Words By: Charlie Gadd
Paramedics work in an ever-expanding profession that allows them to practice in many different environments, not exclusively in the back of an ambulance. Today, many paramedics work at high-risk sporting events, festivals, and within the mining industry, engaging in primary healthcare and referral. Within these settings, patients often present with minor injuries and illnesses, such as minor trauma and soft tissue injuries. Within the general population, soft tissue ankle injuries (STAIs) are one of the most common presentations to primary care providers, with an approximate incidence of 1 ankle sprain per 10,000 people per day, accounting for about 5000 injuries per day in the UK and 23,000 in the US (1,2). Whilst many of these patients make a full recovery, around 30% can develop long term dysfunction, disability, and chronic ankle instability (2,3). This can reduce quality of life, increase the burden on the healthcare system, and contribute to absenteeism from work (1). As a result, it is imperative that we have a firm understanding of current and emerging best practice in treating STAIs when these patients inevitably present to our first aid tents or medical rooms.
STAIs occur when the tissues that support, connect, or surround the ankle joint are damaged. This can include muscles, tendons, ligaments, fascia, nerves, fibrous tissues, fat, blood vessels, and synovial membranes. The ankle joint occurs where the tibia and fibula articulate with the talus bone, and is supported by 3 primary ligament groups: the lateral (Figure 1a), deltoid (Figure 1b), and syndesmotic (Figure 2) ankle ligament groups. These 3 ligamentous complexes, with support from the surrounding muscles and tendons, provide stability to the ankle joint, allowing it to function correctly and withstand force (4). When presenting to paramedics, these patients often have a mechanism of injury that has overloaded the ankle with force or direction that it cannot withstand, causing trauma to the joint and its complex structures. As a result, these patients often present with pain, swelling, feelings of the ankle ‘giving way’, poor range of motion, and activity limitation (2). Within this article, we will discuss isolated, minor, STAIs not requiring further emergent management. This article will examine the current practice, new and emerging principles of management, and where to go in the future.
One of the most prevalent treatment modalities is the use of RICE (Rest, Ice, Compression, Elevation). So, what is RICE and why is it used? RICE stands for rest, ice, compression, elevation, and is normally prescribed for the acute management of minor STAIs, for the first 4-5 days post-injury, as inflammation builds to its peak (7). It is underpinned primarily by studies that measure the statistical significance of changes to metabolic processes, neglecting the long-term clinical significance each intervention will have on the recovery of the ankle joint. These studies also typically examine the components of RICE simultaneously, making it difficult to extrapolate the effectiveness of individual treatments (8).
The application of RICE is widely recognised as the standard approach to the treatment of acute STAIs (8). Despite this, there are wide variations in its application, with specific components within the regime garnering controversy. In a systematic review published by Bekerom et al, it was shown that there is insufficient evidence from randomised controlled trials to support the use of RICE in acute STAIs in the immediate 2 days post-injury (7). A further literature review of acute STAIs by Kaminski et al adds to this, saying that despite near unanimous clinical consensus, there is limited high quality evidence from randomised controlled trials to support RICE as an intervention (8).
Initially, when patients are treated using RICE, rest is prescribed. Rest reduces metabolic demands and physical stresses placed on delicate injured tissues. Ice, applied via ice packs or water immersion, also reduces metabolic demands, limiting bleeding and oedema formation, and reducing pain (8). Compression, using elastic bandaging, tape or braces, and elevation, further reduce bleeding and oedema caused by the leakage of fluid from damaged capillaries to the tissues, with elevation additionally promoting lymphatic drainage (7).
Whilst rest should be promoted in the immediate acute stage after injury, long periods of rest can delay recovery, leading to muscle wastage and altered limb biomechanics (9). Furthermore, whilst ice has analgesic benefits, it too can delay recovery by disrupting normal inflammation and revascularisation that is required for healing (10). There is currently no high-quality evidence regarding the efficacy of ice for treating STAIs (11,12). Although popular, research regarding the effectiveness of compression and elevation is conflicting, with the two therapies seen only anecdotally to reduce swelling and improve functional outcomes (13,14). Lastly, the application of RICE focuses on the acute management, and does not address the subacute and chronic stages of tissue healing, that can significantly influence the long-term rehabilitation and outcomes of the injury (7).
