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Should We Still Be Using “RICE” for Ankle Sprains?
Should we still be using the “RICE” protocol when it comes to acute lateral ankle sprains? Rest, ice, compression, and elevation all seem to be reasonable treatment modalities for various conditions ranging from acute injuries to surgeries. Is this truly evidence-based and in the best interest of our patients? In order to make the best decisions for our patients’ care, one should understand the history and evolution of these classic recommendations.
Gabe Mirkin, MD, introduced RICE in 1978 in his influential text, The Sportsmedicine Book.1 Physicians across many specialties embraced this with open arms and still utilize the book today. It is important to understand that the rationale behind RICE is based on limited evidence with low quality trials and laboratory studies.2-5 RICE continues to be supported only by anecdotal evidence without formal data to support its widespread use.4,5 Since the introduction of RICE there have been various iterations including PRICE (protection, rest, ice, compression, elevation) and POLICE (protection, optimal loading, ice, compression, elevation), but these have continued to be challenged.2,6 In 2013, Dr. Mirkin recanted on his original theory and suggested that based on newer data, ice likely was causing more harm than good in the long run.7
Let's break down the components of RICE and assess their evidence to support the use.
Rest. Rest is one of the most important parts of the equation—if a patient has injured something, it makes sense to remove all external stressors, right? Well, immobilization can also lead to a host of issues by itself. Stopping movement also delays the drainage of edema and swelling, which need to be removed via active movement of the swollen limb. Edematous changes are the result of inflammation secondary to initial trauma and need to be drained by the passive lymphatic system.8 Patients achieve this by movement and muscular contractions in order to alleviate the swelling. Pain-free movement and loading cause muscle contractions, which via mechanotransduction not only prevent atrophy but also enhance lymphatic drainage and remodel fibrous tissues.9 With complete rest, you place patients at risk for disuse atrophy, which can cause up to 5% muscle loss in 1 week.10
Multiple systematic reviews demonstrate that functional rehabilitation is superior to immobilization.11-14 These studies are small, but their data is compelling. Additionally, Bleakly and colleagues compared early rehabilitation versus RICE protocols, and found that the exercise group improved function and patients were able to return to activity, work, and sport sooner.15 Kerkhoffs and colleagues found that early weight-bearing and mobilization reduced symptoms as well as accelerated return to normal range of motion (ROM).16 Conversely, Lamb and colleagues found that immediate casting and immobilization increased ankle function at 3 months; however, there was no control of patients who underwent functional rehab.17 Something important to note is that patients can do this exercise therapy (ROM, strengthening, and stretching) unsupervised at home, without the need for a referral or visit to another specialist.5,18
Ice. Despite the near-universal use of ice (cryotherapy) after an ankle sprain, there is no high-quality evidence demonstrating its benefit.4,6,11 Ice’s mechanism of action involves reducing pain and curbing inflammation—but at what cost? While inflammation is generally regarded as “bad,” it is required as the first stage of the ligament healing process.19-21 While excessive inflammation can lead to negative outcomes, macrophages are recruited during the initial inflammatory response and secrete anabolic peptides to encourage healing, and icing suppresses this response.21
Icing also delays lymphatic drainage to a significant degree which is a key driver in edema reduction. There have been various animal model studies documenting this phenomenon as well as delayed muscle regeneration.22,23 Ice also has the potential to disrupt angiogenesis and revascularization while increasing immature myofibers, which could lead to impaired tissue repair and redundant collagen synthesis.6,24 There is also no data to suggest that icing alone can increase function, decrease pain, and modulate swelling.5,8,25
Compression and elevation. Compression and elevation are far less controversial with both having a very low risk to benefit ratio. While there is not great evidence for either modality, compression seems to reduce swelling and increase quality of life and elevation may promote movement of interstitial fluid out of tissues.4,6,11,18 Compression and elevation may also provide pain relief and may encourage earlier weight-bearing or functional movement of the sprained ankle.
