Help! I’ve Sprained My Ankle…Should I call the POLICE or use RICE?

For anyone who’s had a sprain, you’ve probably heard of RICE, or Rest, Ice, Compression, and Elevation, to take care of your injury. Sprains are extremely common; each year, approximately 1 million people are treated with ankle sprains with costs at about $40 million per year.  A sprain is a stretching or tearing of ligaments, which are fibrous tissue that connect two bones together. Common symptoms include pain, swelling, bruising, and limited mobility in the affected area.  Most doctors and physical therapists recommend RICE for treatment and can be treated at home. RICE is an acronym used for patients to remember when they have sprains for treatments. They first must REST the injured area and ICE the area as soon as possible. Then they must COMPRESS the area with an elastic wrap or bandage and finally ELEVATE the injured area to avoid swelling.

Although RICE has been recommended for treatment for a long time, doctors are beginning to question RICE and are beginning to recommend POLICE for treatment. POLICE stands for protection, optimal loading, ice, compression, and elevation. Optimal loading means creating a balance and incremental rehabilitation program where early activity leads to early recovery.  It also has been shown that long periods of rest are harmful and produce adverse changes to tissue biomechanics and morphology. Progressive mechanical loading is more likely to restore strength and to get patients to recover faster.  The addition of optimal loading raises new questions on whether this is beneficial or detrimental to the healing process of sprains. The challenge also is defining optimal loading for each individual case for dosage, nature, and timing. Let’s take a look at the evidence to see if optimal loading leads to a better recovery than RICE.

A study by Green, et al. showed looked at passive joint mobilization, a technique commonly used by physical therapists for patients with an acute ankle inversion sprain. Their study included forty-one subjects with acute ankle sprains and they were randomly assigned to two groups: the control group who received RICE and an experimental group that received anteroposterior mobilization along with RICE. At the end of two weeks with treatments every second day, the experimental group required fewer treatment sessions to achieve pain-free dorsiflextion, greater improvement in range of movement, and had a greater increased stride speed.  However, a limitation with this study is that the participants followed the RICE protocol at home so the question arises: did the participants actually RICE for as long as they said they did?

Bleakley et al. in another study had two groups with acute ankle sprains, one group had standard treatment (ice and compression) and another group had cryokinetic treatment (ice, compression and exercise consisting of muscle strengthening, neuromuscular training, and sports specific functional exercises five times a week). Function was assessed using the Lower Extremity Functional scale, pain, swelling, and activity levels. Following weeks 1 and 2, the exercise group had a better Lower Extremity Function score and had a higher activity level. The exercise group was also more active as well. They concluded that the aim of initiating early exercise during the acute phase of ankle sprains was to have early reactivation of ankle muscles and movement patterns. For this study as well, the participants wrote in a treatment journal of what they did every day.  Again, the question arises, did the participants actually do what they wrote?

Karlsson et al. also completed a study where one group received functional treatment of compression, elevation, early full weight0bearing, and proprioceptive range of motion training. Another group received conventional treatment with compression, protection, and crutches. They also concluded that return to sports activity was higher in the functional treatment group.  All three of these studies discuss only certain exercises that they had their participants take, there was not a universal exercise to help with ankle sprains.  I think it is interesting that despite having different exercises, they all arrived at the same conclusion.   I believe that a study comparing different exercises compared to healing would be interesting to observe.

Overall, all these studies show that some sort of early mobilization helps patients with acute ankle sprains recover faster and have less pain. Despite all the research conducted about early movement, research also lacks on whether ice, compression, and elevation are significant for recovery from sprains as well. With the new burst of research on optimal loading, I am led to believe that optimal loading may be best for a full recovery. However, I also believe that ankle sprains need to be treated differently for each case. For example, an athlete who exercises regularly and uses their ankle more, may be able to have more optimal loading compared to someone who does not exercise regularly. I also believe that more research needs to be conducted to determine which exercises are best for ankle sprains and what these exercises do internally do the muscles. Hopefully, new research will help to show what should be done to heal ankle sprains.

Recommended for Further Reading:

What is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?

Early functional treatment for acute ligament injuries of the ankle joint

National Athletic Trainers’ Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes

Temporal extracellular matrix adaptations in ligament during wound healing and hindlimb unloading 

Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review 

Should POLICE Replace RICE as the Ankle Therapy of Choice? 

Elevation Training Mask 2.0: “The Swimming Mask”

As technology advances, physical trainers are constantly seeking new ways to improve their clients training so that they can become the best athletes in sports. A relatively new device, the elevation training mask, has been developed in an attempt to mimic exercise at a high elevation, where the air is thinner and less oxygen is present. Training at high elevations has been shown to cause physical adaptations within the human body to compensate for decreased oxygen levels. Evidence shows that there is an increase in production of red blood cells, which carry oxygen throughout the body, and this increase results in improved efficiency of the body’s utilization of the oxygen present.

