Have you or your clients ever suffered an ankle sprain or other soft tissue injury and heard conflicting advice on what to do? Should you rest? Should you ignore it? What do professionals do?
Traditionally after ankle sprains and other soft tissue injuries, RICE was used as a pneumonic to help treat acute injuries – advocating rest, ice, compression and elevation. Some people have heard of PRICE, which adds protection to the equation. Let’s have a look at each of these stages individually as explore how they may help and if there may actually be a more useful method.
Protect – the 1st aim of first aid is “to do no further harm”. This involves the use of crutches, casts, braces, slings etc to help reduce the chance of further injury to the affected area and will depend on the severity and location of the injury
Rest – resting the affected area was hypothesised to help the area by reducing the chance of further injury, whilst allowing the inflammatory process to take place.
Ice – the rational for ice is that it can help reduce swelling post injury along with helping with pain management. The research behind ice application is far from conclusive however, in terms of how to apply it and how it works. In general though through personal experience and general consensus the guide is:
Apply ice for 10-20minutes up to 3-4 times per day for the first 5-7 days post injury. Apply an ice pack wrapped in a damp towel, and monitor for any ice burns or skin alteration.
Compression – According to Knight (1995) compression is deemed to help control oedema formation, and to promote oedema reabsorption. Similar to ice application, the evidence behind compression is inconclusive, but health professionals commonly use this modality. Tubi grip purchased in a pharmacy works well. The area involved should feel compressed but never painful, and it is important to ensure a good blood flow maintains distally (e.g. if ankle is compressed should still have good blood flow to toes). In general, compression is useful during the day, but unnecessary at night as swelling is often controlled when lying down.
Elevation – is an important component that can be combined with compression. By elevating the body part, capillary pressure is reduced at the site of injury and the rate of fluid moving from the capillary into the tissue reduces, therefore reducing oedema.
Stop with RICE and bring in the POLICE
Is total rest often the correct thing to do though? Well recent research suggests that it often isn’t, so “Rest” should be switched with “Optimal Loading” therefore replacing PRICE with POLICE.
Recent studies show that short periods of unloading are required following soft tissue injury, and that aggressive ambulation or exercise should be avoided. Total rest should be of limited duration however and restricted to immediately after trauma, as longer periods of unloading can result in:
- Deconditioning of the tissues, joint stiffness, muscle weakness and reduced proprioception (balance and control).
- Prolonged swelling. The correct amount of activity can improve swelling. Ankle pumps (contracting the calf muscle) can help with the removal of oedema from the ankle, by activating the bodies muscle pumps.
- Impaired healing via reduced mechanotherapy.
Research by Bleakley in 2010 showed early mobilisation with accelerated rehabilitation is effective after acute ankle sprains and was in agreement with studies that showed early weight bearing after lateral ankle sprains was superior to immobilisation in a cast. It is believed that early rehabilitation promotes cellular responses by promoting the creation of key proteins associated with healing, improving the quality of the repair.
The challenge clinically is finding the balance between loading and unloading during the healing process. If tissues are loaded too aggressively after injury, there might be resultant re-bleeding and further damage. Optimal loading in some cases can be total immobilisation in a boot coupled with manual therapy by a suitably qualified clinician. In other cases the individual may optimally load simply by weight bearing as tolerated. As there is no specific recipe, it is important to have the guidance of a professional – getting it wrong can set you up for repeat failure.
The first goal after an injury is to do no further harm and therefore, it is important to consider protection. Ice, compression and elevation are useful to help with swelling management and are important especially in the first few days. Gone are the days of total rest for all injuries. To help speed up the rate of recovery and optimise long-term outcomes, seek the assistance of a suitably qualified professional who can advise on optimal loading.
By Kevin Tucker
Training tutor & Physiotherapist
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Bleakley CM,Glasgow P & MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med 2012; 46:220–221
Bleakley CM, O’Connor SR, Tully MA, et al . Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 2010; 340: c1964
Jones MH & Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res 2007; 455: 169 – 72
Kerkhoffs GM, Rowe BH, Assendelft WJ , et al . Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 2002; 3: CD003762.
Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009; 43: 247 – 52
Knight, K. (1995). Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics.