Should POLICE Replace RICE as the Ankle Therapy of Choice?

Laird Harrison

Disclosures

April 09, 2014

Evidence Supports Early Movement, Not Rest

The NATA researchers found level "A" evidence supporting functional rehabilitation -- in other words, therapies that involve moving the ankle soon after the injury -- for ankle sprains of grade I (stretching and damage to ligament fibers) and grade II (partial tearing of the ligaments).

No one recommends forcing patients to walk on their sprained ankles right away. But some randomized controlled trials have shown that beginning range-of-motion exercises within a couple of days, followed by gradual loading, can get patients back on their feet more quickly.[6] Manipulation of the joint by trained therapists has also shown success in these trials.[6]

For grade III ankle sprains (complete ligament tear), Kaminski and colleagues found "B" level evidence for immobilizing the joint for 10 days.[6] After that, they recommend, patients should begin moving the joint. They also call for more conservative treatment of syndesmotic or "high" ankle sprains.

Which other therapies received an "A" for evidence? Balance training and nonsteroidal anti-inflammatory drugs (NSAIDs). That's it.

Designed to improve proprioception, balance training reduced the risk for reinjury in some clinical trials.

NSAIDs are more controversial. Kaminski recommends not using them for the first 48 hours after the injury because they might interfere with the benefits of inflammation during that period.

But just because evidence is lacking for the rest of the RICE prescription, advocates of a revision aren't ready to throw it out completely.

Rethinking RICE

Kaminski, for one, thinks ice, compression, and elevation still have a role to play. He's most skeptical of ice.

"Maybe our European colleagues know something we don't," he says. "There is very little icing over there." On the other hand, "We do know it's a good pain reliever."

With no contradictory evidence at hand, he's willing to go along with the conventional wisdom behind compression and elevation: Compression can reduce the leaking of fluid through capillary into tissue spaces. And elevation can keep blood from pooling in the limb.

"Extreme swelling adds days, if not weeks, to the healing," he says.

A similar line of thinking has convinced Stephen Rice, MD, PhD, former chair of the ACSM Health Science Policy Committee, to keep recommending ice, compression, and elevation for sprains and strains.

"I think nobody would make the argument that if you get a musculoskeletal injury you should just let it swell," says Rice, a pediatric sports medicine specialist at Jersey Shore University Medical Center in Neptune, New Jersey. "I've known for many years that we don't have the hard science, but I have nearly 40 years of experience that if you can control the swelling, people can return faster."

He believes the therapy should start immediately. "I'm so aggressive with my icing, compression, and elevation that I don't worry about the anti-inflammatories," he says.

Barbara Bergin, the AAOS spokesperson, believes there's a lot of good in RICE as well. "You just can't beat rest, ice, compression, and elevation," she says. "But it's not a treatment guideline; it's an initial management guideline for the general public. You sprain your ankle and it's a Sunday afternoon and you don't want to have to go to the emergency room because you'll have to wait in line for hours, and you'll have to pay a lot, and your doctor will be in on Monday."

As for actual clinical guidelines, she says they can't be summed up in a single acronym. Every patient is different, and every therapy has to be designed for that individual, she says.

In this respect, critics and defenders of RICE agree. It won't hurt and may help patients with self-care until they can get medical attention.

"RICE by itself is not necessarily too dangerous," says Eric Robertson. "But you should know that there is a better way."

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