Is ice recommended for the management of ankle sprain injuries?

Ice Is NOT Recommended as Best Management for Ankle Sprains

Ice (cryotherapy) alone has no proven benefit for reducing pain, swelling, or improving function in acute ankle sprains, and there is no role for RICE (Rest, Ice, Compression, Elevation) alone in treatment. 1

The Evidence Against Ice as Primary Treatment

The most recent high-quality guideline from the British Journal of Sports Medicine (2018) definitively states that isolated ice application does not increase function, decrease swelling, or reduce pain at rest in patients with acute lateral ankle sprains, based on 27 randomized controlled trials involving 1,670 patients. 1

Key Findings on Cryotherapy Efficacy:

• No benefit as monotherapy: The efficacy of cryotherapy for reducing acute ankle sprain symptoms is unclear based on 33 RCTs with 2,337 patients. 1

• RICE protocol lacks evidence: RICE as a conservative treatment method has not been rigorously investigated, and its efficacy as a combination is questionable with little scientific support for reducing injury-associated symptoms. 1, 2

• Compression equally ineffective alone: Evidence regarding compression therapy after acute ankle sprains is inconclusive based on only 3 RCTs with 86 patients. 1

When Ice May Have Limited Utility

Ice shows potential benefit only when combined with exercise therapy, not as standalone treatment:

• Cryotherapy combined with exercise has greater effect on reducing swelling compared to heat application (1 RCT, n=30). 1

• The combination of cryotherapy and exercise results in significant improvements in ankle function in the short term, allowing increased weight-bearing compared to standard functional treatment (1 RCT, n=101). 1

• Intermittent ice applications (rather than continuous 20-minute applications) may provide better pain relief on activity, though this doesn't translate to improved function or swelling reduction. 3

What Actually Works: Evidence-Based Management

The treatment with the strongest evidence (Level 1) is supervised exercise therapy combined with functional bracing, NOT ice. 1, 4, 2

Recommended Treatment Algorithm:

1. Immediate Phase (First 24-72 hours):

   • Apply functional support with semirigid ankle brace immediately 4, 5
   • Avoid activities that cause pain 1
   • Consider NSAIDs (piroxicam, celecoxib, or naproxen) for pain control, which have proven efficacy for reducing pain and accelerating return to activity 1, 4
   • If ice is used for comfort, limit to 20-30 minutes without direct skin contact, but recognize this is for patient comfort only, not therapeutic benefit 1

2. Early Mobilization Phase (48-72 hours post-injury):

   • Begin supervised exercise therapy focusing on proprioception, strength, coordination, and function 1, 4, 5
   • Continue semirigid ankle brace for 4-6 weeks 4, 2
   • Initiate early weight-bearing as tolerated 5

3. Progressive Rehabilitation:

   • Range of motion exercises 4
   • Strengthening exercises addressing muscle deficits 5
   • Proprioception training 4, 5
   • Sport-specific drills when appropriate 1

Functional Treatment Outcomes:

• Patients return to sports 4.6 days sooner with functional treatment versus immobilization 1, 4, 2
• Patients return to work 7.1 days sooner with functional treatment versus immobilization 1, 4, 2
• Lace-up or semirigid supports are more effective than tape or elastic bandages 1, 4

Critical Pitfalls to Avoid

• Relying on RICE alone without active rehabilitation: This delays recovery and provides no proven benefit 1, 2

• Prolonged immobilization: Shows no benefits compared to functional treatment and leads to worse outcomes 1, 2

• Excessive rest without early mobilization: Functional treatment is superior to immobilization for all measured outcomes 1

• Delaying exercise therapy: Exercise should begin within 48-72 hours, as this has the strongest evidence for effectiveness 1, 4, 5

Clinical Assessment Timing

Optimal clinical assessment of ligament damage (anterior drawer test) should be delayed 4-5 days post-injury when swelling has decreased, achieving 84% sensitivity and 96% specificity. 1, 4, 5

The Bottom Line

The 2018 British Journal of Sports Medicine guideline explicitly states: "There is no role for RICE alone in the treatment of acute lateral ankle sprains." 1 The American Heart Association (2024) acknowledges ice may be applied for comfort but emphasizes this is adjunctive only. 1 The evidence overwhelmingly supports functional treatment with bracing and supervised exercise therapy as the gold standard, with ice relegated to an optional comfort measure at best when combined with active rehabilitation.