Recently, Dubois and Esculier proposed a more contemporary and comprehensive management strategy. PEACE (protection, elevation, avoiding anti-inflammatories/ice, compression, and education), for the first 1-3 days post injury, and LOVE (load, optimism, vascularisation, and exercise), for long-term guidance (10). Depending on injury severity, long-term rehabilitation may continue up to 4 months post-injury or longer (15). Immediately post-injury we want to protect the area by restricting movement and weightbearing. This will minimise bleeding, prevent distention of injured fibres and reduce aggravation. Pain signals should guide the cessation of protection, with the goal of loading the injured area as pain decreases. The injured site should be elevated, with anti-inflammatory drugs and ice avoided. In a study of army personnel with acute STAIs by Slatyer et al, patients who took anti-inflammatory drugs reported less pain, returned to training more quickly, and had better exercise endurance than those receiving placebo (16). However, the anti-inflammatory group had greater instability, less range of motion, and more swelling 14 days after injury, possibly because the analgesic effects allowed the participants to return to activity before the healing process was complete (16). These results suggest a negative outcome, however further research is warranted if they are to be applied to the general population. Compression can also be applied with elevation to reduce swelling. Furthermore, as paramedics, we are well placed to educate the patient immediately post-injury to improve their understanding of treatments, thereby improving self-advocacy. Particularly, emphasis should be placed on patients embarking on active treatments like exercise programs, stretching and strengthening, as opposed to passive treatments like acupuncture or electrotherapy, which have minimal impact on long term recovery (11).
During their long-term rehabilitation, from week 1 to week 4 and above, patients should actively load their injury by adding weight and movement (10). Movement, weightlifting and exercise without exacerbating pain will promote repair and, remodelling, and improves tendon, muscle, and ligamentous strength lost via injury. The implementation of cardiovascular exercise also promotes blood flow to injured structures, further improving recovery. The requirement for a positive and optimistic mindset during rehabilitation can also not be understated, with optimism linked to better outcomes and prognosis (10). Care should be taken to educate the patient on treatment and to ensure they can access follow-up care if the injury is not healing appropriately.
Paramedics are often required to treat patients with STAIs and must be able to promote the health and recovery of patients in the acute setting, whilst setting them up for success in the long term. Despite STAIs being a very common condition, minimal research has been conducted into the best practice treatment of the condition. The PEACE and LOVE acronym is currently the most sound treatment regime; however, more research needs to be conducted to expand on and solidify its benefit (10).
1. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain. Sports Medicine 2011;41(3):185-97.
2. Hossain M, Thomas R. Ankle instability: Presentation and management. Orthopaedics and Trauma 2015;29(2):145-51.
3. Bullock SA, Allen GM, Watson MS, Wilson DJ. Predicting poor outcome from simple ankle injuries: A prospective cohort study. The British Journal of Radiology 2018;91(1081):20170213-.
4. Brian W, Sharon Lee W. Acute ankle sprains: A review of literature. Osteopathic Family Physician 2013;5(5).
5. Campagne D. Ankle Sprains. MSD Manual for Professionals2021 [updated Mar 2021; cited 2022 4 January]. Available from: https://www.msdmanuals.com/en-sg/professional/injuries-poisoning/sprains-and-other-soft-tissue-injuries/ankle-sprains
6. McKeon KE, Wright RW, Johnson JE, McCormick JJ, Klein SE. Vascular anatomy of the tibiofibular syndesmosis. The Journal of Bone and Joint Surgery: American Volume 2012;94(10):931-8.
7. van den Bekerom MPJ, Struijs PAA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GMMJ. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training 2012;47(4):435-43.
8. Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, et al. National Athletic Trainers' Association position statement: Conservative management and prevention of ankle sprains in athletes. Journal of Athletic Training 2013;48(4):528-45.
9. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine 2012;46(4):220.
10. Dubois B, Esculier J-F. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54(2):72.
11. Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, et al. Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine 2018;52(15):956.
12. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine 2015;127(1):57-65.
13. Hansrani V, Khanbhai M, Bhandari S, Pillai A, McCollum CN. The role of compression in the management of soft tissue ankle injuries: A systematic review. European Journal of Orthopaedic Surgery & Traumatology 2015;25(6):987-95.
14. Block JE. Cold and compression in the management of musculoskeletal injuries and orthopedic operative procedures: A narrative review. Open Access Journal of Sports Medicine 2010;1:105-13.
15. Thompson JY, Byrne C, Williams MA, Keene DJ, Schlussel MM, Lamb SE. Prognostic factors for recovery following acute lateral ankle ligament sprain: A systematic review. BMC Musculoskeletal Disorders 2017;18(1):421.
16. Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of Piroxicam in the management of acute ankle sprain in Australian Regular Army Recruits: The Kapooka ankle sprain study. The American Journal of Sports Medicine 1997;25(4):544-53.