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
Interesting! I hadn’t heard of POLICE before. I like that loading is being recognized as an important factor to consider when healing. I’m curious what evidence you found to support (or not) icing in general. For example, I’ve read this article, which suggests that icing following acute muscle crush injury in a rat model is detrimental to healing: http://jap.physiology.org/content/110/2/382.short
I think it is really interesting how research about the RICE method has recently been coming about questioning the RICE method. I think it would also be interesting to test whether or not a single factor, like icing, is also affected by elevation, optimal loading, etc.
Going off of what Dr. Rooney said, I’ve come across this guy Gary Reinl who has been waging a campaign against icing minor injuries for a while now (http://www.garyreinl.com). One of the articles posted on his website discusses using METH instead of RICE – Movement, Elevation, Traction, Heat.
Steven, I think it is really interesting how this website that you found mentions METH, which removes ice and adds movement and heat. I definitely think that more research needs to be done to determine the correct method for proper healing.