Should I ice an ankle sprain?

The following is an excerpt from Hard2Guard Player Development Newsletters, 4.18 (May 1, 2010).

The following day, I turned my ankle. I stepped on someone’s foot as I tried to take off and ended up getting called for a charge. I got up, jogged back on defense, limped around on one possession, and was fine. I played the rest of the game, did not ice after the game, had no swelling, and played some pick-up games the next day.

If you ask any athletic trainer, the recommended treatment for an ankle sprain is immediate RICE – rest, ice, compression, elevation. Some say the quicker the better. During the season, a girl on my team lightly turned her ankle while changing directions in a half-speed drill. I encouraged her to walk on it, but she resisted. Someone ran and got ice for her. She missed over two weeks with the ankle sprain. At a local university, a girl sprained her ankle, iced immediately, and the athletic trainer put her foot in a boot for two weeks.

Intuitively, how does the ice and the boot enhance recovery? Ice deadens the pain, but some question whether it promotes recovery. Unfortunately, RICE is such a standard practice that any other ideas are silenced. One person who does not believe in immediate icing is Richard Hartzell, author of Don’t Ice that Ankle Sprain.

As Hartzell writes:

A large percentage of “minor” (Grade I and Grade II) 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.

This is not official medical advice. I am not a doctor, nor is Hartzell. I am merely presenting a different perspective based on my first-hand experience that may cause you to think about why we do certain things in certain ways.

I turned my ankle, maintained movement, and did not suffer swelling or an extended absence from the court. My player suffered a minor sprain, iced immediately, and missed over two weeks.

The video above with Gary Reinl goes into much more detail about icing, but it can be summarized in one simple question: “Do you seriously believe the body’s natural inflammatory response is wrong?” Reinl also stated that “there can be inflammation without healing, but there cannot be healing without inflammation.”

The idea returns to a broader argument, especially in today’s technological age, about human evolution. One side of the argument believes that the body has evolved natural solutions to its problems; the other side believes that human knowledge has expanded, and our knowledge of the body and science allows us to create better solutions. This is the underlying argument in the barefoot running movement and many nutrition arguments, especially the Paleo-centric arguments. With regards to barefoot running, the basic argument is that shoes distort the function of the foot and, left alone, our feet work better and more efficiently without shoes. The Paleo argument is that our digestion systems have not evolved to metabolize our processed foods efficiently and effectively, so we are better off eating the foods of our paleolithic ancestors. The argument about icing is the same argument: our bodies have a natural response to an injury which works better than the more recent remedy of icing. In general terms, the argument states that our technological advances (shoes, processed foods, ice) are bad for us because they inhibit our natural functioning (feet, digestion, lymphatic system) that evolved over billions of years.

My friend Oscar once told me that children are perfect, and it is our job as parents (teachers, coaches) not to fuck them up. This argument is the same: the body is perfect, and it is our job not to mess up its natural functioning. Of course, almost everything we do messes with the body’s natural functioning: wearing shoes, sitting at a desk, watching television, eating fast food, etc. These things lead to postural imbalances, obesity, weak feet, distorted joints, etc., and these maladies lead to industries such as fitness gyms, reality television shows, corrective exercise specialists, weight-loss diets/pills, etc. Our problems are man-made, and we continue to throw more man-made solutions at the problems, and the problems only get worse.

Reinl continued and cited 25+ unnamed text books that describe the three phases on healing as:

  1. Inflammatory response
  2. Repair
  3. Remodel

If this is the way that the body heals itself, and ice is a means to interrupt the inflammatory response, is ice justified as an approach to return a person to normal functioning? Can phase 2 and 3 occur without phase 1, if phase 1 is interrupted by icing?

Earlier in the video, Reinl and Starrett discussed the lymphatic system’s role in repairing an injury. The lymphatic system is responsible for the removal of interstitial fluid from the tissues. Early in the video, Reinl discussed a conversation with an NFL trainer. In the conversation as he recounted it, he convinced the trainer that the inflammation is not the issue; it is the swelling that is the result of the end phase of the inflammatory process. He continued that it is the evacuation of the waste at the end of the cycle that is the problem.

