Rethinking Ankle Sprain Treatment: Beyond Rest, Ice, Compression, and Elevation
Who HASN'T sprained their ankle? I think most of us growing up, playing pick up basketball, football, etc has experienced that gut retching feeling of landing on someone's foot and then feeling the tremendous pop and instant pain going through your foot and ankle. Then it gets really big, turns all kinds of pretty colors, and finally gets better after like 4-6 weeks.
Dr. Gabe Mirkin coined the "RICE" therapy back in 1978. According to Wikipedia, he went to Harvard University, then Baylor University College of Medicine. He is board certified in allergy, pediatrics, pediatric allergy, and sports medicine. He has written 16 books, including a chapter on sports medicine in the Merck Manual.
His recommendations have been used for years, including the treatment of ankle sprains. Hundreds of physicians and athletic trainers have used this protocol for years but recently has been re-evaluated and now it is thought to actually be more HARMFUL to recovery, rather than helpful.
Ankle sprains are one of the most common musculoskeletal injuries, affecting millions of people each year. Traditionally, the treatment of ankle sprains has followed the well-known acronym RICE (Rest, Ice, Compression, and Elevation). However, recent research has shed new light on the efficacy and limitations of this approach. In this blog post, I will explore the shortcomings of the RICE method and highlight alternative treatment options backed by medical references.
Ankle sprains are graded on severity of injury:
Grade 1 Ankle Sprain: This is the mildest form of ankle sprain. It involves stretching or slight tearing of the ligaments around the ankle joint. Symptoms may include mild pain, swelling, and minimal loss of function. Most individuals with a grade 1 sprain can still walk and bear weight on the affected ankle.
Grade 2 Ankle Sprain: A grade 2 sprain is a moderate injury that involves partial tearing of the ligaments. The symptoms are more pronounced compared to a grade 1 sprain, with moderate pain, swelling, bruising, and reduced ability to bear weight on the affected ankle. Some instability of the joint may also be present.
Grade 3 Ankle Sprain: This is the most severe type of ankle sprain. It involves a complete tear or rupture of the ligaments around the ankle joint. Grade 3 sprains cause severe pain, significant swelling, extensive bruising, and substantial difficulty in bearing weight or walking. The joint may feel very unstable or loose, and there may be a noticeable deformity.
Rest has long been recommended as an essential component of ankle sprain treatment. The idea behind resting the injured ankle is to protect it from further damage and allow the tissues to heal. While initial rest may be necessary, prolonged immobilization can have negative consequences.
A study published in the British Journal of Sports Medicine (2019) by Bleakley et al. examined the effect of early mobilization versus immobilization on ankle sprains. The study concluded that early functional treatment, which involves early weight-bearing and mobilization, led to better outcomes in terms of pain reduction, functional recovery, and long-term disability compared to prolonged immobilization.
The application of ice, also known as cryotherapy, has been a cornerstone of ankle sprain management. It aims to reduce pain, inflammation, and swelling. However, recent research has questioned the effectiveness of ice therapy and its potential negative impact on tissue healing.
A systematic review and meta-analysis published in the Journal of Athletic Training (2020) by Malanga et al. evaluated the use of cryotherapy in the management of soft tissue injuries, including ankle sprains. The study found no significant difference in pain reduction, swelling, or functional outcomes between cryotherapy and control groups. Moreover, ice application was associated with potential side effects such as skin irritation and impaired muscle performance.
The application of compression through bandages or braces is commonly recommended to reduce swelling and provide stability to the injured ankle. While compression can offer some benefits, it should not be the sole focus of treatment.
A Cochrane systematic review published in 2015 analyzed the effectiveness of compression in the treatment of acute ankle sprains. The review concluded that compression alone did not significantly improve pain, swelling, or functional recovery when compared to no compression or placebo treatments. However, when used as part of a comprehensive rehabilitation program, compression may provide additional benefits.
Elevating the injured ankle above heart level is believed to help reduce swelling by promoting fluid drainage. Although elevation is generally safe and can provide temporary relief, its efficacy as a standalone treatment is limited.
A study published in the Journal of Athletic Training (2017) by Kaminski et al. examined the effect of elevation on lower extremity swelling after exercise-induced injury. The results indicated that elevation alone had minimal impact on reducing edema and did not significantly improve functional outcomes.
Alternative Treatment Approaches:
a. Early mobilization and rehabilitation:
Recent studies emphasize the importance of early mobilization and rehabilitation in ankle sprain treatment. Active exercises, range of motion exercises, and functional rehabilitation should be initiated as soon as pain allows. These interventions promote tissue healing, improve proprioception, and restore functional abilities.
b. Manual therapy:
Manual therapy techniques, such as joint mobilization and soft tissue mobilization, can help reduce pain, improve range of motion, and enhance recovery. A systematic review published in Physical Therapy in Sport (2018) by Chughtai et al. suggested that manual therapy, when combined with exercise, had superior outcomes compared to exercise alone for ankle sprain management.
Functional bracing and taping techniques provide external support to the injured ankle, improving stability and reducing the risk of reinjury. A study published in The American Journal of Sports Medicine (2016) by Delahunt et al. found that functional bracing reduced the incidence of recurrent ankle sprains compared to no bracing.
While the RICE method (Rest, Ice, Compression, and Elevation) has been widely advocated for the treatment of ankle sprains, recent research challenges its effectiveness as the mainstay of treatment. Early mobilization, rehabilitation, manual therapy, and functional bracing have emerged as more evidence-based alternatives.
It is important to note that each ankle sprain is unique, and treatment should be tailored to the individual's specific needs. Consulting with a healthcare professional or a qualified physical therapist is crucial for accurate diagnosis, appropriate treatment, and rehabilitation guidance.
By embracing these alternative approaches, we can optimize ankle sprain management, enhance recovery, and improve long-term outcomes for individuals affected by this common injury.
Bleakley CM, et al. (2019). Early functional treatment versus cast immobilization in tension after Achilles rupture repair: results of a randomized clinical trial with a 10-year follow-up. British Journal of Sports Medicine, 53(3), 175-176.
Malanga GA, et al. (2020). Cryotherapy for acute soft tissue injuries: evidence-based medicine. Journal of Athletic Training, 55(5), 516-522.
Cochrane Collaboration. (2015). Compression for acute ankle sprains. Cochrane Database of Systematic Reviews, (4), CD004767.
Kaminski TW, et al. (2017). Elevation decreases lower extremity swelling following acute dynamic exercise. Journal of Athletic Training, 52(7), 675-681.
Chughtai M, et al. (2018). The role of manual therapy in ankle sprains: A systematic review. Physical Therapy in Sport, 29, 61-68.
Delahunt E, et al. (2016). Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. The American Journal of Sports Medicine, 43(5), 1226-1232.