Other forms of treatment, including non-steroidal anti-inflammatory (NSAID) use, have also been discouraged as they may delay long-term tissue healing.26,27 While research has shown NSAIDs to be helpful in the short term in reducing pain, there are no placebo-controlled studies comparing long-term outcomes.28,29 The same cytokines and prostaglandins that cryotherapy interferes with—which remove debris and encourage an anabolic response—are blocked by NSAIDs.30 With the initial inflammatory phase hindered, this delays each subsequent step in the healing process. There was an Australian study in 1997 with army recruits who had ankle sprains and the group given the NSAIDs returned to activity sooner, but had increased instability and decreased ROM compared to those given placebo.31
A curious and interesting side note is that research has shown anabolic steroids, which increase inflammation, to hasten the healing of muscle and soft tissue injuries in animal models, and there is emerging data to suggest positive effects on humans as well.32-34
Lateral ankle sprains are very common in the athletic population, so returning to sport is of utmost importance. It appears that functional rehabilitation, compression, and joint mobilization during early care lead to a quicker return to activity.35 There are also no clear and high-quality evidence-based guidelines for when exactly an athlete can return to sport, so we rely on clinical experience and expert opinion.36-38 While early mobilization is important, understand that returning to sport too early can increase the likelihood of reinjuring the affected limb.
In Conclusion
The “RICE” theory is outdated, with “... no evidence that it has any positive influence on pain, swelling, or patient function,” yet physicians across the globe still learn and practice RICE.5 While the majority of the recent literature surrounds ankle sprains, it can likely be extrapolated to other acute soft tissue injuries. This blog is not meant to dissuade physicians from treating acute ankle sprains with a RICE protocol, but rather, to consider other options and explore early mobilization and functional rehabilitation, which may allow for faster recovery and return to sport.
Dr. Ehlers is in private practice in Arvada, CO, and is an attending at the Highlands-Presbyterian/St. Luke’s Podiatric Residency Program. He finds interest in debunking medical myths and dogma.
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
References
1. Mirkin G, Hoffman M. The Sportsmedicine Book. Little Brown & Co, 1978.
2. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012 Mar;46(4):220-1. doi: 10.1136/bjsports-2011-090297. Epub 2011 Sep 7. PMID: 21903616.
3. Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers' Association. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45. doi: 10.4085/1062-6050-48.4.02. PMID: 23855363; PMCID: PMC3718356.
4. van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012 Jul-Aug;47(4):435-43. doi: 10.4085/1062-6050-47.4.14. PMID: 22889660; PMCID: PMC3396304.
5. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956. doi: 10.1136/bjsports-2017-098106. Epub 2018 Mar 7. PMID: 29514819.
6. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020 Jan;54(2):72-73. doi: 10.1136/bjsports-2019-101253. Epub 2019 Aug 3. PMID: 31377722.
7. Reinl G. Iced! The Illusionary Treatment Option. 2nd Edition. Gary Reinl. 2014.
8. Coté DJ, Prentice WE Jr, Hooker DN, Shields EW. Comparison of three treatment procedures for minimizing ankle sprain swelling. Phys Ther. 1988 Jul;68(7):1072-6. doi: 10.1093/ptj/68.7.1072. PMID: 3133668.
9. Buckwalter JA, Grodzinsky AJ. Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice. J Am Acad Orthop Surg. 1999 Sep-Oct;7(5):291-9. doi: 10.5435/00124635-199909000-00002. PMID: 10504356.
10. Dirks ML, Wall BT, van Loon LJC. Interventional strategies to combat muscle disuse atrophy in humans: focus on neuromuscular electrical stimulation and dietary protein. J Appl Physiol (1985). 2018 Sep 1;125(3):850-861. doi: 10.1152/japplphysiol.00985.2016. Epub 2017 Sep 28. PMID: 28970205.
11. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35. doi: 10.1093/bmb/ldq028. Epub 2010 Aug 14. PMID: 20710025.
12. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(3):CD003762. doi: 10.1002/14651858.CD003762. Update in: Cochrane Database Syst Rev. 2013;3:CD003762. PMID: 12137710.
13. Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed). 1981 Feb 21;282(6264):606-7. doi: 10.1136/bmj.282.6264.606. PMID: 6781588; PMCID: PMC1504416.
14. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. 2007 Feb;455:169-72. doi: 10.1097/BLO.0b013e31802f5468. PMID: 17279044.
15. Bleakley CM, O'Connor SR, Tully MA, Rocke LG, Macauley DC, Bradbury I, Keegan S, McDonough SM. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010 May 10;340:c1964. doi: 10.1136/bmj.c1964. PMID: 20457737.
16. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilisation for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001 Sep;121(8):462-71. doi: 10.1007/s004020100283. PMID: 11550833.
17. Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2009 Feb 14;373(9663):575-81. doi: 10.1016/S0140-6736(09)60206-3. PMID: 19217992.
18. Halabchi F, Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World J Orthop. 2020 Dec 18;11(12):534-558. doi: 10.5312/wjo.v11.i12.534. PMID: 33362991; PMCID: PMC7745493.
19. Singh DP, Barani Lonbani Z, Woodruff MA, Parker TJ, Steck R, Peake JM. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol. 2017 Mar 7;8:93. doi: 10.3389/fphys.2017.00093. PMID: 28326040; PMCID: PMC5339266.
20. Yang G, Rothrauff BB, Tuan RS. Tendon and ligament regeneration and repair: clinical relevance and developmental paradigm. Birth Defects Res C Embryo Today. 2013 Sep;99(3):203-222. doi: 10.1002/bdrc.21041. PMID: 24078497; PMCID: PMC4041869.
21. Singh P, Chazaud B. Benefits and pathologies associated with the inflammatory response. Exp Cell Res. 2021 Dec 1;409(1):112905. doi: 10.1016/j.yexcr.2021.112905. Epub 2021 Nov 1. PMID: 34736921.
22. Takagi R, Fujita N, Arakawa T, Kawada S, Ishii N, Miki A. Influence of icing on muscle regeneration after crush injury to skeletal muscles in rats. J Appl Physiol (1985). 2011 Feb;110(2):382-8. doi: 10.1152/japplphysiol.01187.2010. Epub 2010 Dec 16. PMID: 21164157.
23. Schaser KD, Disch AC, Stover JF, Lauffer A, Bail HJ, Mittlmeier T. Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats. Am J Sports Med. 2007 Jan;35(1):93-102. doi: 10.1177/0363546506294569. Epub 2006 Dec 1. PMID: 17197574.
24. Crystal NJ, Townson DH, Cook SB, LaRoche DP. Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise. Eur J Appl Physiol. 2013 Oct;113(10):2577-86. doi: 10.1007/s00421-013-2693-9. Epub 2013 Jul 20. PMID: 23873339.
25. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. Br J Sports Med. 2006 Aug;40(8):700-5; discussion 705. doi: 10.1136/bjsm.2006.025932. Epub 2006 Apr 12. PMID: 16611722; PMCID: PMC2579462.
26. Koester MC, Amundson CL. Preparticipation screening of high school athletes: are recommendations enough? Phys Sportsmed. 2003 Aug;31(8):35-8. doi: 10.3810/psm.2003.08.460. PMID: 20086484.
27. Chen ET, Borg-Stein J, McInnis KC. Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2019 Jun;18(6):217-223. doi: 10.1249/JSR.0000000000000603. Erratum in: Curr Sports Med Rep. 2019 Aug;18(8):310. PMID: 31385837.
28. van den Bekerom MPJ, Sjer A, Somford MP, Bulstra GH, Struijs PAA, Kerkhoffs GMMJ. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc. 2015 Aug;23(8):2390-2399. doi: 10.1007/s00167-014-2851-6. Epub 2014 Jan 29. PMID: 24474583.
