Professional Documents
Culture Documents
doi: 10.4085/1062-6050-47.4.14
Ó by the National Athletic Trainers’ Association, Inc systematic review
www.nata.org/journal-of-athletic-training
Context: Ankle sprains are common problems in acute and assessed the quality of included studies. If feasible, the
medical care. The variation in treatment observed for the results of comparable studies were pooled using fixed- or
acutely injured lateral ankle ligament complex in the first week random-effects models.
after the injury suggests a lack of evidence-based management Data Synthesis: After deduction of the overlaps among the
strategies for this problem. different databases, evaluation of the abstracts, and contact with
Objective: To analyze the effectiveness of applying rest, ice, some authors, 24 potentially eligible trials remained. The full
compression, and elevation (RICE) therapy begun within 72 texts of these articles were retrieved and thoroughly assessed
hours after trauma for patients in the initial period after ankle as described. This resulted in the inclusion of 11 trials involving
sprain.
868 patients. The main reason for exclusion was that the
Study Selection: Eligible studies were published original
authors did not describe a well-defined control group without the
randomized or quasi-randomized controlled trials concerning at
least 1 of the 4 subtreatments of RICE therapy in the treatment intervention of interest.
of acute ankle sprains in adults. Conclusions: Insufficient evidence is available from random-
Data Sources: MEDLINE, Cochrane Clinical Trial Register, ized controlled trials to determine the relative effectiveness of
CINAHL, and EMBASE. The lists of references of retrieved RICE therapy for acute ankle sprains in adults. Treatment
publications also were checked manually. decisions must be made on an individual basis, carefully
Data Extraction: We extracted relevant data on treatment weighing the relative benefits and risks of each option, and
outcome (pain, swelling, ankle mobility or range of motion, return must be based on expert opinions and national guidelines.
to sports, return to work, complications, and patient satisfaction) Key Words: ankle ligament injury, cryotherapy, bandages
Key Points
Randomized controlled trials provide insufficient evidence to determine the effectiveness of rest, ice, compression,
and elevation (RICE) therapy for acute ankle sprains in adults.
Treatment decisions must be made on an individual basis, carefully weighing the relative risks and benefits of each
option, and must be based on expert opinions and guidelines.
Sufficiently powered, high-quality, and appropriately reported randomized trials of the different elements of RICE
therapy for acute ankle sprains are needed.
A
nkle sprains are one of the most prevalent injuries trainers, physiotherapists, and orthopaedic and trauma
of the musculoskeletal system. Researchers have surgeons. Each year, approximately 1 million patients with
estimated that 1 ankle sprain occurs per 10 000 acute lateral ankle ligament injuries are examined by
people each day.1 The most common mechanism of injury primary care physicians in the United States.9 The annual
is inversion of the plantar-flexed foot. Inversion injuries cost to society for ankle injuries has been estimated to be
involve about 25% of all injuries of the musculoskeletal approximately E40 million (US $30.4 million) per 1
system, which affect more than 20 000 patients in the million people.10 Most authors use the term sprain to
United States each day.2,3 About 50% of these injuries are describe a morphologic condition representing a diversity
sport related4,5; some sports (basketball, soccer, and of pathologic conditions, ranging from overstretching of the
volleyball) have a particularly high incidence of ankle ligament to complete rupture with gross instability of the
injuries.6,7 If not treated properly, inversion injuries of the joint.11
ankle can result in persistent problems in 30% to 40% of The ankle ligaments are the anterior talofibular ligament
patients.4,8 (ATFL), calcaneofibular ligament (CFL), and posterior
The treatment of inversion ankle injuries is provided by talofibular ligament (PTFL), and together they form the
emergency and primary health care physicians, athletic lateral ligament complex of the ankle.12 The ATFL is the
full texts of these articles were retrieved and thoroughly searches yielded 68 articles for the intervention compres-
assessed as described. This resulted in the inclusion of 11 sion. Full texts of 5 articles were retrieved for further
trials involving 868 patients (Tables 2 and 3). The most analysis, and 1 article was included in this review.41 For the
common reason for exclusion was that the researchers did intervention elevation, the computerized searches yielded
not describe a well-defined control group without the 25 articles. Full text of 1 article was retrieved for further
intervention of interest but described a control group with analysis. However, no articles were included in this review
another form of intervention. The study by Tsang et al32 concerning the comparison of elevation and no elevation in
was excluded because the follow-up was too short. The the treatment of acute ankle sprains.
publication dates spanned 34 years; Basur et al33 was the
earliest report, and Bleakley et al34 was the most recent Data Extraction
publication. Six studies were performed in Europe, 3 in
The data from the included studies that could be meta-
North America, and 1 each in Australia and New Zealand
analyzed were extracted by 1 reviewer (M.P.J.v.) using a
(Tables 2 and 3).
