PEACE & LOVE

Ankle sprains are common musculoskeletal injuries, ranging from a grade 1 (mild sprain) to 3 (complete ligament rupture). A LAS (lateral ankle sprain) has a high prevalence in both the general and sporting population. Vuurberg et. al (2018) report that 40% of all traumatic ankle injuries occurring during sports. A systematic review by Fong et. al (2007) found that the ankle was the most injured body site in 24 of 70 studied sports. Sharma et. al, 2020 report that 5000 new cases of ankle sprains occur every day in then United Kingdom, with a relatively high number reporting to the emergency department. Lin et. al (2010) found that ankle injuries represented 22% of all sports injuries reporting to the ED. Specifically, the lateral ligament complex is the most commonly injured area (anterior talofibular ligament (ATFL), the posterior talofibular ligament (PTFL) and the calcaneofibular ligament (CFL)), accounting for 85% of ankle sprains. (Lin et. al, 2010). The most prevalent mechanism of injury in plantarflexion and inversion.

Although an ankle sprain is a common injury and is often dismissed as insignificant, it

can have serious long-term implications. A large portion (30% Lin et. al, 2010) of individuals who sustain a LAS will develop chronic ankle instability which can result in

a time lost from work and sports (Vuurberg, 2018). According to Lin et. al, (2010), the proportion of people who fully recovered in three years ranged from just 36 – 85%.

The initial management of ankle sprains can be difficult as assessment is challenging due to swelling and pain. In 1978, Dr. Gabe Mirkin introduced RICE (Rest, Ice, Compression and Elevation) as a protocol for the management of acute soft tissue injuries. In 1998, the acronym was changed to PRICE to include protection. (Tan, D). In 2012, the acronym changed again to POLICE with the addition of “Optimal Loading” and removal of rest. Most recently, the acronym PEACE (Protect, elevate, avoid anti inflammatories, compress and educate) & LOVE (Load, optimism, vascularisation, and exercise) was introduced (2019).

Previous protocols focused on acute management. This protocol aims to encompass the management continuum from immediate care (PEACE) to subsequent rehabilitation and management (LOVE). (Dubois et. al, 2020)

For many years, inflammation was believed to impair the body’s ability to heal and recover. In recent years, that thinking as changed and inflammation has been seen to be an integral part of the body’s ability to heal fully after injury. The most recent acronym PEACE & LOVE is based around then belief that inflammation is part of the recovery process.

Like POLICE before it, this new protocol does not advise rest after an acute injury. Instead, it advises protection. Protection and relative rest after injury are supported by numerous interventions that stress shields, unload and / or prevent joint movement for various periods (Bleakley et. al, 2014). In some severe cases, full rest may be necessary, but should be of limited duration and restricted to immediately post – trauma. (Vuurberg et. al, 2018) (Bleakley et. al, 2014) Martin et. al (2013) reference a systematic review that advises weight bearing as tolerated instead of immobilisation.

In general, recent research advises the use of functional supports to help protect the joint rather than immobilisation with a cast. (Vuurberg et. al, 2018) ( Martin et, al, 2013) (Lin et, al, 2010) Functional support involves the use of a removable and variable immobility device, such as a brace, bandage, tape, soft cast or wrap. (Lin et. al, 2010). The type of functional devise you choose to use will depend on what your preferable outcome is. A systematic review comparing types of functional support found that they were equally effective in reducing pain, swelling, instability and preventing recurrent sprain. However, a semi – rigid support was more effective for an earlier return to sport and tape resulted in more skin complications (Lin et. al, 2010)

Bleakly et. al, 2014 found that functional rehabilitation of an ankle sprain (involving early weight – bearing with an external support) is superior to cast immobilisation for most types of sprain severity. People who utilised functional support had a higher percentage of return to sport, shorter time to return to work, less persistent swelling and greater range of motion (Lin et. al, 2010)

Although no protocol previously mentioned explicitly advises the use of non – steroidal anti – inflammatory drugs, they are routinely used by health care providers to reduce pain and swelling after an acute injury. In recent years, it has become clear that inflammation is a natural and healthy part of the healing process. (Tan, D). The widespread use of anti – inflammatories has been challenged over the last number of years.

Anti – inflammatory medication has been shown to reduce pain and increase function when compared to placebo in a wide range of studies. (Lin et. al, 2010) However, one study included in Lin’s study found that the intervention group had a restricted range of motion and increased mechanical instability. Further to this, in the Kapooka ankle sprain study, recruits who sustained an ankle sprain were randomised to receive a placebo or an anti – inflammatory. The group that received anti – inflammatories had a quicker return to training. However, the intervention group had more joint instability and reduced joint range of motion in multiple planes compared to the control group. The authors of this study felt that the analgesic effect of the anti – inflammatory allowed the recruits to return to training prematurely and therefore compromising healing. (Fowler et. al, 2018).

This evidence that NSAIDs may negatively impact tissue healing is supported by Fowler et al, 2018 who found that NSAID’s have a negative effect on bone healing and an inhibitory effect on collagen production by tenocytes, therefore affecting tendon healing. Additionally, they note that most NSAID’s inhibit COX-1 and COX – 2 which pathways promote muscle repair. To add further evidence against the use of NSAID’s where possible, the renal and gastrointestinal complications of their use are well known and documented. It has been shown that there is no difference in pain between patients who have been treated with paracetamol and NSAID’s at 1 hour, 2 hours, or 2 – 3 days. (Jones et. al, 2020)

Tan, D, uses the same rationale when advising against the use of ice in the initial management of injury. By applying ice, you do limit the inflammatory process which will in turn reduce swelling. This has been supported in the research and reflected in the fact that ice has been recommended in all the protocols prior to this one (RICE, PRICE and POLICE). Dubois et. al, (2020) advise against the use of ice in their protocol, noting that although the effect of ice is probably mostly analgesic, it may still have a negative effect on the natural healing process by disrupting inflammation

Thank you for taking the time to read this blog post, I hope that it gives you some guidance when it comes to the initial management of ankle sprains!

If you have any questions, please let me know!