skin. Apply for 10 to 15 minutes, and remove if the skin becomes very red, white or painfully numb.

Cold gel pack. Cover with a cloth; do not use straight from the freezer without a barrier.

Cold water or cool towel. Gentler, for sensitive skin.

Ice massage. Gently rubbing an ice cube over a small area for a few minutes; use with a cloth if skin is sensitive; not for fragile skin.

Cold sprays and gels. Cool the skin; avoid breathing the fumes; do not use on broken skin; not for repeated use.

How long and how often

• Heat: about 10 to 20 minutes at a time, a few times a day. Do not exceed 20 to 30 minutes in one session.
• Cold: about 10 to 15 minutes, with at least an hour between sessions, up to several times a day.
• Check the skin every 5 minutes at first. Stop if it is very red, blotchy, painful, blistered or numb.
• Do not apply heat or cold while sleeping or when drowsy, and not when taking medicines that make you very sleepy.

Who needs extra care or should not use heat or cold

• Reduced sensation: diabetes with neuropathy, after stroke, spinal conditions, nerve damage, some medicines, dementia. A person may be burned or frostbitten without noticing. Use only with advice, use mild temperatures and check skin visually every few minutes, ideally with a helper; see neuropathy foot care and diabetic foot care at home.
• Poor circulation or peripheral arterial disease: cold can worsen blood flow; heat can burn skin that cannot cool.
• Raynaud's phenomenon (fingers that turn white or blue in cold): avoid cold.
• Skin conditions, wounds, rashes, ulcers or infections.
• Swelling or redness of unknown cause, or a hot, swollen calf: do not apply heat; seek help; see swollen legs in older adults.
• Acute inflammation with heat and redness: heat may worsen it.
• Cognitive problems, where the person may not report pain or may misuse devices.
• Heart conditions and low blood pressure, with hot baths and large-area heat.
• Pacemakers or implants, with heating devices that use electromagnetic fields; ask the doctor.
• Cold sensitivity, or cold allergy.
• Thin skin, bruising or on blood thinners: pressure from packs can bruise.

Protecting skin

• Always put a cloth layer between the pack and the skin.
• Test hot items on the inside of your wrist.
• Check skin during and after use. Mild pinkness that fades within an hour is acceptable; blotchy red-brown marks (like a net pattern, called erythema ab igne) from repeated heat are a sign to stop.
• Never use heat over a wound or burn.
• Do not use heat and cold on the same area back to back without a gap.
• Avoid resting on the pack.
• Keep water and electricity apart.
• Take care with children and pets.

Combining with other measures

• Movement: gentle exercise is the main treatment for arthritic stiffness. Heat before, cold after if sore; see chair exercises for seniors and stretching for stiff older bodies.
• Supports: a sleeve may hold warmth; see knee support buying guide and wrist supports.
• TENS: do not use heat and TENS on the same spot at the same time; see TENS units for pain.
• Pacing and rest; see knee osteoarthritis at home.
• Sleep, mood and pain diary; see chronic pain in older adults and keeping a pain diary and talking to the doctor.
• Medicines as advised by a doctor or pharmacist.
• Warm clothing in cold weather; see cold weather health risks for seniors.

Indian home notes

• In winter, a warm bath and a hot water bottle are common; add a cloth cover and check skin.
• Many homes use bucket baths with water from a geyser or heated on a stove; mix to a comfortable temperature before pouring; see safe use of heaters and geysers.
• Traditional remedies such as warm oil massage, mustard oil, turmeric paste, hot compresses with salt or sand are used. Warm oil massage may feel soothing, but oil must not be too hot, and skin should be checked. Avoid applying anything to broken skin.
• In the summer, cold compresses with a wet cloth are gentle.
• Keep electric heaters and hot objects away from bedding.

When to ask a professional

See a doctor for joint pain with a hot, red, swollen joint, fever, sudden severe pain, inability to bear weight, deformity, pain after a fall, or night pain that does not ease. Seek urgent care for burns, blisters, or skin that turns white, black or numb after heat or cold. A physiotherapist can advise on safe use of heat, cold and exercise. A pharmacist can advise on creams and packs. A nurse can check skin.