29. Predel HG, Giannetti B, Seigfried B, Novellini R, Menke G. A randomized, double-blind, placebo-controlled multicentre study to evaluate the efficacy and safety of diclofenac 4% spray gel in the treatment of acute uncomplicated ankle sprain. J Int Med Res. 2013 Aug;41(4):1187-202. doi: 10.1177/0300060513487639. PMID: 23908551.
30. Stovitz SD, Johnson RJ. NSAIDs and musculoskeletal treatment: what is the clinical evidence? Phys Sportsmed. 2003 Jan;31(1):35-52. doi: 10.3810/psm.2003.01.160. PMID: 20086440.
31. Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits. The Kapooka Ankle Sprain Study. Am J Sports Med. 1997 Jul-Aug;25(4):544-53. doi: 10.1177/036354659702500419. PMID: 9240990.
32. Beiner JM, Jokl P, Cholewicki J, Panjabi MM. The effect of anabolic steroids and corticosteroids on healing of muscle contusion injury. Am J Sports Med. 1999 Jan-Feb;27(1):2-9. doi: 10.1177/03635465990270011101. PMID: 9934411.
33. Weber AE, Gallo MC, Bolia IK, Cleary EJ, Schroeder TE, Rick Hatch GF 3rd. Anabolic androgenic steroids in orthopaedic surgery: current concepts and clinical applications. J Am Acad Orthop Surg Glob Res Rev. 2022 Jan 4;6(1):e21.00156. doi: 10.5435/JAAOSGlobal-D-21-00156. PMID: 34982051; PMCID: PMC8735789.
34. Kicman AT. Pharmacology of anabolic steroids. Br J Pharmacol. 2008 Jun;154(3):502-21. doi: 10.1038/bjp.2008.165. PMID: 18500378; PMCID: PMC2439524.
35. Al Bimani SA, Gates LS, Warner M, Bowen C. Factors influencing return to play following conservatively treated ankle sprain: a systematic review. Phys Sportsmed. 2019 Feb;47(1):31-46. doi: 10.1080/00913847.2018.1533392. Epub 2018 Nov 2. PMID: 30324860.
36. Tassignon B, Verschueren J, Delahunt E, Smith M, Vicenzino B, Verhagen E, Meeusen R. Criteria-based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis. Sports Med. 2019 Apr;49(4):601-619. doi: 10.1007/s40279-019-01071-3. PMID: 30747379.
37. Wikstrom EA, Mueller C, Cain MS. Lack of consensus on return-to-sport criteria following lateral ankle sprain: a systematic review of expert opinions. J Sport Rehabil. 2020 Feb 1;29(2):231-237. doi: 10.1123/jsr.2019-0038. PMID: 31141438.
38. Herring SA, Kibler WB, Putukian M. The team physician and the return-to-play decision: a consensus statement-2012 update. Med Sci Sports Exerc. 2012 Dec;44(12):2446-8. doi: 10.1249/MSS.0b013e3182750534. PMID: 23160348.
Comments
Submitted by Dr. Fred Ferlic - 11/17/22
I congratulate Dr. Thomas Ehlers on an excellent article on a modern-day treatment of ankle sprains. After treating Notre Dame athletes (30 years) and the general population (40 years), I believe his program of early weight-bearing, ROM, and compression is now the standard of care. Grade 3 sprains may require some immobilization for a limited time, and then a gradual ROM treatment protocol. At the present time, there is an external ankle/hindfoot AFO that fits over and under the shoe/work boot, and it allows "progression of care" from complete immobilization to limited ROM (5° dorsi/10° plantarflexion) to full ROM.
Invented by a trainer at the University of Notre Dame, and now used by over 80 NCAA teams and 20 NFL teams, this external AFO fulfills all the modern-day criteria for treatment of Grade 3 sprains, whether athletes or office patients.
Dr. Ehlers' article of 11/03/22 in Podiatry Today gives the foundation for evidence-based "functional rehabilitation" of ankle sprains, which is the present standard of care treatment every patient deserves.
Fred Ferlic, M.D.
Dr. Ferlic discloses that he is Chief Medical Officer for TayCo Brace, Inc.