prepiloted data-extraction tool and were verified by the
Different inclusion criteria, durations of treatments, second reviewer (L.W.). Disagreements were resolved in a
outcome measurements, and timing of outcome measure- consensus meeting or, if necessary, by third-party adjudi-
ments among the trials prohibited pooling of the results and cation (G.M.M.J.K.). Articles were not blinded for author,
statistical comparison among the included trials. affiliation, or source.42–44 If necessary and possible, the
The searches yielded 101 articles for the intervention authors were contacted for additional information.
rest. Full texts of 8 articles were retrieved for further
analysis, and 5 articles were included in this review.1,31,35,36
For the intervention ice, the searches yielded 28 articles. Methodologic Quality
Full texts of 11 articles were retrieved for further analysis, Two independent reviewers (P.A.A.S. and L.B.) obtained
and 5 articles were included in this review.33,37–40 The the full text of all potentially eligible articles for
In the best methodologic study included in this review, Palmieri et al56 reported that a 20-minute cryotherapy
Bleakley et al34 concluded that an accelerated exercise treatment applied to the ankle did not alter core
protocol during the first week after ankle sprain improved temperature. Based on our review, evidence from RCTs
ankle function. However, some limitations existed in to support the use of ice in the treatment of acute ankle
performing this study and drawing the conclusions, as sprains is limited.
described in a letter to the authors.50
McCulloch et al51 compared mobilization with immobi- Compression
lization and concluded that mobilization was more effective
for reducing tenderness but produced no difference in ankle Airaksinen et al41 suggested that a combination of elastic
function. The use of nonsteroidal anti-inflammatory drugs bandaging and IPC is better than elastic bandaging alone.
was a co-intervention in this study. We excluded this study When reviewing the use of a compression bandage for all
soft tissue ankle injuries, Pollard and Cronin57 concluded
because the treatment duration was 8 days and the first
that little evidence is available to support this type of
assessment was at 10 days.
treatment. Based on their comparison of different modes of
Although pooling is not realistic and the methodologic
compression, they could not make uniform recommenda-
quality is low, a preliminary conclusion can be drawn. All
tions regarding the type and level of compression.57
included studies had a similar conclusion: some type of
Based on our review, evidence from RCTs to support the
immediate posttraumatic mobilization is beneficial in the use of compression in the treatment of acute ankle sprains
treatment of acute ankle sprains.1,31,34–36 is limited. No information can be provided about the best
way, amount, and duration of compression or the position
Ice in which the compression treatment is given (recumbent or
Despite its widespread clinical use, the precise physio- elevated).29,41
logic responses to ice application have not been fully
elucidated. Moreover, the rationales for its use at different Elevation
stages of recovery are quite distinct. Using cryotherapy to We did not include the study by Rucinkski et al24 because
manage acute soft tissue injury is based largely on they did not examine the intervention of interest but
anecdotal evidence.52 In a systematic review, Bleakley et concluded that elevation is the most appropriate of the 3
al53 assessed the evidence base for using cryotherapy in the used treatment protocols if the major therapeutic objective is
treatment of acute soft tissue injuries. Although they to minimize edema in the postacute phase of rehabilitation.
included 22 trials, the authors concluded that many more Based on expert opinions, several guidelines do recommend
high-quality trials were needed to provide evidence-based elevation in the treatment of acute ankle sprains.19,29 No
guidelines for the treatment of acute soft tissue injuries.53 randomized trials were found and included in this review, so
Based on the 4 studies included in their systematic no evidence based on studies with high levels of evidence is
review, Hubbard et al54 concluded that cryotherapy available for the effectiveness of elevation.
positively affected return to work and sports. Bleakley et
al52 performed a randomized controlled study to compare
CONCLUSIONS
the effectiveness of 2 different, clinically appropriate
cryotherapy protocols for patients with ankle sprains.
Because they did not compare these treatments with a no- Implications for Practice
ice treatment, we did not include this study in our review. Insufficient evidence is available from RCTs to deter-
They concluded that in accordance with basic science mine the relative effectiveness of RICE therapy for acute
research, the results highlighted that shorter, intermittent ankle sprains in adults. Evidence that some type of
applications might enhance the analgesic effect of ice after immediate posttraumatic mobilization is beneficial in the
acute ankle injury. Ice application seems relatively safe and treatment of acute ankle sprains is moderate. Evidence that
seems to influence ankle function.14,51,55 Cold application ice provides no effect in the treatment of acute ankle
can be used before therapeutic exercise programs without sprains is limited. Evidence supporting the use of
interfering with normal sensory perception and can be used compression in the treatment of acute ankle sprains is
before strenuous exercise without altering agility.14,55 limited. No evidence exists to support or reject the use of
Address correspondence to Michel P.J. van den Bekerom, MD, Academic Medical Centre, Department of Orthopaedic Surgery,
Orthopaedic Research Center Amsterdam, Meibergdreef 15, PO Box 22660, 1105 AZ Amsterdam, The Netherlands. Address e-mail to
Bekerom@gmail.com.