The way in which an acute injury is managed initially may make a significant difference in the duration of disability suffered by the injured athlete. It is often the amount of bleeding and edema rather than the severity of the underlying lesion that determines the time lost from participation. This article reviews current recommendations for the initial management of a soft tissue injury using an inversion sprain of the ankle as an example. Much of the basis for first aid is empirical, but research supports some current practices. The elements of first aid are rest, ice, compression, and elevation - RICE. This acronym can help the clinician, the coach, and the athlete remember these components. In addition, the article reviews the use of anti-inflammatory medications, which is controversial.
INVERSION ANKLE SPRAIN
The inversion ("lateral") ankle sprain is one of the most common soft tissue injuries in sport. The anterior talofibular ligament is almost always injured, sometimes in combination with one or more others. Most of these injuries can be treated without casting or surgery. Optimal first aid is an important part of the management.
Hemorrhage, edema, extension of the injury, and pain need to be minimized; these goals may require rest, which in the ankle means avoidance of weight bearing. An indicator of the need for rest is the presence of pain with walking. Crutches are usually the most effective way of resting the ankle. A splint, eg, the Aircast ankle brace, can also be helpful initially or during rehabilitation (Figure 1 ). Complete rest is usually required for no more than 72 hours.
Figure 1. The Aircast ankle brace supports an injured ankle.
Figure 2. Ice held in place with an elastic bandage.
Cryotherapy, or cooling of the injured part, is now an accepted part of first aid for athletic injuries. Research studies on the use of cryotherapy are often difficult to interpret because they involve small numbers of subjects with heterogeneous injuries that are treated with additional therapies.1,2 However, it is generally accepted that cryotherapy reduces hemorrhage, inflammatory edema, pain, and muscle spasm when used soon after an injury.1,2 The only absolute contraindications to cryotherapy are Raynaud's disease and cold allergy.
There is convincing evidence that cold is more effective than heat in initial management.3 The available data suggest that ice should be applied as soon after the injury as possible, and then approximately every 4 hours for the next 1 to 3 days, until bleeding and swelling have stabilized.1,2 Cryotherapy continues to be useful before and after exercise during rehabilitation.
Crushed ice, ice cubes, or ice chips contained in a plastic bag or wet towel conform well to the geometry of the ankle and are the recommended form of cryotherapy. If a towel is not used, a layer of wet cloth, eg, a compression bandage, should be placed under the ice to prevent cold damage to the superficial tissues (Figure 2). Cryotherapy using a bucket with ice slush or ice water is another method of cooling the ankle, but this may be uncomfortable for the athlete. Alternative cooling agents are not superior to ice and are less convenient and more expensive. Chemical ice packs may not become cold enough. Frozen gels may be too cold because they reach the temperature of the freezer in which they are stored. Ethyl chloride spray may overcool the skin while undercooling the deeper structures of the ankle.1,2,4
Each application of ice should last for about 20 minutes. Shorter use may not allow adequate cooling of the deeper tissues. Longer use may lead to overcooling of the superficial tissues. There is also some evidence that use for 30 minutes or more may increase swelling by causing vasodilatation.1,2
To minimize continued hemorrhage and inflammatory edema, compression of the injured areas of the ankle is a very important part of early management. If possible, it should not be interrupted during ice therapy. Garrick and Webb4 recommend the use of elasticized stockinette (Tubigrip) for compression. Not only is this easy to put on and take off, unlike an elastic bandage, but it also is thin enough that ice can be applied directly over it. Elasticized stockinette is not readily available except from a health-care provider, and therefore many athletes will use an elastic bandage, preferably one that is 3" wide.
Compression of the ankle must take into account regional anatomy. In an inversion ankle sprain, edema and hemorrhage accumulate in the hollow areas beneath and around the lateral malleolus. An elastic bandage applied directly over the ankle does not compress these areas effectively because the malleolus pulls the bandage away from the depressions. Garrick and Webb4 recommend one of several techniques of filling the hollows before applying the elastic material. ABD pads can be used. Disposable diapers can be folded three times so that they are five layers thick and cut into a horseshoe shape to surround the malleolus. The absorbent side of the diaper should be placed against the skin. A horseshoeshaped piece of 1A"- or 3/s"-thick felt can also be used (Figure 3). If elasticized stockinette is used for compression, it should be long enough so that it covers the ankle once and then doubles back over the material that surrounds the malleolus.
