The Ice-less Management of Acute Ankle Sprains

I’ve written several articles on the use of ice on injuries, the need for inflammation, and the intricate physiological process of tissue healing.  Despite the mounds of evidence that ice is not all it is cracked up to be, there still exists a dogmatic polarization that it has magical tissue-healing properties. I often get told “Prove to me that ice does not work.” No; that is not how evidence-based practice works. You need to prove that ice does work for the reasons you use it.

Read the comments I receive, and you will recognize our ice dependency. “If I don’t ice, then what do I replace it with?” That statement screams dependency. When we take away ice, we feel that a void must be filled. It doesn’t! The treatment decision is multifactorial; the injury type, severity, tissues involved, the person, etc., all play a role in how you treat that specific injury.

A 2013 position statement made by the National Athletic Trainers’ Association on the management of ankle sprains found ice therapies had a C-level of evidence 1. Meaning little or poor evidence exists. In an interview, the author of that article said: “I wish I could say that what we found is what is really being done in a clinical setting…. Maybe our European colleagues know 20151221_102243_resizedsomething we don’t…there is very little icing over there.”

The blog shows how I treated an acute ankle sprain without ice by using all of the fun little tools learned through school and further honed with clinical experiences, trial, and error. I did what I thought was best. This protocol should not be used for every ankle injury. My treatment and rehabilitation plan changed daily. Everything I did was based on my ankle needs. I did NOT use any biophysical or electromagnetic modalities. Everything I did was manual. This is not to say that I would not use other modalities, I just chose not to. My only rule? No ice.

On Thursday 11/5/15, I rolled my ankle (classic inversion + plantar flexion) while playing basketball. I assessed the injury as a grade 2 inversion ankle sprain. (This was based on my judgment and was not assessed through MRI or other diagnostic imaging.) It was a pretty significant sprain. I immediately headed for the shower, put on a sock, and hobbled back to my office. There I sat for the rest of the day with my leg elevated as high as possible, while maintaining the ability to do my job. Within an hour, my ankle ballooned.

Day 0: Hour 0 to Hour 24

My goals

  1. Allow inflammation to do its job
  2. Minimize pain
  3. Minimize pooling and facilitate lymphatic drainage (reduce risk of hypoxic injury)

For this first stage, I was conservative. In this early stage, I wanted inflammation, but I also wanted to prevent pooling of inflammatory fluids by facilitating lymphatic drainage. I stayed off my ankle as much as possible. Technically, I should have been on crutches for the first 24 to 48 hours, but I am stubborn. When given the chance, my leg was elevated. I also applied a compression stocking. My aim was to control excessive inflammation without impeding tissue healing.  Around 8 hours post-injury, I had the first of many massages. This was a very light effleurage. Thankfully, my wife is an athletic trainer and spent time doing massage therapy. I kept my leg elevated most of the evening and slept with a light compression stocking overnight.

Day 1 (Friday)

24 hours post injury after compression.

24 hours post injury, after removing a compression wrap.

My goals remained the same. You could say I was very aggressive with these goals. I had four massages and sat with my foot elevated and in a compression wrap. With my foot elevated, I constantly performed isometric contractions of my lower leg musculature. That night (Friday), I had a fundraiser to attend. This required me to constantly stand in dress shoes. I was in pain and hobbled around, but with enough alcohol, I was able to suck it up. I would not advise others to do this, but I wasn’t going to skip out on an event that I already paid $100 to attend. This was a fantastic event for the Monticello Area Education Foundation. The foundation benefits students by enhancing educational opportunities for students and strengthens community involvement in Monticello.  The Monticello public school system is one of the best in the state and is the school my son will attend. Despite the injury, I had to attend. Besides, my friend and neighbor, Erica Bryant, was on the board and busted her tail to pull it together.

Day 2 (Saturday)

My goals

  1. Remove swelling
  2. Initiate restoration of function

I continued with an aggressive mindset to remove swelling through constant work. The day was filled with compression, elevation, massage, and isometrics. I began ankle pumps and very light inversion/eversion AROM. I stayed off of my foot as much as I could, because the night before did me no favors. I had an internal motivation to prove that ice was not needed. I also bet my co-worker, Roger Earle, that I would play basketball on Monday. Roger is a fitness guru and has authored several books, including previous editions of NSCA’s CSCS text, Essentials of Strength and Conditioning. Roger is a super-smart guy, but he cannot accept that the science of icing injuries is non-supportive. My mind was focused on playing basketball on Monday.

