Should I use ice or heat for shoulder impingement?

Ice or Heat for Shoulder Impingement

Both ice and heat can be beneficial for shoulder impingement, with ice being preferred for acute pain and inflammation, while heat is better for chronic cases and improving range of motion.

Initial Management Approach

Ice Therapy

• Ice is most effective for acute shoulder impingement with active inflammation
• Apply ice through a wet towel for 10-minute periods 1
• Benefits of ice:
  • Reduces tissue metabolism
  • Slows release of blood and proteins from surrounding vasculature
  • Blunts inflammatory response
  • Provides short-term pain relief 1
  • Beneficial for pain relief after rotator cuff surgery (consensus recommendation) 1

Heat Therapy

• Heat is beneficial for chronic shoulder impingement cases
• Helps with:
  • Improving tissue elasticity
  • Enhancing circulation
  • Facilitating range of motion
  • Soft tissue mobilization 1

Treatment Algorithm

1. For acute shoulder impingement (symptoms < 2 weeks):

   • Use ice therapy for 10-minute periods through a wet towel
   • Apply 3-4 times daily, especially after activity that aggravates symptoms
   • Combine with relative rest and avoiding overhead activities

2. For chronic shoulder impingement (symptoms > 2 weeks):

   • Begin with heat therapy to improve tissue elasticity before exercises
   • Apply for 15-20 minutes
   • Follow with gentle stretching focusing on external rotation and abduction
   • Consider alternating heat and ice (heat before activity, ice after)

3. For mixed presentations:

   • Use heat before rehabilitation exercises to improve mobility
   • Apply ice after exercises to minimize post-exercise inflammation
   • Adjust based on which provides better symptom relief

Additional Management Considerations

• Avoid overhead pulley exercises as they encourage uncontrolled abduction and can worsen impingement 1, 2
• Combine thermal therapy with:
  • Eccentric strengthening exercises 2
  • Stretching focusing on external rotation and abduction 1
  • NSAIDs for short-term pain relief (topical preferred to minimize side effects) 1, 2
  • Acetaminophen (up to 4g/day) as first-line analgesic 2

Common Pitfalls to Avoid

• Applying ice directly to skin (can cause frostbite)
• Using heat during acute inflammatory phase (may increase inflammation)
• Relying solely on thermal therapy without addressing biomechanical issues
• Continuing activities that worsen symptoms
• Using overhead pulleys for rehabilitation 1
• Complete immobilization (can lead to muscle atrophy and deconditioning) 1

When to Consider Additional Interventions

If symptoms persist after 4-6 weeks of conservative management including appropriate thermal therapy, consider:

• Corticosteroid injection for short-term relief 2
• Referral for physical therapy with focus on scapular stabilization
• Advanced imaging (MRI) to assess for rotator cuff tear 2

Remember that approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 2.