How do you manage acute ankle sprains without routine icing?

Managing Acute Ankle Sprains Without Routine Icing

Based on current evidence, RICE (Rest, Ice, Compression, Elevation) is no longer recommended as a treatment modality for lateral ankle sprains, as there is no evidence that RICE alone, or cryotherapy alone, has any positive influence on pain, swelling, or patient function. 1

Current Evidence on Icing

The traditional approach to ankle sprains has long included icing as part of the RICE protocol. However, recent high-quality evidence has challenged this practice:

• The 2018 British Journal of Sports Medicine guideline explicitly states that RICE is not advised as a treatment modality after lateral ankle sprains 1
• There is limited scientific support for the efficacy of ice in reducing injury-associated symptoms following acute lateral ankle sprains 1
• No evidence shows that isolated use of ice can increase function or decrease swelling and pain at rest 1

Modern Approach to Ankle Sprain Management

Immediate Management (0-72 hours)

• Functional support: Use a brace rather than immobilization or elastic bandages

  • Semirigid or lace-up ankle supports are more effective than tape or elastic bandages 1
  • Bracing leads to shorter time to return to sports and work compared to elastic bandages 1

• NSAIDs: May be used to reduce pain and swelling 1

  • NSAIDs help improve pain control, decrease swelling, and allow quicker return to activity 1
  • Options include piroxicam, celecoxib, naproxen, or diclofenac 1

• Early weight bearing: Begin as soon as tolerable to promote healing

Rehabilitation Phase (Starting 48-72 hours post-injury)

• Exercise therapy: Should be started as soon as possible to recover joint functionality 1

  • Begin with range-of-motion exercises and isometric strength training
  • Progress to proprioception and balance training
  • Exercise therapy helps prevent recurrence of ankle sprains 1

• Manual mobilization: Only advised in combination with other treatment modalities 1

Return to Activity

• Supervised exercises: Focus on proprioception, strength, coordination, and function 1
• Functional testing: Ensure adequate stability before returning to sports
• Continued bracing/support: Consider for prevention of recurrent sprains

Why Icing Is No Longer Recommended

1. Lack of evidence: Multiple studies show no significant benefit of ice application alone on recovery outcomes 1

2. Potential interference with healing: Some research suggests that the inflammatory response is a necessary part of the healing process

3. Focus on functional recovery: Evidence strongly supports early mobilization and exercise therapy over passive treatments like icing 1

Common Pitfalls in Ankle Sprain Management

• Overreliance on RICE: Continuing to use outdated protocols despite newer evidence
• Unnecessary immobilization: Delaying functional treatment can prolong recovery
• Inadequate rehabilitation: Failing to progress through appropriate exercise therapy
• Premature return to activity: Returning before adequate strength and proprioception are restored

Special Considerations

For certain populations or specific circumstances, limited cold application might still be considered:

• The 2024 American Heart Association and American Red Cross guidelines suggest that first aid providers may apply cold for pain and swelling in acute sprains, limited to 20-30 minutes per application 1
• When combined with exercise therapy, cryotherapy may have some benefit for reducing swelling compared to heat application 1

Algorithm for Management

1. Assessment: Rule out fracture using Ottawa Ankle Rules
2. Support: Apply semirigid brace for protection and stability
3. Medication: Consider NSAIDs for pain and swelling control
4. Early mobilization: Begin weight-bearing as tolerated
5. Exercise progression:
   • Days 2-3: Range of motion exercises
   • Days 3-7: Add isometric strengthening
   • Week 2+: Progress to balance and proprioception training
   • Week 3+: Sport-specific exercises
6. Return to activity: Based on functional testing and absence of pain

By following this evidence-based approach that emphasizes functional treatment over passive modalities like icing, patients can achieve better outcomes with faster return to normal activities and reduced risk of recurrent injury.