Have you ever sprained your ankle? You know the old adage RICE? Rest, Ice, Compression, and Elevation? Well, I am here to tell you there is a new sheriff in town.
Evidence is showing that for soft tissue injury we should be following the POLICE protocol. Protection, Optimal Loading, Ice, Compression, and Elevation.
Why the switch?
We are learning more and more about how to rehabilitate our bodies. Through research, we have learned that we can improve outcomes by following a new principle.
The new rule, adding in protection and optimal loading, enables us to get moving earlier after an ankle sprain. The research suggests that early mobilization aids in increased healing of the ankle.
Let’s first take a deeper dive into soft tissue injury and ankle sprains. Then, we will discuss how to rehab the sprain and what your physical therapist can do to help.
It is important to note that with any injury, you seek the advice of a medical professional prior to attempting to heal yourself.
Types of soft tissue injury
The two most common types of soft tissue injury are a strain and a sprain.
A strain is defined as “overstretching, overextension, overuse of soft tissue. It tends to be less severe than a sprain and occurs from a slight trauma or unaccustomed repeated trauma of minor degree. This term is frequently used to refer specifically to some degree of disruption of the musculotendinous unit” (4).
A sprain is identified as “severe stress, stretch, or tear of soft tissues” (4). There are three types of sprains which are defined in “grades”. You may have also heard of subluxation, dislocation, or tendinitis - these are all types of soft tissue injury. For the purposes of this article, we will focus specifically on soft tissue sprains.
The most common type of ankle sprain is a lateral (outside) ankle sprain (3). You may know this as “rolling your ankle”.
A grade I ankle sprain is characterized by minimal swelling and localized tenderness over the lateral ankle. On average, the healing time is 11.7 days before resuming athletic activity for a grade I sprain (3).
A grade II ankle sprain is defined as localized swelling with more diffuse tenderness over the lateral ankle. You will be out for approximately 2-6 weeks with this type of sprain.
Lastly, a grade III sprain is characterized by significant swelling, pain, and bruising and you should be seeing a specialist. These injuries will require greater than 6 weeks to return to athletic activity (3). They often require to surgery to repair damaged structures.
A medical professional will help diagnose the type of ankle sprain, and they may use imaging to aid in the diagnostics.
Now, let’s talk about what POLICE means and ways we can comply with this protocol.
When experiencing an ankle sprain, you want to start by protecting the joint. In most cases, protection does NOT mean casting and not moving.
It is important to get moving early, but with the right support. This could mean the use of crutches, a walker, braces, or any other assistive devices (5).
A good rule of thumb is to weight bear as tolerated (WBAT)- this means to let pain be your guide. Do not work through the pain but put as much weight on the ankle as you can comfortably tolerate (1).
Your physical therapist can work with you to determine the least restrictive assistive device that will give you the best support and increase your safety.
This is where all the research is pointing. There was a man named Wolff and he observed that the correct amount of stress put on soft tissue (and bone) aids in the most favorable healing. In the physical therapy world, we call this Wolff’s Law.
Wolff’s Law states that there is an appropriate amount of loading (weight) we need to put on a joint to increase healing and maintain proper nutrition of soft tissue or bone (3).
It is important to note that optimal loading will also maintain the joint function, reduce atrophy, and prevent excessive scarring on a tissue level.
Researchers are finding negative effects of not performing optimal loading, AKA RESTING (or immobilization). These include reduced muscle mass, joint stiffness, and reduce proprioception (balance and control) (1).
There is also evidence to support that the right amount of loading will improve swelling (5). Reduced swelling, increasing nutrition to the joint, and minimizing side effects of the injury will all lead to increased healing time and get you back to your athletic adventures quicker.
Good ole ice. According to the Journal of Orthopedic and Sports Physical Therapy, there is strong evidence that “repeated intermittent applications” of ice helps to reduce pain, decrease need for pain medication, and improve weight bearing following injury to the ankle (5).
There is no concrete evidence for the amount of time to ice, but a good rule of thumb is for 10-20 minutes (1).
There needs to be safety measures taken when utilizing ice to ensure no thermal injury occurs. Ice should not be applied directly to skin and should not be applied over open wounds or numb areas.
To get the maximal effect, ice can be applied using a damp towel or pillowcase. You should also stop using ice if you experience any negative side effects, such as increased pain or swelling. Your physical therapist can help you with the technique to applying ice if you have questions.
This is another tool in the chest to help reduce swelling and pain. Maybe you are like me and think of an ace wrap or taping job for compression.
While the evidence shows this is a great alternative to reduce swelling, the best type of compression is a lace-up ankle brace (5).
It has been found that a semi-rigid brace is more practical for performing daily functional mobility tasks with reduced pain (5).
Other forms of compression your doctor or physical therapist may use is an elastic bandage, pneumatic device, or a felt pad and elastic wrap or taping (3). You and your care provider will work together to decide the right type of compression for you.
They will take into consideration your daily activities, the severity of the sprain, and the level at which you are required to perform.
Get that bad boy up. Elevation has been shown to help with reducing swelling but also decreasing pain by assisting in venous return (AKA fight gravity to get the fluid out of your ankle). Combining elevation with gentle range of motion exercise can help bring nutrition to the joint and speed up the healing time (3).
The rule of thumb is to have the affected limb at or above the level of the heart. You can use pillows, a wedge, or even the arm of the couch to achieve this.
So, as you can see, the main difference between the POLICE and RICE principles are rest and optimal loading (moving the joint sooner).
Through research we have found that the quicker we get our bodies moving, at the right pace, and with the right amount of weight bearing, the faster we see injuries heal. By resting too much, we increase incidence of muscle atrophy, joint stiffness, and delay healing time.
What are the benefits of working with a physical therapist for a sprained ankle?
Working with a physical therapist can also help with rehabilitation of a sprained ankle. Your physical therapist can help to provide the right type of compression brace for you as well as ice therapy.
It is also important to note that your physical therapist can provide different types of manual therapy to provide several benefits. Manual therapy can help with pain reduction, improve joint mobility, aid in remodeling of connective tissue, increase gliding of tendons, and increase joint lubrication (3).
It has also been found that the proper amount of manual therapy can help to normalize walking (5). There are different types of manual therapy ranging from soft tissue massage to gentle joint mobilization.
Upon evaluation and examination your physical therapist will prescribe the proper type of manual therapy for you.
Your physical therapist will also be able to provide gentle therapeutic exercise to further aid in the recovery process of a sprained ankle.
These musculoskeletal experts are trained in grading the exercises depending on your fitness level, the acuity of your ankle sprain, and the types of mobility tasks you are required to perform.
Performing exercises with the help of a physical therapist will ensure you are putting the proper weight through the affected tissues at the right time. It is important you follow the prescribed exercises and do not add or take away exercises as this may delay the healing process as well.