A basketball player leaps up, grabs a rebound, comes down on another player’s foot, twists his ankle, and screams in pain.
Basketball, squash, tennis, ice-skating, volleyball, and soccer all have one thing in common: explosive movements. For this reason, almost everyone who plays these sports will at one time or another sprain their ankle. Indeed, ankle sprains account for 20 percent of all sports injuries. But you don’t have to be an athlete to sprain your ankle. People sprain their ankles when they step awkwardly off a curb or slip on a wet patch.1 Every day, twenty thousand people in the United States sprain their ankle, and every day they put ice on the sprain.2 What many people fail to realize is that this is exactly the wrong thing to do.
When people sprain their ankle, they injure three ligaments that stabilize the outside of the joint. Ligaments are short, tough, flexible, fibrous bands that connect one bone to another and hold the joint together. The seriousness of an ankle injury is determined by how badly these ligaments are damaged. Doctors assign three grades:
If ligaments in the joint don’t heal completely, long-term ankle instability can result. Indeed, up to 30 percent of people with severe ankle sprains suffer permanent looseness of the joint. For this reason, those first few days of treatment are crucial.
Although many have offered a variety of treatments for ankle sprains, in the late 1970s, one physician, Gabe Mirkin, revolutionized the field.
Mirkin is a man of many talents. After graduating from Harvard University and Baylor College of Medicine, he developed an expertise in allergy, immunology, sports medicine, and pediatrics. During one of his fellowships, specifically at Johns Hopkins Hospital in Baltimore, Mirkin began training for long-distance races, running twice a day. When his fellowship ended, he moved to Washington, DC, because it was the only city in the United States that offered competitive racing fifty-two weeks a year.
In 1978, when Dr. Mirkin was forty-three, he had his breakthrough moment, writing an instant bestseller titled The Sports Medicine Book. Although Mirkin discussed many sports-related injuries, it was his advice on how to treat sprains that became a mantra for orthopedists, sports medicine doctors, and team trainers. He called it RICE, an acronym for rest, ice, compression, and elevation. For decades, RICE became the go-to treatment for groups such as the American Academy of Family Physicians, the American Academy of Orthopedic Surgeons, and the National Athletic Trainers’ Association. Unfortunately, Mirkin’s advice was based more on instinct than evidence.
The first cracks in the wall appeared in the late 1980s.
In 1989, researchers from New Zealand divided thirty adult patients with ankle sprains into two groups. One group received an ice pack for twenty minutes; the other didn’t. The authors concluded that “no significant differences were noted between the two groups with regard to pain, swelling or speed of recovery.”3
In 2006, researchers from Ireland divided eighty-nine athletes and nonathletes with grade 2 or 3 ankle sprains into two groups. Patients received either ten minutes or twenty minutes of ice therapy every two hours for three days. At the end of the experiment, patients with less ice therapy had less pain.4
In 2012, researchers from Amsterdam reviewed eleven more studies, involving 870 patients, to determine whether RICE improved outcomes. Again, they couldn’t find evidence to support Mirkin’s recommendations. In addition to the lack of effectiveness for ice, the authors couldn’t find evidence that rest, compression, or elevation worked, either. Indeed, they found three studies that showed that early movement instead of rest led to better outcomes.5
In 2013, researchers from Taiwan performed a study that explained why ice worsened outcomes. Eleven male subjects, all twenty years of age, performed six sets of elbow extensions at 85 percent maximum tolerance. This level of exercise is enormously strenuous. When the exercise concluded, researchers measured the subjects’ blood for two proteins that are found in muscle cells: creatine kinase and myoglobin. High levels of these proteins had spilled into the bloodstreams of all these young men, proving that the exercise had caused some minor muscle damage.
The researchers then divided the subjects into two groups. In one group, cold packs were applied to the stressed muscles for fifteen minutes immediately after the exercise as well as three, twenty-four, forty-eight, and seventy-two hours later. The other group received no ice therapy. The researchers found that the ice therapy group had significantly higher levels of the muscle proteins, and therefore more muscle damage, than the nontreatment group. Consistent with these findings, seventy-two hours after the exercise ended, the ice group was more fatigued than the no-ice group.6
The key to healing is inflammation. When ligaments or muscles are damaged, they release substances that promote inflammation. In response, the body increases blood flow to the area. The bad news is that inflammation is painful. The good news is that it promotes healing. Here’s how:
Therefore, anything that decreases blood flow (such as rest, ice, compression, and elevation) or decreases inflammation (such as ibuprofen) only lengthens the time to healing.8
In 2013, about thirty years after publication of The Sports Medicine Book, Dr. Mirkin, to his credit, recanted. “There are no data to show that ice does anything more than block pain,” he said. “And there are data that show it delays healing. RICE is just something that stuck—and it’s wrong.” Regarding rest, Mirkin said, “Nobody believes in rest anymore. You can get a hip replacement and you’re on the bike 12 hours after surgery.”9 As a consequence of recent studies, as well as Dr. Mirkin’s mea culpa, a small but growing number of doctors no longer recommend RICE for joint or muscle strains.10
So, what are you supposed to do now? The simple truth is that sprains and strains hurt and that decreasing inflammation, whether with rest, ice, compression, elevation, or anti-inflammatory drugs, lessens the pain. Anything that lessens pain will be hard to resist. Unfortunately, we now know that RICE and anti-inflammatory drugs delay healing. The better choice would be to warm the affected joint or muscle. Regarding ankle sprains, the current recommendation isn’t complete rest but, rather, some movement; specifically, don’t bear weight if it still hurts, but pretend to write letters of the alphabet with your toes within a couple of days of the sprain.11 This gentle continuous movement promotes blood flow to the area, and therefore healing.
The situation of treating the pain of sprains or strains with ice is analogous to treating fever caused by infections. Although we feel better when the fever is gone, we might prolong or worsen illness. The process of inflammation, although painful and uncomfortable, is necessary for recovery. We pay a price when we try to eliminate it.