What is the evidence
for rest, ice, compression, and elevation therapy in the treatment of ankle
sprains in adults?

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?

by: Jane McDevitt MS, ATC, CSCS
by: Stephen


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