What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?
van den Bekerom, MP, Struijs PA, Blankevoort L, van Dijk N, Kerkhoffs GM. Journal of Athletic Training. 2012; 47:435-443
Ankle sprains are one of the most common musculoskeletal injuries. Rest, ice, compression, elevation (RICE) is an easy and popular therapy option in the acute stage of an ankle sprain, however, there is a lack of evidence-based research supporting this treatment. Therefore, the objective of this study was to utilize a systematic review to determine the effectiveness of using RICE therapy within 72 hours after an ankle sprain. This systematic review found 222 studies that fulfilled their search criteria and utilized 11 randomized control trial studies involving 868 patients that focused on rest (5 articles), ice (5 articles), and compression (1 article). There were no articles that compared elevation to no elevation. The dates of the articles ranged from 1976 to 2010, where 7 of the articles were published before 1990. The quality of the articles were assessed using 10 quality assessment questions from the Cochrane Collaboration systematic review guidelines and were given a score of 0, 1, or 2, where 20 is the best score. The articles that examined rest also included immobilization versus mobilization, and observed conflicting results. Green et al (quality assessment = 11), Karlsson et al (quality assessment = 11), and Brooks et al (quality assessment = 6), stated mobilization improved pain free ankle dorsiflexion, shorter sick leave, and earlier return to sport participation, respectively. However Eisenhart et al (quality assessment = 10) suggested single session osteopathic manipulative treatment resulted in less swelling and pain and Bleakley et al (quality assessment = 13), found that accelerated exercises improved ankle function. Opposed findings were also found in articles focusing on ice versus no ice. Sloan et al (quality assessment = 11), showed that using a cooling anklet with or without elevation found no difference after 7 days of application or following a single application when also given a nonsteroroidal anti-inflammatory medication. Laba (quality assessment = 10) did not show differences in pain, swelling, or ankle function between ice pack application and no ice therapy. Conversely, Hocutt et al (quality assessment = 4) found that ice whirlpool was more effective in decreasing pain and returning to play faster than using a heating pad. Additionally, Basur et al (quality assessment = 4) showed that cryogel and bandaging resulted in faster reduction in edema, pain, and disability of ankle sprain compared to bandaging alone. The only article examining compression was by Airaksinen et al (quality assessment = 6), which demonstrated that using intermittent pneumatic compression and bandaging decreased edema, pain, and increased ankle function compared to just bandaging.
Despite the widespread use of RICE therapy there seems to be insufficient data from randomized control trials to support the effectiveness of RICE therapy. The highest quality articles do show that some type of immediate immobilization after injury is beneficial in the treatment of ankle sprains. Yet, the poor quality of the articles testing different cryotherapy methods suggests that research involving ice for the treatment of acute ankle sprains is limited, and there are very few studies drawing any conclusions on the effects of compression and elevation for acute ankle sprain injuries. Due to the fact that the few articles included in the study were poor quality and had out dated conclusions should be interpreted with caution. These authors conclude that treatment decisions must be made on an individual basis by weighing the relative risks and benefits with each option, as well as, bring attention to the need for more sufficiently powered, quality randomized control studies to investigate the elements of RICE therapy for acute ankle sprain. Will you still use RICE? What is your specific RICE methodology?
Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Stephen Thomas
Consensus Statement: Diagnosis, Treatment and Prevention of Ankle Sprains: an Evidence-Based Clinical Guideline