You’ve tweaked a calf, rolled an ankle or your back has “gone”. Ice or heat? Nurofen? Rest it completely, or carry on? Physio, osteopath, chiropractor or a sports massage, and do you go now or wait? Most people guess, and the guess often costs them weeks. Here’s what the evidence says, graded, what the NHS advises, and what I see go wrong.
Call 999 or go to A&E if, after an injury, you heard a crack when it happened; the injured part has changed shape or is pointing at an odd angle; it’s numb, tingling or has pins and needles; or the skin around it has turned blue or grey, or is cold to the touch. You may have broken a bone.
Call 999 or go to A&E if you have back pain with pain, tingling, weakness or numbness in both legs; loss of feeling around your genitals or anus; changes in your bladder or bowels, such as difficulty peeing or peeing or pooing yourself; chest pain; or if it started after a serious accident.
Get help from NHS 111 if the injury is very painful or getting worse; there’s a lot of swelling or bruising, or it’s getting worse; you can’t put any weight on it or walk more than a few steps; it’s very stiff or hard to move; it isn’t getting better after looking after it yourself; or you also have a very high temperature or feel hot, cold or shivery. With back pain, ask for an urgent GP appointment or call 111 if you feel hot, cold, shivery or generally unwell, or the pain is severe and came on suddenly or is getting worse quickly.
Don’t drive yourself to A&E: ask someone to drive you, or call 999 for an ambulance. A head injury is different: see the injury nutrition article for the NHS head-injury signs.
The grades in this post: Strong means good randomised trials agree. Mixed means the trials are few, small, short or of moderate quality. Mechanistic means the biology makes sense but it hasn’t been shown to change outcomes in people. None means there’s no usable evidence in people. Observational studies and expert opinion are labelled as such.
The two mistakes I see most
Stopping everything. Someone hurts a knee and stops the gym, the walking, the meal plan and the supplements, for weeks or sometimes years. The injury was one tissue. The plan was everything.
Not knowing who to see, or when. Ice or heat, physio or massage, wait two days or go straight away, and nobody quite knows the difference between a physio, an osteopath and a chiropractor. So people either do nothing or do everything.
Rest completely, or keep moving?
Keep moving, within what the injury allows.
- After a grade 1 or 2 ankle sprain, people given gentle therapeutic exercise in the first week had better ankle function at one and two weeks than people given standard protection, rest, ice, compression and elevation. They were more active, and re-injury was no higher (2 people in each group) (Bleakley 2010, 101 people). Mixed One good randomised trial.
- For new low back pain, advice to stay active gave small improvements in pain and function compared with advice to rest in bed (Dahm 2010, Cochrane). For sciatica, there was little difference either way. Mixed Moderate-quality evidence.
The two NHS sites put it differently. The NHS in England advises “PRICE” for the first 2 to 3 days after a sprain or strain: protect it, rest it and try not to put weight on it, ice, compression and elevation. Then, once you can move it without pain stopping you, keep it moving so it doesn’t stiffen. NHS inform in Scotland leans earlier: “Too much rest can slow down your recovery so, as soon as you can, start moving and using the affected area.” It says pain of up to 5 out of 10 during activity is acceptable, as long as it settles quickly and is no worse the next morning. For backs, both say stay active and avoid long spells in bed.
Bed rest used to be the default. It isn’t now. “Relative rest” means protecting the injured bit for a day or two, not stopping your life.
Ice, heat, compression, or “lots of Nurofen”?
