rice to POLICE.
As a trauma orthopaedic surgeon, there are always some unlucky people who are happy to be unlucky, mainly adolescents – ankle sprains, which are almost the most seen in orthopaedic emergencies, accounting for about 25% of skeletal muscle system injuries, the vast majority of which are lateral ligament injuries.
RICE principles.
The RICE principles have become classic in the emergency management of ankle sprains.
Rest: Stop walking and allow the injured area to rest to reduce further damage.
Ice: lower the temperature of the injured area to reduce the inflammatory response and muscle spasm and to relieve pain and inhibit swelling. Apply ice for 10-20 minutes at a time, more than 3 times a day, taking care not to apply ice directly to the affected area, but to wrap it in a wet towel to avoid frostbite. Ice should only be applied within 48 hours of injury.
Compression: Wrap the injured ankle with an elastic bandage and apply appropriate pressure to reduce swelling. Be careful not to overcompress as this may increase the swelling and ischemia of the limb farther away from the wrap.
Elevation: Elevate the limb above the heart position to increase venous and lymphatic return, reduce swelling and promote recovery.
But is the RICE principle enough for ankle sprains? Which patients need immobilization? Which patients need surgery?
Obviously, RICE is only a principle for the emergency management of ankle sprains (within 24-48 hours), but what is the subsequent management?
Grading of ankle sprains.
There are usually 3 levels of ankle injury based on the mild to moderate severity of the injury.
Grade 1: There is stretching of the ligaments, only microscopic damage to the ligament fibers and mild pain. As long as it is tolerated, weight bearing is possible; no splinting is required; isometric contraction exercises are possible; if tolerated, full range of joint mobility exercises and muscle strength training can be performed.
Grade 2: Partial rupture of ligament fibers, moderate pain and swelling, limited mobility, and possible joint instability. Immobilization with splinting or bracing, physical therapy, and muscle strength and joint mobility exercises are required.
Grade 3: Complete ligament rupture with significant swelling and pain and joint instability. Braking and rehabilitation are the same as grade 2, but the rehabilitation time is longer and in a few cases surgery is required.
POLICE Principles.
In 2012, the British Journal of Sports Medicine recommended replacing the current RICE principles of ankle injury treatment with POLICE: Protect, Optimal loading, Ice, Compression, Elevation, which places a strong emphasis on early activity.
It has been suggested that for grade 1 and 2 ankle sprains, joint mobility exercises and gradual weight bearing after a few days can lead to a faster recovery. In grade 3 ankle sprains (complete ligament tears), there is evidence to support early braking within 10 days of the injury, after which ankle motion is initiated. Of course, many scholars still support 2-3 weeks of immobilization for grade 3 injuries.
General recommendations.
Phase 1, 1 week RICE principles of rest to protect the ankle and reduce swelling.
Phase 2, weeks 2-3, gradually restore mobility, strength, and flexibility to the joint.
Phase 3, over the next few weeks to months, gradually begin to return to sports, starting with sports that do not require twisting of the ankle joint and eventually returning to sports.
Medication.
The available evidence recommends only nonsteroidal anti-inflammatory drugs to control pain and inflammatory response.
It is worth mentioning that there is no clear evidence to support all external medications and manipulative rubbing for revision.
Surgical treatment.
Only a very small number of patients with grade 3 injuries require surgical treatment after failure of systematic non-surgical treatment over several months. These patients are typically those with severe injuries, significant instability, and high motor demands.
Ankle instability usually presents with a positive anterior drawer test and a positive talar tilt test, as well as a positive talar tilt test on orthogonal inversion stress radiographs of the ankle, and MRI is useful in determining ligament tears.
The stability of the ankle joint can be better determined by a later examination.
The surgical approach can be considered arthroscopic or open reconstruction to repair the ligamentous structures