Sports Medicine Research: In the Lab & In the Field: Re-evaluating RICE for Ankle Sprains (Sports Med Res)
Tuesday, September 4, 2012

Re-evaluating RICE for Ankle Sprains

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

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van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, & Kerkhoffs GM (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47 (4), 435-43 PMID: 22889660

8 comments:

athleticmedicine said...

This is fantastic. I have often asked the question: 'Why are we inhibiting our body's natural healing mechanisms?'Inflammation is done to initiate repair and remodeling of damaged tissue. So why are clinicians consumed with the conception of put ice on to inhibit inflammation? Are we not preventing the body from doing its job?

The thought process stems from the secondary effects of inflammation (pain, spasm, muscle inhibition, etc). This led clinicians to believe that inflammation needed to be stopped. I do not think this should be our thought process.

Look at innovative treatment techniques being used today - Graston, massage, PRP, burring - these all provoke inflammatory response and show efficacy in treating chronic pain.

I began adapting this thought process in my own clinical experience. I will only apply ice in the first 48-72 hrs post significant injury. After that, I say let the body heal itself.

When I made the transition from ice to no ice in athletes suffering from chronic tendinopathy (patellar, biceps, achilles, etc) the results were pretty significant. Many of these athletes had a significant reduction in symptoms. My goal was to let the body heal and adapt - it appeared to work. Anyone want to perform a clinical trial with me?

chiropractor jacksonville fl said...

Due to the point that the few content involved in the research were low quality and had out old results should be considered with warning.

Bethany said...

I just graduated from my undergraduate program, and we are still being taught the RICE method. That is essentially the first thing you learn as a freshman (if you did not learn it sometime before then!). I use the RICE method, although I definitely pair it with rehab exercises and modalities (as needed). My perspective and what I have seen thus far is that rest is definitely effective (although not always practical depending on the injury severity and a multitude of other factors) and that ice/compression have been effective too. I have seen compression do great things if applied right after an ankle sprain (especially when also using a horseshoe pad!). I would almost never consider a situation in which I would use RICE alone without some form of rehabilitation as well. The rehabilitation is where I see the most benefits for the athletes I have worked with.

Jane McDevitt said...

Bethany,

I agree with you. Many people still learn and practice the RICE method. However, as you pointed out exactly how long you rest, what ice method you use, how or how long you use compression, and how long you elevate the injured area is all based around the injury and the athlete. This review is only for ankles, and as pointed out in the previous comment and the review the quality of the articles included in the review were low and old. I was also surprised at the fact that there were no compression articles that talked about the horseshoe pad. Finally, this article did not really review the RICE method, but as separate variables. From a research point of view it would be very difficult to look at different types of rest, ice, compression, and elevation methods in addition to looking at the RICE method as a whole. I think much more research needs to be done to view best RICE practices for ankle injuries (probably many different injuries).

sportinjurymatt said...

The main argument I hear for not allowing inflammation to proceed indefinately as "nature intends" is that it is an example of the body over-reacting to provide an important short term solution to injury, rather like the erratic creation of misaligned fibres to repair a tear. Both responses can lead to long term complications if left to take their "natural" path. The body frequently chooses short term fixes to deal with issues...postural compensation for example. Research may not backup the effectiveness of RICE but I this does not imply that therapeutic intervention is not appropriate.

Jane McDevitt said...

Sportinjurymatt,

I do agree that some sort of intervention needs to happen so the injury is guided to repair/rehabilitate properly. It is difficult to actually perform a RICE study since there are so many different variables that could be measured. I think this article points out that you have to apply the RICE method by an individual basis. One RICE method may not work for one person as well on another.

Brian said...

This is a very interesting take on a widely used practice. I will continue to use RICES in addition to rehabilitative exercises. Whenever I personally use RICES, my ankle always feels much better compared to when I do not.

What kind of accelerated exercises did the participants in this study engage in?

Jane McDevitt said...

Brian,

I think it is important that you noted in addition to rehabilitative exercises using RICES following an injury since you cannot just treat an injury just using one modality. I also feel there is a psychological component and pain modifying component that RICES helps with. Additionally, the authors did not consider RICES together, but looked at each of the RICES components separately so together they may be very beneficial.

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