Day 3 (Sunday)

My ankle felt fantastic that morning. When I say fantastic, I mean it felt like nothing was wrong. The swelling was minimal, and I had nearly normal ROM for plantar- and dorsiflexion. I was able to squat to full-depth without compensation. My gait was normalized. But, as my wife would agree, I was stupid, really stupid. My son is learning how to ride a dirt bike. The teaching required me to run alongside him over uneven terrain. Despite wearing a tight boot and a tight compression wrap, I re-rolled my ankle 3 to 4 times that day. I didn’t care; I was teaching my son how to ride a dirt bike, my life-long passion. That said, I would never advise doing this for anyone with a 4-day old ankle sprain.

After the time with my son, I did everything humanly possible to get my ankle ready for the next day. I continued with compression, elevation, massage, isometrics, and range of motion exercises (both active and passive). By the time I went to bed that night, I was confident I would play basketball the following day. One should never be so confident.

Day 4 (Monday)

I woke up, and my ankle was killing me. I literally couldn’t walk. My foot was limited to –5 degrees of dorsiflexion. Twenty-four hours earlier, I had near normal dorsiflexion and was running around like nothing was wrong, but on this day, my pain was worse than day 0.  Let it be known that my inability to walk had nothing to do with skipping the ice. It had everything to do with my ignorance and doing too much, like running on uneven ground in work boots. I was bummed. I had to prove that I could play basketball.

I knew why my ankle hurt so much—swelling, spasm, positional fault—and I knew what I had to do to control the pain. I did three massages that morning at 6:00 a.m., 9:00 a.m., and 11:00 a.m. I performed AROM and towel stretches (sagittal plane only) two or three times.

Studies demonstrate that after a lateral ankle sprain the distal fibula and talus will have an anterior positional fault after an ankle sprain.2,3 The degree of positional fault can be correlated to the degree of swelling.1 Mulligan, 2011, Landrum, 2008, and Holland, 2015 demonstrate that joint mobilization of the fibula and talus will increase dorsiflexion.3,4,5 This is something I really needed. (To read more about these positional faults, this link will take you to previous articles I’ve written.) Being an evidence-based practitioner, I performed self-administered posterior fibular and talar glides using a TheraBand and tubing. This helped me a lot! I got my ankle back to a functional level. I taped the crap out of it and played hoops. I wasn’t 100%, but I played and was pain-free.

If you don't have a therapist, TheraTubing can be used to mobilization.

TheraTubing can be used for mobilization. Here, posterolateral mobilization is applied.

Day 5 to Day7

My goals

  1. Continued removal of swelling
  2. Increase ROM
  3. Regain strength and proprioception
  4. Facilitate tissue healing

More of the same. To remove swelling, I continued with massage and compression. I elevated the ankle when convenient. For range of motion, I continued with self-administered posterior fibular and talar glides, static stretching of the gastrocnemius, and AROM in all directions. On day 5, I did a simple weight training program and paid special attention to doing exercises without compensation, including squats, lunges, and heel raises.

For proprioception, I followed the short foot intrinsic muscle exercises as described by Janda.6 There have been a lot of studies showing the benefit of short foot exercises in improving proprioception, balance, and dynamic function.7,8 I’ve been using this technique on runners with lower extremity pain and dysfunction and my results have been amazing.

I played basketball again on day 6. It went better than Monday’s game, but not great. I still had some bruising in the area, but the ankle was about back to normal size.

Still some light bruising and swelling. Looks pretty good for 6 days out.

Still some light bruising and swelling, but looks pretty good for 6 days out.

On day 7, I added friction massage to the lateral ankle ligaments and did instrument-assisted soft tissue mobilization (IASTM) on the plantar fascia, flexor and adductor hallicus, Achilles tendon, and peroneal tendon. I did all of this in addition to everything mentioned above. Every exercise session was followed by compression (or massage) and elevation. Swelling is a son of a b**** and will return to wreak havoc on your ankle in no time. The goal is to keep swelling out and never let it back.

Week 1 to Week 2

My goals

  1. Obtain full ROM
  2. Continue to enhance proprioception and balance
  3. Continue to improve foot and ankle strength
  4. Restore functional strength

While my goals had changed from the previous week, I was still concerned with swelling and the subtle nuances of the acute and subacute problems. I continued to monitor and treat those nuances as needed, but it was not a primary focus. Range of motion, strengthening, and proprioceptive work from the last few days continued during this week.  I adjusted intensity, duration, and frequency as my ankle would tolerate.

Like any injury, you must not focus on the injured structure. You need to address the entire kinetic chain. An injured ankle can lead to myriad problems up the kinetic chain, including the

Update

11 days post-injury, looking near normal.

knee, hip, and lower back. People with chronic ankle sprains have ipsilateral gluteus medius weakness and decreased hip stability.9 In addition, ankle sprains yield mechanical shortening of the lateral gastrocnemius, TFL, and biceps femoris,10 which is why whole-body and multiplanar functional training must be incorporated. During this time, I did a lot of core and glute strengthening. My strengthening was primarily closed chain and as functional as possible. Dynamic, multiplanar flexibility was a continued emphasis as well.

 

During this week, I played basketball two times. At week 1, day 3, I took my son riding again and ran approximately 2 miles in boots without a problem. At week 1, day 6, I managed to go for a 3-mile run at a 9:30 mile pace. This is a pretty solid clip for me.

Week 2 and beyond

My goals

  1. Continue with functional strength gains
  2. Facilitate tissue healing using the principles of mechanobiology

I have four main problems with ice: (1) It is overused. (2) People use ice to prevent the necessary process of inflammation. (3) People believe that ice helps remove swelling. (4) People believe that ice aids in tissue healing. I avoided ice. I allowed inflammation, but I reduced swelling and did so without significant problems. In addition to continued strengthening to improve my functional status, my goal during this phase was to facilitate tissue healing. Facilitate is the operative word here. Our cells encode genes that stimulate tissue repair. Our job is to help our cells determine how and what genes get encoded. Will a progenitor cell become a tenocycte or an osteocycte? This is mechanobiology. The act of placing load on tissue whereby a signal is transmitted from cell to cell is mechanotransduction. I have written about mechanobiology, mechanotransduction, and tissue healing a lot; if you want to read more, those articles can be found here.

Ice does not stimulate repair. Exercise and load stimulate repair. I had the pleasure of working with Craig Denegar and his co-authors on the fourth edition of Therapeutic Modalities for Musculoskeletal Injuries. There is so much research coming out on mechanobiology that the new text has two full chapters dedicated to it. Here is an excerpt from the book.

After a period of 2 or 3 weeks, I felt normal. I had full range of motion, and I had no functional deficits. I could jump, run, and cut at full speed without problem. I am not an idiot; I know that physiologically it is impossible to be 100% healed in only 3 weeks. I knew there was still progress to be made. However, I was confident in my ankle rehab and my strength gains. During the third week, I played basketball three days, without taping my ankle. Stupid?  Perhaps. But I am still going strong. I’ve run, sprinted, jumped, and lifted.

Notice that my program had no heat or ice. I could have used other modalities, but I stayed away from that as well. My rehab focused on removing swelling (which reduced pain) and normalizing ROM with muscle activation, soft-tissue mobilization, joint mobilization, and AROM exercises. Lastly, I wanted to facilitate tissue healing. All I did was allow the human biology to take over and respond to the actions I placed on it. This facilitated gene upregulation and cellular development of tendons, ligaments, and muscles. So far, I’ve had no problems. And I did all of this without ice. Well, this is not entirely true. I did have ice in my scotch a few times a lot.

 

References

  1. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and preventing of ankle sprains in athletes. J Athl Train. 2013;48:528-545
  2. Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy. 2008; 13: 63-67.
  3. Mulligan, EP. Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport. 2011; 12(2): 57-69.
  4. Landrum, EL, Kelln, BM, et al. Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: A preliminary study. J Man Manip Ther. 2008; 16(2): 100-105.
  5. Holland, CJ, Campbell, K, et al. Increased treatment durations lead to greater improvements in non-weight bearing dorsiflexion range of motion for asymptomatic individuals immediately following an anteroposterior grade IV mobilisation of the talus. J Manip Ther. Aug;20(4):598-602.
  6. Janda V, Vavrova M, Herbenova A, Veverkova M. Sensory motor stimulation. In Liebenson C, ed. Rehabilitation of the spine. Baltimore, MD: Lippincott, Williams, & Wilkins; 2007; 513.
  7. Moon, DC, Kim, K, Lee, S. Immediate effect of short-foot exercise on dynamic balance of subjects with excessively pronated feet. J Phys. Ther Sci. 2014; Vol. 26(1): 117-119.
  8. Mulligan, EP, Cook, PG. Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function. Manual Therapy. 2013; 13: 425-430.
  9. Friel, K, McLean N, Myers, C, Caceres, M. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006; 41(1): 74-78.
  10. Bell, DR, Padua, DA, Clark, MA. Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement. Arch Phys Med and Rehab. 89(7):1323-1328.

