So, you rolled your ankle, you're thinking it will be fine, I’ll just walk it off. Little did you know as you continued to play the last 10 minutes of the game, the phases of healing have already begun. As you continue to run, your ankle throbs and feels unstable beneath your body. You feel sick as the pain won’t go away but continues to get worse. Thoughts race through your mind, what have I done? Should I see someone? Finally, you make the decision to come off the court, but what do you do now?
In the past, the process to assist with recovery was known as R.I.C.E.R. (Rest, Ice, Compression, Elevation and Referral). This has been proven to be effective, however, methods of management have changed to the P.O.L.I.C.E. protocol  :
P – Protection: this reminds individuals that a little bit of pain is okay but if the injury causes severe pain then the ankle should be protected using bandages, taping or crutches to off-load the ankle.
O – Optimal: the right amount of pain/discomfort (not too much but tolerable).
L – Loading: placing weight on the ankle (optimal-loading is advised).
I – Ice*: applied for 8-10 minutes at a time [2,3] alternating between 10 minutes on then 10 minutes off. This should be done as often as possible in the first 48 hours.
C – Compression: apply a compression bandage around the ankle, ensuring it is firm enough without cutting off circulation to the foot (Pinch test: squeeze toe, it should turn white then red again).
E – Elevation: raise leg above heart height to prevent pool of blood around the ankle due to gravity.
* Warning: any burning sensations in the region REMOVE the ice. Do not place ice directly on skin (apply a 1-2 cm cloth in between ice and skin). Never place ankle on top of the ice but rather the ice on top of the ankle.
Why this protocol?
Recent studies have shown that protecting the joint should be only as required as resting or offloading the joint could be detrimental causing changes as to how the tissue recovers [1, 4, 5]. These studies therefore promote optimal loading, where an individual can start placing body weight onto the ankle, as tolerable. This encourages correct fiber type and alignment to develop, early mobilisation and can facilitate accelerated recovery times [1, 4]. Further benefits of optimal loading are positive as changes to mechanical properties regarding load alter sensory feedback. This informs the brain that this painful feedback, which it was experiencing earlier on, is no long dangerous thus de-sensitizing the injury and reducing pain levels . Previously the R.I.C.E.  method did not consider optimal loading and referral but rather focused on resting and went straight into management. Though icing is effective, studies have shown this has a limited effect depending on the duration and severity of the injury and should only be utilised in the acute phases . Benefits of using ice should still be utilised as icing reduces the analgesic (pain) response and facilitates optimal healing by reducing swelling that would otherwise delay an individual’s rehabilitation process [7, 8].
So, when in doubt, don’t run, follow the P.O.L.I.C.E. protocol. If pain persists or worsens or you are unable to weight bare, contact your local physiotherapist and book an appointment.
What would a Physiotherapist do to help?
- Perform a thorough movement examination of the lower body to provide education and understanding of the condition.
- Provide tailored strategies and modifications to correct improper biomechanics of the ankle, i.e., taping, ergonomic assessment.
- Design a personalised exercise program tailored to resolving muscle imbalances that would otherwise cause ankle instability.
- Assist with improving range of movement and pain management strategies.
- Provide education on self-management techniques.
- Improve balance and retrain an individual back to pre-injury status.
If you have any questions regarding your acute injury, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
- Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?. British Journal of Sports Medicine. 2011 Sep 7:bjsports-2011.
- Adie, Naylor, & Harris. (2010). Cryotherapy After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Arthroplasty,25(5), 709-715.
- Prins, J., Stubbe, J., Van Meeteren, N., Scheffers, F., & Van Dongen, M. (2011). Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: A pilot randomized controlled trial. Clinical Rehabilitation, 25(5), 433-41.
- Glasgow, P., Phillips, N., & Bleakley, C. (2015). Optimal loading: Key variables and mechanisms. British Journal of Sports Medicine, 49(5), 278-279.
- Bleakley, C., Dischiavi, S., Taylor, J., Doherty, C., & Delahunt, E. (2017). Rehabilitation reduces re-injury risk post ankle sprain, but there is no consensus on optimal exercise dose or content: A systematic review and meta-analysis. British Journal of Sports Medicine, 51(20), British Journal of Sports Medicine, Oct 15, 2017, Vol.51(20).
- Hing, Wayne, Lopes, Justin, Hume, Patria A., & Reid, Duncan A. (2011). Comparison of multimodal physiotherapy and "R.I.C.E." self-treatment for early management of ankle sprains. (RESEARCH REPORT)(Report). New Zealand Journal of Physiotherapy, 39(1), 13-19.
- MacAuley, D. (2010). Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ. British Medical Journal (Clinical Research Ed.), 340(10), 1122.
- Bleakley CM, O'Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010; 340:1964.