| What | What the evidence shows | Grade |
|---|---|---|
| Ice | A systematic review of 22 trials found ice probably eases pain, but the trials were poor quality (average 3.4 out of 10), few studied ordinary sprains and strains, and there was no evidence for how long or how often (Bleakley 2004). Ice combined with exercise looked better than ice alone. Both NHS sites still advise ice for swelling, wrapped in a towel, never straight on the skin. | Mixed Weak. Fine for pain relief; not proven to speed healing. |
| “Don’t ice, it stops healing” | The PEACE & LOVE framework advises against anti-inflammatory treatments, ice included, in the first days, because inflammation starts repair (Dubois & Esculier 2020). That’s an editorial, not a trial. I haven’t found good human evidence that ice slows healing either. | None Expert opinion, both ways. |
| Heat | For acute and sub-acute low back pain, heat wraps gave a small short-term reduction in pain and disability, and adding exercise helped more (French 2006, Cochrane, 9 trials). Not enough evidence on cold for backs. On a fresh sprain or strain it’s different: the NHS advises avoiding heat (hot baths, heat packs), alcohol and massage for the first couple of days, to limit swelling. | Mixed Moderate, short-term, backs. |
| Anti-inflammatory tablets (ibuprofen, naproxen) | For sprains, strains and bruises, they were no better than paracetamol for pain at 1–2 hours or at 2–3 days, with slightly more stomach side effects (Jones 2020, Cochrane, 20 trials). Most participants were young adults; the results shouldn’t be applied to over-65s. NHS inform adds that they “may have limited value” for soft tissue injuries, and “may even slow down the healing process” if taken too early. | Strong High certainty for “no better than paracetamol for pain”. |
| Anti-inflammatory gels | Some gels work well for sprains and strains: diclofenac Emulgel (78% got good relief vs 20% on placebo gel) and ketoprofen gel (72% vs 33%), with side effects no more common than placebo (Derry 2017, overview of Cochrane reviews). The exact product matters; evidence for many other gels and creams, ibuprofen gels included, is weak. | Strong Moderate to high, for the named gels. |
| Heat rubs (Deep Heat-type, wintergreen/salicylate) | For new strains and sprains: very low-quality evidence, mostly single studies (Derry 2017). They make the skin feel warm. | None Nothing worth the name for acute injury. |
| Compression and elevation | Common sense for swelling, and part of both NHS sites’ advice; in the ice review, adding ice to compression made little difference (Bleakley 2004). | Mixed Weak. |
Where I land: for pain, use what your pharmacist or GP suggests. For a sprain or strain, the NHS suggests trying paracetamol first, with an ibuprofen gel, mousse or spray for swelling, and tablets only if needed. Backs are different: NICE’s back pain guideline says “Do not offer paracetamol alone for managing low back pain” and to consider an anti-inflammatory, taking your own risks into account. Either way, don’t take anti-inflammatory tablets to heal faster; the pain trials don’t show them doing better, and the inflammation is part of repair (see injury nutrition). Ice if it helps the pain or swelling; keep heat for backs and stiffness, not a sprain in its first couple of days. Then move.
Who to see: physio, osteopath, chiropractor or massage?
| Who | Regulated? | What they’re trained for | Notes |
|---|---|---|---|
| Physiotherapist | Yes. “Physiotherapist” and “physical therapist” are titles protected by law; to use them you must be registered with the HCPC | Assessment, exercise rehabilitation, manual therapy, advice | Available on the NHS and privately. Whether you can refer yourself to NHS physio depends on where you live (below). |
| Osteopath | Yes. “It is against the law for anyone to call themselves an osteopath unless they are registered with the GOsC” (General Osteopathic Council) | Manual therapy (including manipulation), soft tissue work, exercise and advice | Private in most cases. |
| Chiropractor | Yes. It’s a criminal offence to describe yourself as a chiropractor without being registered with the General Chiropractic Council | Manipulation, mainly of the spine, plus soft tissue work and exercise | Private in most cases. |
| Sports or massage therapist | No statutory regulation. Not among the professions the HCPC regulates. Voluntary registers exist, such as the CNHC, whose register is accredited by the Professional Standards Authority | Soft tissue work | Training varies widely. Ask what qualification they hold and whether they’re on an accredited register. |
Can you go straight to an NHS physio?
- In Scotland, it depends on your health board. NHS inform: “Your local health board decide how each service is accessed and whether you can self-refer.” In Greater Glasgow & Clyde, Lanarkshire, Grampian, Borders, Dumfries & Galloway and Shetland, adults can refer themselves for physiotherapy. In Ayrshire & Arran, Fife and Forth Valley, adult physio needs a referral from a GP or another healthcare professional. Lothian varies by area, Highland and parts of Tayside go through a First Contact Physiotherapist at your GP practice, and Dundee offers both. NHS inform lists each board.
- In England, most adults registered with a GP can refer themselves to community musculoskeletal (MSK) services, physiotherapy included, though not yet everywhere. You don’t need a diagnosis first.
What matters more than the title: a proper assessment, a clear explanation, a plan that gets you doing things (exercise, load, return to activity), and a sense of how many sessions you’ll need. Be wary of anyone who wants you back weekly for months with no end point, or who tells you something is “out of place” and only they can put it back.
Does manipulation work? For chronic low back pain, across 47 trials and 9,211 people, spinal manipulation worked about as well as other recommended treatments (such as exercise) for short-term pain, and slightly better for function. Most side effects were mild and short-lived (Rubinstein 2019). Mixed Moderate-quality evidence. So the same treatment does about the same whether a chiropractor, osteopath or physio delivers it. NICE’s back pain guideline (NG59) says: “Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package that includes exercise.”
“Chiropractors scare me.” I hear this a lot, mostly about neck manipulation and stroke. The best-known study, from Ontario, found people under 45 who had a rare type of stroke were about three times more likely to have seen a chiropractor beforehand, and about three times more likely to have seen their GP. Over 45, there was no link with chiropractic visits. The authors’ explanation: the artery tear that causes the stroke often starts as neck pain or headache, so people seek help for the early symptom (Cassidy 2008). Observational: it can’t rule out a small risk. Serious harm is very rare whoever you see, but it’s fair to ask what the manipulation is for and whether there’s an alternative.
When to go: the NHS says to see a GP (or, in many areas, refer yourself to physio) if a sprain or strain is getting worse or not feeling better after looking after it yourself, and if back pain hasn’t improved after a few weeks or is stopping your day-to-day activities. Most sprains and strains feel better after 2 weeks; severe ones can take months. My own rule, from practice rather than a trial: if you can bear weight and it’s easing day by day, looking after it yourself is reasonable. If it’s not improving, it keeps coming back, or it’s stopping you working, training or sleeping, get it assessed. Don’t wait months “to see”.
“It’s probably arthritis”
People in their fifties often decide a sore knee or back is “arthritis” and reach for rubs, bandages and shark cartilage. Two things are true at once:
- Over 45, a diagnosis without a scan is normal practice. NICE’s osteoarthritis guideline (NG226) says: “Diagnose osteoarthritis clinically without imaging in people who: are 45 or over and have activity-related joint pain and have either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.” So you don’t need a scan to start doing the right things.
- And a scan often wouldn’t settle it anyway. In people with no back pain, disc degeneration showed up in 37% of 20-year-olds and 96% of 80-year-olds (Brinjikji 2015). In pain-free, uninjured knees of people 40 and over, cartilage defects showed up in 43% and meniscal tears in 19% (Culvenor 2019). “Wear and tear” on a scan is often just age. More in Your scan is probably normal for your age.
What helps knees and hips is covered in my knees article: exercise first, weight if relevant, and a graded look at the supplements. In short: glucosamine and chondroitin didn’t beat placebo in the large independent trials; turmeric extracts show promise but the trials are short and inconsistent. Shark cartilage is sold mainly as a source of chondroitin. I found no convincing trial of shark cartilage itself for joint pain in people: a PubMed search turned up laboratory and animal work, and the only randomised trial was in horses, of a blend. None
Turmeric for an injury? The trials are in knee osteoarthritis, not new injuries, and the stronger absorbed forms carry liver-injury reports and medicine interactions (see the coffee add-ins article). If you’re on a blood thinner, read the blood clots article first.
Don’t let it derail everything
The injury is local. Keep the rest going:
- Train what isn’t hurt. Upper body with a sore ankle, legs with a sore shoulder.
- Keep eating well, and don’t slash food because you’re “not training”. Protein matters more, not less: see injury nutrition.
- A “baby workout” (light movement, mobility, gentle stretching) keeps the habit and helps you feel better. Stretching won’t speed healing, but it has a place in feeling like you’re still training. Coaching practice, not a trial.
- Set a return date with whoever’s treating you, so “resting it” doesn’t quietly become stopping.
