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March 27, 2013
Treating Ankle Sprains, Why RICE never Works
Of all reported injuries, one stands out as the most common. Ankle sprains range from 15-30% of all sports injuries, these issues can take up to 8-12 weeks to heal. More alarming is the high likelihood that this setback will reoccur again and again. The most common prescription for an ankle sprain is RICE (rest, ice, compression, and elevation). However, RICE could actually prolong the healing process (see Sparta Point). The good news about ankle sprains is that this injury is preventable, very preventable.

What is a Sprain?

The word “sprain” refers to the complete or partial tearing of the ligaments in the ankle. The most immediate symptom is swelling, which is just a sign that torn blood vessels are leaking fluid. Fortunately, this process allows white blood cells into the area, causing inflammation and the start of the healing process. The main injury mechanism is a twisting or rolling over on the ankle, usually occurring during a cutting maneuver or landing from a jump, often on top of another player. But the real cause for these injuries start well before this incident.

Why Does it Happen?

The primary cause for ANY injury, including ankle sprains, is a previous injury in the same area. In this case, ligaments have been previously stretched, and then the athlete is subject to stress before these structures have time to heal (i.e. shorten). This primary cause for re-injury, excessive flexibility  can also be the major cause if no previous history exists. Such laxity is why a January 2013 study found females to be 1.25x more likely to sprain ankles. They are just more flexible, more mobile, which is the opposite of stability. Such a mobility-stability imbalance explains why the majority of females test low on stability, or the EXPLODE portion of a movement signatureTM. This need is objectively evident on our force plate, shown to the right by the large dip between the first and second peak.

If you had only 10 minutes a day…

We have been clear on ankle injury causes, excessive mobility allows too much twisting, an inability to control the lateral plane. As usual, the approach to an injured ankle requires a combination of strength, skills, and regeneration. Strength– Keep with the 1 leg deadlift normally used to improve that EXPLODE portion of your movement signatureTM. This movement specifically targets your ability to control twisting. Skills-Until you get back into dynamic movements like jumping and sprinting, include some ankle mobilizations. This intervention keeps range of motion front to back, again preventing the twisting motion. Regen-We have to be careful here because mobility is not necessarily helpful, as it could compound the natural or required laxity causing an ankle sprain. We know the sprains occur from twisting or rolling over, and the muscles that counteract this motion are the peroneals the outside of the lower leg. If these muscles are slow to react, re-injury will reoccur, so reducing trigger points can improve the muscle spindle functioning and ability to respond quickly (see Sparta Point). Prevention and rehabilitation are a lot closer than we recognize. In the case of ankle injuries, the lack of EXPLODE , or stability, on the movement signatureTM unites us all. Swenson DM, Collins CL, Fields SK, Comstock RD. Epidemiology of US High School Sports-Related Ligamentous Ankle Injuries, 2005/06-2010/11. Clin J Sport Med. 2013 Jan 16.
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March 27, 2013
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12 thoughts on “Treating Ankle Sprains, Why RICE never Works”

  1. It is agreeable that prevention is very important for all injuries, but it is misleading to say RICE NEVER works on an injury. The first step in getting back from any injury is reduction of swelling, which RICE helps with.

  2. Swelling can limit ROM and mobility. Also, a patient’s perceived pain may discourage them to do any kind of movement. I have seen with most post-surgery patients that PT’s aim for mobility as soon as possible, but swelling seems to be the limiting factor.

    I would like to hear your thoughts on what is the first step, and also why RICE is even used anymore if it never works.

  3. Absolutely, icing can help pain, the anesthetic effect on the skin is the major benefit to using the cold stimulus. I also agree swelling can limit ROM (yous said it also limits mobility, but I believe this is the same thing). The point of this post and others is that the swelling is natural process that should not be hindered because it can provide healing to the joint. Hence the adaptation process that has been used by the body for centuries.

    The first step and last step would be to return function. After a knee replacement, that might be just walking. After an ankle sprain, squatting with less weight or less depth.

    Have not seen any research to ever show the reduction of swelling will increase healing time, though I agree icing will reduce pain temporarily, which is why RICE is still used.

    Thank you for the interest

  4. Thank you for the clarification and explanation. Now I better understand the point you were trying to make and agree. Thanks for the read and keep them coming.

  5. To my understanding of your comments, the first step after an immediate ankle sprain would be to perform squats with less weight over reduction of swelling with RICE?
    How can you squat on the ankle if DF is limited due to TCJ/STJ swelling, not to mention significant pain? Why would you put the distal extremity in a WB position where swelling will further increase due to gravity and have them squat on an unstable ankle?
    Swelling is absolutely necessary for the healing process to begin but excessive swelling prolongs the inflammatory phase, reduces time to return to play and is the major limiting factor along with pain in progressing one’s rehab program.

  6. Thanks ATC. In a short blog post, it is hard to convey all aspects. There is actually limited dorsiflexion in a deadlift, and we also raise the distance with plates to limit this ankle ROM even further and avoid any pain.

    This movement teaches WB to occur primarily through the hip and trunk, rather than the ankle.

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