In its attempt to simulate these conditions, the elevation training mask has received mixed opinions from doctors, athletes, and trainers. Dr. Teo Mendez, a New York based sports medicine doctor has claimed that the device is actually “unlikely to cause adaptive change, such as an elevation of hemoglobin or blood oxygen carrying capacity.” He claims that this is due to the fact that the air being breathed through the mask still contains the same concentration of oxygen as the air at sea level elevation. On the other hand, the Seattle Seahawks former running back, Marshawn Lynch, used the device during the teams run to Superbowl XLIX. Lynch has praised the device and claims that it has improved his endurance and gives him an extra “boost” when using it to warm up minutes before the game. So why does Lynch praise the device, while Mendez claims that it cannot mimic altitude training effectively? Here’s what the evidence has to say.

In 2016, the Journal of Sports Science and Medicine published a study in which 24 participants completed a six week training program of high-intensity exercise twice a week. The experiment was designed to measure the maximum volume of oxygen a person can use (VO2max), pulmonary function, ventilatory threshold, and hemoglobin levels before and after training. The results showed that the mask improved the participants’ VO2max as well as their ventilatory threshold, the point at which oxygen exchange in the lungs is occurring faster that the intake of oxygen, and their power output at this point. However, the mask did not result in any differences in pulmonary function or hemoglobin levels.. In another study, nine participants completed a six week exercise program and the masks were tested as a breathing resistance device. The results of this study showed that the participants’ ventilatory thresholds went up, as well as their maximal voluntary ventilation, which is the maximum volume of air inhaled and exhaled during one minute. Both studies, though, do have several limitations that arise, the biggest one being a small number of participants. This does not allow them to look into differences between genders, age, and physical builds. However, they do show similar results in that the training masks are effective at increasing the user’s ventilatory threshold and voluntary lung capacity increased.

Based on the evidence provided, the elevation training mask has failed its intended purpose. The mask cannot simulate high altitude training and does not result in increased red blood cell production because the air being inhaled contains the same percentage of oxygen as does the air at sea level. However, the mask is effective at improving training and the endurance of its user. The mask adds resistance while breathing that strengthens the user’s diaphragm and other respiratory muscles which lead to the ability to take deeper, fuller breaths. These larger breaths increase VO2max and push the ventilatory threshold higher as there is more available oxygen to combat the rising exchange rate in the lungs as exercise continues. Essentially, the device mimics the training of swimming, and cause the body build stronger respiratory muscles that allow for larger breaths of air and so more oxygen can be delivered. So while the mask does not fulfill its intended purpose, it is beneficial for endurance training in a similar way to swimming exercises.

Recommended Further Readings

Carlton, Lindsay. “Can Elevation Training Masks Improve Your Endurance?” Fox News. FOX News Network, 02 Aug. 2016. Web. 19 Feb. 2017.

Friedman, Daniel. “The Story behind Marshawn Lynch’s Unique High-altitude Training Mask.” Sports Illustrated. Sports Illustrated, 26 Jan. 2016. Web. 19 Feb. 2017.

Gabarda, Christian. “Elevation Training Mask Review | UPMC Health Plan.” UPMC MyHealth Matters. UPMC, 12 Feb. 2016. Web. 19 Feb. 2017.

Kido, Satoshi et al. “Effects of Combined Training with Breathing Resistance and Sustained Physical Exertion to Improve Endurance Capacity and Respiratory Muscle Function in Healthy Young Adults.” Journal of Physical Therapy Science 25.5 (2013): 605–610. PMC. Web. 19 Feb. 2017.

Porcari, John P. et al. “Effect of Wearing the Elevation Training Mask on Aerobic Capacity, Lung Function, and Hematological Variables.” Journal of Sports Science & Medicine 15.2 (2016): 379–386. Print.

Seawater, The Ideal Rehydration Beverage?

You have probably seen the cool commercials showing sweating professional athletes making a legendary play, or training to their maximum level, while drinking their Gatorade or Powerade bottle. Many people, including the brands of these commercially available sport drinks, believe these sport drinks are good for you because they replenish the electrolytes you lose when sweating. However, certain nutritionists and other health and fitness guru’s tell you to stay away from them because they do more harm than good. How does this really work? Do we need to consume these sport drinks when exercising in order to replenish electrolytes?

It is well-known that we sweat during exercise, and that our sweat mainly consist of water and electrolytes. These electrolytes include sodium, potassium, calcium, and magnesium, sodium being the most abundant in our sweat. Sodium is the main cation in extracellular fluid, and its presence has a large effect on plasma osmolality. The amount of sweat and electrolytes lost during exercise varies greatly between individuals, showed by a study done on soccer players. They showed it is affected by factors such as fitness level, sweating rate, and prior diet. For example, sodium concentration in sweat can vary from 20-80 mmol/L. As sodium is the most important electrolyte in our body, it will be the main focus of this review.

