Does contrast therapy using hot and cold routines really speed up recovery from injuries?

Contrast Therapy for Injury Recovery

Contrast therapy (alternating hot and cold applications) does not have sufficient evidence to support its routine use for speeding up recovery from injuries, and current high-quality guidelines recommend functional treatment with bracing, early mobilization, and supervised exercise therapy instead.

Evidence Quality and Limitations

The research base for contrast therapy is fundamentally weak and insufficient to guide clinical practice:

• A systematic review of randomized controlled trials found both a lack in quantity and quality of research regarding contrast therapy efficacy, with insufficient evidence that it aids in sports recovery 1
• The limited methodological quality of existing studies makes it difficult to draw clear conclusions about this form of therapy 1
• A 2025 scoping review of 303 patients across 7 studies found considerable heterogeneity in treatment protocols (application method, duration, hot/cold cycle sequences, total treatment time) and concluded that the modest quality of trials does not allow clear conclusions about effectiveness compared with other therapies 2

Performance Recovery Evidence

When specifically tested for athletic performance recovery, contrast therapy shows minimal to no benefit:

• In trained runners, 6 minutes of contrast water therapy showed a small performance benefit (0.8% faster 3000m time), but 12 or 18 minutes showed no effect compared to passive rest 3
• For resistance training recovery, neither cold-water immersion nor contrast water therapy improved any perceptual or performance measures over a 4-hour recovery period compared to passive sitting 4
• Peak torque and jump performance remained depressed for at least 4 hours post-recovery regardless of whether contrast therapy was used 4

Evidence-Based Alternative: Functional Treatment Protocol

Instead of contrast therapy, current guidelines strongly recommend functional treatment for musculoskeletal injuries, particularly ankle sprains:

Immediate Management (First 48 Hours)

• Apply a lace-up or semi-rigid ankle brace immediately and continue for 4-6 weeks, which is superior to immobilization and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) 5, 6
• Use cold application (ice and water surrounded by damp cloth) for 20-30 minutes per application, avoiding direct skin contact 5, 6
• Apply compression wraps for comfort while ensuring circulation is not compromised 5
• Elevate the injured area 5
• Begin weight-bearing as tolerated immediately, avoiding only activities that cause pain 6

Pharmacological Management

• NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) are effective for reducing pain and swelling in the short term (<14 days), with diclofenac showing superior results at days 1-2 for pain during motion 5, 6
• Acetaminophen is equally effective as NSAIDs if NSAIDs are contraindicated, with fewer side effects 6
• Avoid opioids as they provide equal pain relief to NSAIDs but cause significantly more side effects 6

Exercise Therapy (Starting 48-72 Hours Post-Injury)

• Begin supervised exercise therapy within 48-72 hours, which has Level 1 evidence for effectiveness 5, 6
• Include range of motion exercises, proprioception training (critical to prevent recurrent sprains), strengthening exercises targeting ankle stabilizers, and coordination/sport-specific functional exercises 5, 6
• Supervised exercises are superior to non-supervised home exercises 5

Limited Role for Contrast Therapy in Specific Contexts

If contrast therapy is considered despite weak evidence, one study provides limited guidance:

• For grade I-II lateral ankle sprains in the subacute phase (day 5 post-injury), contrast therapy reduced swelling after 3 days of continuous application, while heat therapy increased swelling 7
• However, both modalities showed no difference in pain reduction or range of motion improvement after 3 days 7
• Heat therapy reduced pain more effectively immediately after application compared to contrast therapy 7

Critical Pitfalls to Avoid

• Do not use prolonged immobilization beyond 10 days maximum, as this delays recovery, increases risk of chronic instability, and prolongs return to work/sport by over a week compared to functional treatment 5, 6
• Do not rely on contrast therapy as a primary recovery modality given the insufficient evidence base and availability of superior alternatives 1, 2
• Do not use platelet-rich plasma injections, hyaluronic acid injections, or Traumeel as none show superiority over standard functional treatment 6
• Inadequate treatment can lead to chronic problems including decreased range of motion, pain, and joint instability 5

Follow-Up Protocol

• Re-examine at 4-5 days post-injury when swelling has decreased, allowing optimal clinical assessment of ligament damage 5, 6
• Continue brace use during sports activities after recovery, particularly for those with history of ankle sprains 6
• Incorporate proprioceptive and neuromuscular exercises into regular training activities for recurrent injury prevention 5, 6