As Starrett said, “the swelling particle” is cleared through the lymphatic system because it is too big for the circulatory system. The lymphatic system requires movement to clear the swelling, which is why compression is important. According to this viewpoint, it is the compression that alleviates the swelling, not the icing (this will be important below). Movement or muscular contraction helps the lymphatic system move the junk and clear the swelling.

Starrett asked about pain; for a twisted ankle, for instance, what is one cannot put any pressure on the foot without pain, thereby eliminating the possibility of walking it off? Muscular contraction, as suggested by Reinl, around the effected tissues may work. Can you flex and extend your toes? your knee? Can you massage the area just above or just below the painful area? According to this theory, this might be the best way to decrease the swelling, along with compression (which is why athletic trainers tell players to tie their shoes tighter immediately after an injury).

I have never been one to ice, and as I highlighted above, I wrote about avoiding icing three years ago, so the video supports my biases. However, since I am a scientist now, I am trained to look for things that do not fit my viewpoint.

The video above, I believe, stated that there is no research on the effectiveness of ice. However, a study by Hocutt et al. (1982) in the American Journal of Sports Medicine found that “early use of cryotherapy, continued with adhesive compression, is an effective treatment of ankle sprains yielding earlier complete recovery than late cryotherapy or heat therapy.” Now, I imagine the argument from the video (Reinl and Kelly Starret) would be that it was the compression, and not the ice, that led to the improved recovery. That is entirely possible, and a randomized study that compared a control group, an icing-only group, and a compression-only group might answer that question. The problem, of course, is finding enough patients with the same grade of ankle sprain who are willing to try a modified treatment plan.

Additionally, if one uses ice, a review of the literature by MacAuley (2001) in the International Journal of Sports Medicine found that “that melting iced water applied through a wet towel for repeated periods of 10 minutes is most effective” when compared to continuous icing or other durations of repeated icing. Starrett referred to this tangentially when he asked about contrast baths or contrast methods – icing for 10 minutes then using heat. Reinl did not dispute the contrast method; instead, he said that it would work during the heat. Another study examining the benefits of a hot/cold contrast method with strictly icing and strictly heat would further our knowledge.

In the video, Reinl referred to a study in the Emergency Medical Journal. I believe the study may be one published by Collins (2008).  The author examined six human studies and dismissed four due to poor protocols (lack of randomization). Of the two remaining studies, one showed support for a cooling gel and the other had no statistically significant results. From this, the author reported that there was “insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.” His conclusion is accurate; if there is only one study that has found support for using ice or a cooling gel, the evidence is certainly limited. However, this review did NOT conclude that icing is incorrect. This is a leap that one cannot make from the review. Sure, there may be insufficient support for icing, but the review did not conclude that there was sufficient evidence to stop icing. These are two different, though related arguments.

I could do a review of literature and find that there was a lack of support in peer-reviewed studies for using a permanent pivot foot. However, that is not the same as finding support in peer-reviewed literature that using a permanent pivot foot is incorrect. The study cited by Reinl basically found that we do not know whether or not icing is the best method; it did not conclude that icing is incorrect. That was a leap that was made by combining that study with some physiology of the lymphatic system.

What’s the take away? Should you ice? The medical community, including athletic trainers, would say yes because that is what is taught and how things have been done for generations, just like static stretching and long-distance running to train for basketball. Are they correct? In my quick search through journals, and Reinl’s search, there is not a lot of evidence to support icing, and the evidence that does support icing may actually support compression because it is a confounding variable in the study. Of course, in my quick study, I did not find any evidence to support not icing. Who knows?

Personally, speaking from a non-medical perspective, I avoid ice if possible. I recommend, when players ask my non-medical advice, to walk on it as much as possible, to move, and to use some form of compression. If they are adamant about icing, as many are, I recommended the contrast method – ice for 10 minutes, then use heat.

The best answer, of course, is to avoid an ankle sprain. We use single-leg exercises, lower-leg flexibility, and stability exercises to attempt to prevent injuries and/or to speed recovery from an injury.

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