How strong is the evidence?
| Claim | Grade | Main source |
|---|---|---|
| Early exercise after an ankle sprain improves function in the first two weeks | Mixed one good trial | Bleakley 2010 |
| Staying active beats bed rest for new low back pain | Mixed moderate | Dahm 2010 |
| Ice eases pain | Mixed weak | Bleakley 2004 |
| Ice slows healing | None expert opinion | Dubois & Esculier 2020 |
| Heat wraps help acute back pain, short term | Mixed moderate | French 2006 |
| Anti-inflammatory tablets are no better than paracetamol for sprain pain | Strong | Jones 2020 |
| Diclofenac Emulgel and ketoprofen gel relieve sprain pain | Strong | Derry 2017 |
| Heat rubs help a new sprain | None | Derry 2017 |
| Spinal manipulation works about as well as other recommended treatments | Mixed moderate | Rubinstein 2019 |
| Chiropractic neck treatment causes stroke | Observational: no excess risk compared with GP visits | Cassidy 2008 |
| Scan changes are common without pain | Systematic reviews, consistent | Brinjikji 2015; Culvenor 2019 |
| Shark cartilage helps joint pain | None | No trial in people found |
Nutrition, testing and movement from one practitioner, so the plan agrees with itself. I sell personal training and movement coaching, so I declare an interest: the post grades my side too. I’m not a physiotherapist (my wife is), an osteopath or a chiropractor; for diagnosis and treatment of an injury, see one.
Sources
- Bleakley CM et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 2010;340:c1964. PMID 20457737. doi:10.1136/bmj.c1964
- Bleakley C et al. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 2004;32:251–61. PMID 14754753. doi:10.1177/0363546503260757
- Brinjikji W et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811–16 (online 2014). PMID 25430861. doi:10.3174/ajnr.A4173
- Cassidy JD et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33(4 Suppl):S176–83. PMID 18204390. doi:10.1097/BRS.0b013e3181644600
- Culvenor AG et al. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med 2019;53:1268–78 (online 2018). PMID 29886437. doi:10.1136/bjsports-2018-099257
- Dahm KT et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010;6:CD007612. PMID 20556780. doi:10.1002/14651858.CD007612.pub2
- Derry S et al. Topical analgesics for acute and chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017;5:CD008609. PMID 28497473. doi:10.1002/14651858.CD008609.pub2
- Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE (editorial). Br J Sports Med 2020;54:72–73 (online 2019). PMID 31377722. doi:10.1136/bjsports-2019-101253
- French SD et al. Superficial heat or cold for low back pain. Cochrane Database Syst Rev 2006;1:CD004750. PMID 16437495. doi:10.1002/14651858.CD004750.pub2
- Jones P et al. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev 2020;8:CD007789. PMID 32797734. doi:10.1002/14651858.CD007789.pub3
- Rubinstein SM et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019;364:l689. PMID 30867144. doi:10.1136/bmj.l689
- NICE. Low back pain and sciatica in over 16s: assessment and management (NG59), recommendations 1.2.7 and 1.2.26. Last updated 29 July 2026; read 13 October 2026. nice.org.uk
- NICE. Osteoarthritis in over 16s: diagnosis and management (NG226), recommendation 1.1.1. Published 19 October 2022; read 13 October 2026. nice.org.uk
- NHS. Sprains and strains. Page last reviewed 23 April 2024; read 13 October 2026. nhs.uk
- NHS. Back pain. Page last reviewed 5 March 2026; read 13 October 2026. nhs.uk
- NHS. Get NHS help for back or joint problems. Page last reviewed 18 November 2025; read 13 October 2026. nhs.uk
- NHS inform. Soft tissue injury advice. Last updated 17 March 2026; read 13 October 2026. nhsinform.scot
- NHS inform. How to access MSK services. Read 13 October 2026. nhsinform.scot
- Health and Care Professions Council. Professions and protected titles. Read 13 October 2026. hcpc-uk.org
- General Osteopathic Council. Protecting the title ‘osteopath’. Read 13 October 2026. osteopathy.org.uk
- General Chiropractic Council. What we do. Read 13 October 2026. gcc-uk.org
- Complementary and Natural Healthcare Council (CNHC). Read 13 October 2026. cnhc.org.uk