Ankle sprains are common; as a family physician I treated a lot of them. My most memorable ankle sprain patient was a young woman I saw during my residency training. Doctors had diagnosed a sprain. They gave her crutches and told her not to try to bear weight on the injured ankle until the pain had subsided. Now, several weeks later, she continued to require crutches and she continued to complain of pain. The orthopedic doctors knew her ankle had had plenty of time to heal by now and they assumed the pain must be all in her head, so they ordered a Psychiatry consult. I happened to be doing a Psych rotation as part of my family practice training, and she was assigned to me.
A brief conversation was enough to reveal the problem: it was a simple matter of miscommunication. The message she thought she had heard was that any attempt to bear weight on that ankle must be avoided until it was pain-free, and she was afraid that weight-bearing while she had any pain would cause permanent damage. I explained to her that they had only wanted her to avoid weight-bearing until the pain had subsided; they did not expect it to entirely go away. And now, after weeks of crutches, her muscles were out of practice and she would have to expect some pain while they recovered their strength. She understood and was grateful for my explanation. She was relieved to know that walking would not permanently damage her joint. She said the pain wasn’t that bad, and she didn’t really need the crutches to walk. She immediately discarded her crutches and walked across the room with no difficulty. It was like a miracle: I had made the lame walk! She was cured! The orthopedic surgeon who had referred her to Psychiatry was amazed. He might have been less amazed if he had taken the time to talk to his patient.
I recently reviewed Paul Offit’s book Overkill for Science-Based Medicine. It is all about surgeries, medicines, and screening tests that have been tested and proven not to work but that are still popular and commonly used by doctors who think they can disregard the scientific evidence. One of the ineffective treatments he covers is the practice of treating sprains with RICE (Rest, Ice, Compression, and Elevation). He has a chapter titled “Don’t ice sprains.” Every day, twenty thousand people in the US sprain their ankles, and most of them put ice on it, which is exactly the wrong thing to do! It all started with a doctor named Gabe Mirkin. In 1978 he wrote a book about sports-related injuries in which he recommended RICE (Rest, Ice, Compression, and Elevation) and that quickly became the standard treatment for sprains. But his “expert” advice was based on intuition rather than on evidence.
Numerous studies have now compared ice to no ice and found no difference. In 2012, researchers in Amsterdam did a systematic review of eleven studies of RICE involving a total of 870 patients. They didn’t find any evidence that rest, ice, compression, or elevation improved outcomes. Instead, they found three studies where early movement led to better outcomes. A 2013 study in Taiwan found that strenuous exercise damaged muscle tissue, causing increased levels of creatine kinase and myoglobin in the blood, and ice therapy produced higher levels of these muscle-damage proteins, reflecting greater muscle damage. And the patients treated with ice reported more fatigue.
Offit explains that the key to healing is inflammation. Inflammation is painful, but it promotes healing. Inflammation increases blood flow. Increased blood flow brings clotting factors and immune cells to the area of damage, and it promotes the manufacture of new collagen. So anything that decreases blood flow can be expected to lengthen the time to healing. What decreases blood flow? Rest, ice, compression and elevation. Anti-inflammatory drugs like ibuprofen, often prescribed for the pain of sprains, also delay healing. In 2013, Dr. Mirkin recanted, saying that RICE was wrong. He also said that nobody believes in rest anymore. Indeed, bedrest used to be prescribed for low back pain, but today patients are encouraged to stay out of bed and be as active as possible; they heal faster with activity. Today a small but growing number of doctors no longer recommend RICE for sprains. But many authorities and many websites still recommend RICE. What to do? Warmth can be applied, and gentle ankle exercises can be done without weight-bearing. Inflammation is painful, but tolerating the pain speeds recovery. Some patients might prefer delayed healing to pain, but they can only make an informed choice if they know the facts.
For years, I had been treating sprains with ibuprofen and RICE. Now it turns out that my treatment was likely delaying recovery for most of my patients. I was doing what I had been taught to do, and I had every reason to think I was doing the right thing – but when those treatments were put to the test, it turned out that what I was doing was exactly wrong. Offit’s book quotes Mark Twain: “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” For instance, I was taught to do episiotomies routinely on every woman when I delivered a baby; now we know that did more harm than good. Offit’s book is a stark reminder that we don’t really know many of the things we think we know. My teachers often justified their recommendations with “in my experience” rather than with scientific evidence. But experience is not reliable. We simply can’t trust any knowledge that hasn’t been properly tested in a well-designed randomized controlled trial. It’s disappointing to contemplate that many of our standard medical treatments may be wrong. I wish I knew which ones. Offit’s book is a good start.
This article was originally published as a SkepDoc’s Corner column on the CSI website.