Should you Ice an Ankle Sprain?
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CHAPTER 11 BONUS CHAPTER
Ice an Ankle Sprain
“The measure of intelligence is the ability to change.” — Albert Einstein
Nearly every team will lose game time to ankle sprains during a basketball season, as 45% of ankle injuries lead to at least one week of missed participation.1 Ankle sprains are the most common practice injury and second-leading game injury (concussions) in high school sports, and they contribute to over half of the time missed due to injury.2-4 They are the most diagnosed injury in college sports with men’s and women’s basketball suffering the greatest number.4,5 NBA players suffer ankle sprains at a rate of 4.5 per 1000 player-games, and the single-season risk of an ankle sprain for an NBA player is 26%.4,6
Two players on my team suffered ankle sprains this season. Their responses and recoveries differed greatly. The first occurred during preseason conditioning. The player rolled her ankle as she reached the baseline and decelerated to change directions. Although far from a diagnosis, the injury appeared minor, but she felt the injury and pain. Pain is a construct of the brain.7 The initial pain is the perception of threat: The ankle signals danger.7 This was her first exposure to competitive sports, and she had never suffered an acute sports injury. Athletes’ perceptions differ based on their experiences, personality, and more. She was scared and immediately asked for ice, refusing to stand or put pressure on her injured leg. The athletic trainer diagnosed a Grade 1 ankle sprain and advised her to rest, ice, and elevate for two weeks. She started rehab after roughly two weeks and missed three weeks of practices and games.
An experienced player who had sprained her ankle previously suffered the second injury during a game. Players are five times as likely to sprain their ankles after a previous ankle sprain.1 She limped off the court with a few tears; the injury appeared serious, as she landed from a jump and rolled her entire ankle. She caught her breath and walked behind the bench. She declined ice from the athletic trainer, tied her shoelaces tighter, and returned to the game. The presence or absence of pain does not equate to the health of the ankle tissue because the perception of pain occurs in the brain.7 This may not be the best way to treat all ankle sprains, but she exhibited few problems and did not miss any additional practices or games.
Recovery time increases as soon as an athletic trainer ices an ankle sprain and puts the player in a boot. Two weeks tends to be the magic number. The most common treatment for Grade 1 and 2 ankle sprains is RICE: Rest, ice, compression, and elevation.8 Researchers have suggested the use of RICE is a reasonable, routine, and probably safe method for treating ankle sprains, although there is no sufficient, supporting evidence for its effectiveness.4,10,11 Few randomized controlled trials or studies have demonstrated the effectiveness of RICE as a treatment method for ankle sprains despite its pervasiveness in athletic training rooms.8,11-13
Rest is prescribed to prevent further injury, and often a boot is used to immobilize the ankle and restrict movement. The body converts mechanical loading into cellular responses, which promote structural changes in a process called mechanotransduction.14 The absence of activity weakens the signal and connective tissue is lost.14 There is no evidence for the effectiveness of immobilization when treating a Grade 1 or 2 ankle sprain.4,15 Weight-bearing and range of motion (ROM) exercises should begin as soon as pain permits, frequently starting immediately.16-18
Functional treatment appears preferable to immobilization when considering time to return to pre-injury activities, swelling reduction, joint stiffness, and subjective and objective joint instability.10,11,19,20 A functional treatment with movement decreased pain and swelling and increased ROM compared to immobilization over the first two weeks post-injury.21 Early weight-bearing with support reduced the symptoms of acute ankle sprains, and integrating early weight-bearing and movement reduced swelling, restored normal ROM, and accelerated the return to normal activity.20,22,23 Early mobilization and functional ankle support appear better than rigid immobilization in the management of acute Grade 1 and 2 ankle sprains.15,24
Ice is applied immediately to induce analgesia and numb the pain, but prolonged application may delay healing and lengthen the recovery.25 Our body signals our inflammatory cells (macrophages) when we are injured, and these cells release the hormone-insulin-like growth factor (IGF-1).25 Icing may prevent the body’s natural release of IGF-1 and impede the transport of those inflammatory chemicals and cells to the injured site.25-27 Reducing the inflammation delays healing because inflammation is essential for recovery.25
There is a lack of support for icing or cryotherapy for the management of an acute ankle sprain.12 There is limited evidence that cryotherapy reduces Grade 1 ankle-sprain symptoms.13,15,28,29 There is no evidence icing decreases pain and swelling and improves function in an acute Grade 2 ankle sprain.15,29-31
Richard Hartzell, author of Don’t Ice that Ankle Sprain, wrote:
“A large percentage of minor (Grade 1 and Grade 2) ankle sprains are treated in a manner that incapacitates the person for several weeks. When an ankle is sprained, some ligaments have been over-stretched and are possibly misaligned. When you ice an ankle at this stage, blood flow is stopped and ligaments are essentially frozen out of place. Combine that with rest and now you’ve got muscle atrophy and a host of other problems. Ice should never be applied to an injured ankle, because it stops the healing process. What the injured ankle needs is movement, as quickly as possible after the injury, in order to restore proper range of motion by realigning the ligaments.”
Mild swelling, tenderness, and minimal difficulty in ROM are seen in Grade 1 and 2 sprains.29 Compression, typically the use of an elastic bandage or wrap around the ankle, is another means of reducing swelling and attempting to circulate the blood. Compression has been shown to reduce swelling and improve quality of life and was superior to a splint in alleviating edema after an ankle sprain.32,33
Treatment decisions should be individualized rather than automatic.13 Each injury and each individual is different. Players react differently to injuries and require different treatments. The Philadelphia Union’s Bill Knowles differentiated the medical model and the performance model at the 2011 Boston Sports Medicine and Performance Group conference. The medical model treats the injury; the performance model treats the person. Said differently, the medical model focuses on the biology of the injury (and preventing litigation), whereas the performance model focuses on returning the athlete to performance. These lead to different processes and outcomes.
Players often base their recovery on pain or its absence, which is not a good indicator of the ankle’s health and mobility. Pain dissipates quickly, and players return to play without concern for the strength or health of the joint. Many players never strengthen or rehabilitate their ankles because pain fades quickly with minor ankle sprains, leading to the recurrence of ankle sprains and creation of new movement patterns.34 A treatment has not worked until the players return to their pre-injury performance.35
A functional approach centers on returning athletes to their pre-injury performance through an individualized approach focused on mobilization and weight-bearing exercises as quickly as possible. Often, players must address a potential underlying cause of the injury. As one example, single-leg balance has been shown to predict future ankle injuries.36,37 I challenge players with previous ankle injuries to work daily on single-leg balance until they can maintain balance with their eyes closed without swaying for one-minute. I also attempt to incorporate players into the dynamic warmup as soon as possible, as the addition of dynamic activities trains the anticipatory postural adjustments identified as a key factor in injuries.38 These are initial steps to return to practice after an injury. Additionally, as with the player who injured her ankle when changing directions in preseason conditioning, we may need to address movement skills, and practice skills such as hockey stops in closed drills before introducing reactions to external stimuli.
The goal with any injury is to return as quickly and as safely as possible, ideally with a better base to prevent future injuries. Often, injuries afford a dedicated time to train basic movements, qualities, and skills that may be ignored, especially in the middle of a season. Rather than immobilize and ice the ankle for two weeks, this time can be valuable when used to correct weaknesses that may have contributed to the injury. As with everything, the first rule is to do no further harm. However, once it is established the injury is relatively minor (no torn ligaments), mobilization and a functional, individualized approach generally benefits the athlete and the ankle more than rest and ice.
NOTE: I am not a medical doctor, and this is not medical advice.
References
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