Despite the variability within individuals as described above, several studies have researched the effect of sodium concentration in drinks on rehydration during and post exercise. A study published in the European Journal of Applied Physiology found that the addition of sodium to fluids consumed after exercise-induced dehydration has an effect on the rehydration process. More fluid was retained if the sodium concentrations were higher. Subjects did not remain in a positive fluid balance for more than 2 hours when the sodium concentration was low (20 mmol/L). However, drinking fluids with a volume of 1.5 times their sweat loss and a sodium concentration of 60 mmol/L did allow them to remain in a positive fluid balance (meaning that the fluid intake is greater than the fluid output). Another study from University Medical School in Scotland got similar results. They found that in order to sufficiently rehydrate after exercise, both the sodium concentration and volume of the beverage need to be high enough. It is important to note that both of these studies only looked at males, and included a minimum number of subjects. It should also be mentioned that these studies did not take effects of any other components into consideration that are present in many commercially available sports drinks, such as carbohydrates. According to a study about the maintenance of fluid and electrolyte balance during exercise, the total carbohydrate concentrations in drinks consume during exercise should be 5-10%, to avoid delay of fluid and electrolyte absorption. Therefore, sodium concentrations in sport drinks cannot simply be compared to these data in order to determine its efficiency on rehydration.

In addition to drinks, food is also a source of electrolytes. Maughan et al found that urine production was significantly less in subjects that consumed a meal with water after exercise, than in those that had a carbohydrate-electrolyte beverage (sport drink) after exercise. However, they did not give any data on the electrolyte content of the meal and sport drink. Melinda L. et al compared post heat- and exercise-rehydration when consuming chicken broth, soup, sport drinks, and water. They found that plasma volume was not significantly different from predehydration values in the chicken broth and soup trials, but remained significantly below predehydration values for the water and sport drinks trails. Considering the fact that chicken broth and soup had the highest sodium concentrations (109.5 and 333.8 mmol/L respectively versus 0.0 and 16.0 mmol/L in water and sport drinks), this might indicate that higher sodium concentrations have a positive effect on plasma volume recovery. However, it has to be taken into account these four products have large variation in substance (solid/fluid) and electrolytes and carbohydrates composition, so conclusions have to be drawn very carefully.

Analyzing various studies that have been performed on electrolyte and fluid replenishment after exercise, I think it is fair to say that electrolyte composition of fluids consumed after exercise does matter for a successful rehydration process. Looking at the results from University Medical School in Scotland and the article from the European Journal of Applied Physiology, we might be able to say that after intense exercise sport drinks might positively influence the rehydration process, especially compared to water. However, considering the study from Maughan et al and Melina L. et al, I do not think we should say that sport drinks are the ultimate way to rehydrate, as some commercials might suggest. According to this study, subjects remained in positive fluid balance when consuming beverages containing sodium concentrations of 60 mmol/L. This is equivalent to 1379 mg/L, which is not close to the 423 mg/L that for example Gatorade contains. The sodium content of sport drinks is relatively low, while the carbohydrate concentration is relatively high. This makes sense, as a very salty drink most likely does not have a preferable taste. However, if you were to replenish your water and electrolytes purely with sport drinks, you would consume a lot of (unnecessary) sugars. Therefore, I think that consuming sport drinks in order to rehydrate is mostly beneficial during longer training sessions, as the carbohydrates function as a fuel source. However, after exercising I think the calories from the sport drink might counteract the purpose of exercising, and should therefore mostly be consumed after exercise if you don’t have access to food containing high concentrations of sodium. Otherwise, the combination of consuming water and a “salty meal” might be the most efficient way to rehydrate.


Recommended Further Reading:

Rachael Rettner, Are Sports Drinks Better of Worse Than Water? April 25, 2016. Available from:

Christie Wilcox, Sport Drinks: More Harm Than Good? 2009 [cited 2017Feb19]. Available from:

Gatorade [Internet]. c2016 [cited 2017Feb19]. Available from:

Maughan R.J., Shirreffs S.M., Rehydration and Recovery After Exercise. Science & Sports, 2004, 19;234-238. Available from:

Maughan R.J., Leiper J.B., Sodium intake and post-exercise rehydration in man. European Journal of Applied Physiology and Occupational Physiology, 1995, 71;4:311. Available from:

Gethin H. Evans, Susan M. Shirreffs, Ronald J. Maughan, Postexercise rehydration in man: The effects of osmolality and carbohydrate content of ingested drinks. Nutrition, 2009:905-913. Available from:

Eric T. Wittbrodt, Maintaining Fluid and Electrolyte Balance During Exercise. Journal of Pharmacy Practice, 2003, 16;1:45–50. Available from:

Melinda L. et al, Effect of sodium in a rehydration beverage when consumed as a fluid or meal. Journal of Applied Physiology, 1998, 85;4:1329–1336. Available from:



Welcome to BMEG467-014: Engineering Exercise, The Blog.  Our Spring semester starts February 6, 2017, so you can expect posts to begin populating by February 19, 2017.  Until then, we encourage you to visit the other pages to learn more about the course and the blog.