10 thoughts on “The Ice-less Management of Acute Ankle Sprains

  1. Jill McMurray

    I found this very interesting. I have always believed that the sooner you move and work with an injury that it would heal faster. But, I have never been told not to use ice. I do understand and am interested in the practice.

    Reply
  2. Victor sellinger

    I haven’t iced for over 2 years but I do use heat to dilate blood vessels, nutrients in, trash out, more quickly. And I use the MarcPro. Would adding these two treatments to your injury have resulted in quicker healing?

    Reply
    1. Joshua Stone Post author

      Heat, possibly could have helped, but I DO NOT advise heat in the early phases. As for the MarcPro, I’ve heard great things. I need Gary Reinl to give me a demo.

      Reply
      1. Dr. Chad Nowlin

        Great article I really appreciate you coming back with that since your first article about ice. I have been posting all over this thing because I think its a battle worth fighting! And you definitely need to get ahold of a Marc Pro! I have been using them in the clinic for about 2 years now and it makes a huge difference. Total knee replacements are looking like the non operative need within 4-6 weeks after surgery where it used to be 6 months to a year of a congested nasty looking knee. And this is only with using it 2 to 3 times per week for 15-30 mins. The only downside is that some of the older patients can not get a very good contraction on Marc Pro due to severe atrophy, severe edema, or large amounts of adipose tissue but that has only been the case a few times. And that is when I really hammer home the active recovery model. The Marc Pro is a game changer and I hope it catches on as years go by. Even though it is not necessary to replace ice with anything, it sure is nice to be able to speed the process up with a viable replacement that fits into every biomechanical model (tissue loading, muscle pump for lymphatics, increase blood flow for nutrition in and nasty out, and it even is good for pain gating) not to mention patients love it!

        Reply
  3. Elizabeth Narducci

    Josh, always love the no ice stuff you report on!

    I love this one ankle traction with AROM technique I learned back in the day when I was a high school/college athlete (1999-2007) using theraband – I used to do it when I played basketball and would sprain my ankle horribly. I never iced one time, just tractioned with AROM and graded WB. I was back in 3 days every time. As a PT, if I could get a patient acutely in the clinic for once without them gonig to the ER or MD, being put in a boot and told to “Rest and Ice,” then I can traspose my adectodal evidence (of my own experience) into clinical evidence! I would love to have a research study on this with long term follow up – see what group heals faster, is back on the playing field and to function much quicker! It is a rare occurance to see them acutely, and I see many of my own PT friends/colleagues still recommending ice, contrast bath, CAM walkers, etc even 3-4 weeks out. Would love to find a way to capture acute ankle sprains and perform true data collection and long term follow up on this!

    Reply
    1. Dr. Chad Nowlin

      Great reply!! It would be great if we could get full direct access and have it become the norm to see more acute injuries rather (even acute injuries that are not ankles) than them going to to ER or even PCP since most are not aboard the no icing wagon.

      Reply
  4. Dan Nelson

    I have had tremendous success without using ice for the past year and a half or so at the high school that I am employed at. I feel that once you explain to people why you are not using ice and the reason why they understand. Another thing that I have been doing for my acute ankle sprains is the Flex-Band technique from Dick Hartzell http://stores.flexbandonline.com/dont-ice-that-ankle-sprain-e-book/ It has made a tremendous difference in my treatment of ankle sprains. I have also been using a Marc Pro Plus since August and it has also made a huge difference. Ankle sprains that were the 2 week variety are now back in 4-5 days with less swelling and discomfort.

    Reply
  5. Colin Butler

    Josh,

    I’m assuming since you were massing so frequently that you were doing self massage? Asking for a friend 😉 I came down on a players foot after driving to the hoop and also did my ankle in with a classic inversion sprain.

    Fortunately, I am an athletic training student, and am going to take it easy tonight and keep this elevated and compressed to facilitate removal of swelling.

    Reply

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