When the athlete is sitting, the ankle should be raised above the level of the waist. In an educational audiocassette, Garrick noted that asking an athlete to sleep with his leg elevated on a pillow is not very practical (Garrick JG. Unpublished data). Instead, a suitcase may be placed under the foot of the mattress.
Figure 3. Horseshoe-shaped piece of material compresses the area around the lateral malleolus.
Prostaglandins play a role in the initial inflammatory response to injury. Theoretically, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and Ibuprofen, which are prostaglandin inhibitors, might help to reduce edema after an injury, although their platelet-inhibiting function might also increase bleeding. Only a few studies have compared the effectiveness of anti-inflammatory medications to placebo in a large group of athletes with similar injuries.5 In one of the best of these studies, 2400 mg/day of ibuprofen for 7 days was not superior to placebo in the treatment of ankle sprains.6 From the available evidence, it is unclear if NSAIDs should be used in the initial treatment of athletic injuries. Given their ability to increase bleeding, which has been shown in postoperative studies,7 it is probably wise to avoid NSAIDs and use acetaminophen with or without codeine to control pain.
Again on theoretical grounds, some authors recommend against using anti-inflammatory therapy during the rehabilitation phase. Healing is itself an inflammatory process, with which NSAIDs might interfere.1
For many ankle sprains and other soft tissue injuries, prompt use of RICE will allow the athlete to return to play in a few days. For more severe injuries, rehabilitation will be needed, with management of swelling; reestablishment of range of motion, proprioception, and muscle strength; and gradual resumption of activity. Pediatricians should refer their patients to athletic trainers or physical therapists for rehabilitation. However, clinicians should know the basic principles because they must make sure that their patients are receiving appropriate treatment and because they may at times have to prescribe these programs themselves. The book Athletic Training and Sports Medicine is a good source of information on this subject.8
Pediatricians often do not see injured athletes until many hours after an acute injury, if at all. Because prompt institution of RICE is important in minimizing the number of days that an athlete will be disabled, athletes and their coaches must be taught how to perform first aid. Figure 4 provides a detailed handout that is relatively easy to prepare and that should be included as part of anticipatory guidance during preparticipation examinations.
ADVICE TO PHYSICIANS
You may need to have or do the following to help your athletes use the First Aid handout:
* give the patient a note so that the elevator can be used at school,
* give the patient a note for school to allow elevation of the ankle during class,
* tell the patient whether he or she can partially bear weight on the ankle while using the crutches,
* have either tubular elasticized stockinette material or 3″ elastic bandages to provide compression, and
* have ½″ -thick felt or disposable diapers available for compression of the tissues surrounding the malleolus.
Figure 4. Patient handout on first aid for a sprained ankle.
1. Kellett J. Acute soft tissue injuries - a review of the literature. Med Sd Spores Exerc. 1986;18:489-500.
2. Meeusen R, Lievens R The use of cryotherapy in sports injuries. Sports Med. 1986;3:398-414.
3. Hocutt JE, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. AmJ Sports Med. 1982;10:316-319.
4. Garrick JG, Wehb DR. Sports injuries: Diagnosis and Management. Philadelphia, Pa: WB Saunders Cb; 1990:7-9, 284-286.
5. Clyman B. Role of non-steroidal anti-inflammatory drugs in sports medicine. Sports Med. 1986;3:242-246.
6. EXipont M, Beliveau P, Theriault G. The efficacy of antiinflammatory medication in the treatment of the acutely sprained ankle. Ami Sports Med, 1987;15:41-45.
7. Skjelbred P, Album B, Lokken R Acetylsalicylic acid vs paracetamol: effects cm postoperative course. Eur ] Clin Pharmacol. 1977;12:257-264.
8. American Academy of Orthopaedic Surgeons. Athletic Training and Sports Medicine. Park Ridge, III: American Academy of Orthopaedic Surgeons; 1984.