PEACE & LOVE: A PT’s Guide to Recovering from an Acute Ankle Sprain
This past weekend, I played in my third Marin Co-ed Soccer League game and ended up with a Grade I ankle sprain. I had some hesitancy about joining the league because I hadn’t touched a soccer ball since playing intramurals in grad school roughly eight years ago, and I am under one year postpartum. However, my love for soccer overcame my fears, and I joined the team earlier this fall. Admittedly, it is a bit of a blow to the ego when the ball doesn't go where you want or your foot doesn’t do what you planned. That was precisely the situation leading to this injury: my mind was too busy thinking about what my body used to do naturally, and my ankle wasn’t ready to absorb the impact as I went to cross the ball.
I have always been blessed with stable ankles and couldn't remember the last time I rolled one, so this came as a bit of a shock. The incident happened five minutes after I blocked a ball without locking out my leg, creating a torsional moment on my knee that led to intense lateral knee pain. Both instances occurred in the second half of the match after I had been sprinting up and down the sideline without a substitution.
Upon reflection, there were a lot of factors working against me:
Lack of warm-up (I had good intentions, but time ran out)
Fitness fatigue (turns out sprinting repetitively adds up)
Heat (90+ degrees on turf)
Neuromuscular coordination (practice is helpful)
Psychological readiness ("Should I even be out here?")
I could write an entire blog post on each of these factors, but I mainly want to focus on the aftermath. A sweet woman on the sidelines asked, “Are you going to use the RICE protocol to help heal your ankle?” Sometimes I don’t know whether I should politely nod my head and leave it at that, but I decided to speak up and offer the updated recommendation: RICE is out; PEACE & LOVE is in.
The old protocol, RICE, stood for Rest, Ice, Compression, and Elevation. This evolved into PRICE (adding Protection), which then evolved into POLICE (replacing Rest with Optimal Loading). Now, we have comprehensive new guidelines: PEACE & LOVE.
Acute Phase: PEACE
P: Protection
E: Elevation
A: Avoid anti-inflammatories
C: Compression
E: Exercise
Subacute Phase: LOVE
L: Load
O: Optimism
V: Vascularization
E: Exercise
Because of my background, I surmised it was a Grade I sprain (versus Grade II or III) and felt confident after some self-testing that no fractures were present. (Ruling out a base of the 5th metatarsal fracture was a big relief!) Different grades lead to different timelines in the acute and subacute phases, with severe sprains requiring more emphasis on early protection than immediate exercise. Proper grading is extremely helpful.
Here is how I applied the PEACE & LOVE framework:
Protection: In my case, as a Grade I sprain, I didn’t feel the need to protect the joint with a brace. However, if someone has a Grade II or III sprain, I typically suggest a flexible brace. I strongly discourage a firm cast or rigid boot for Grade I or II scenarios, as joint stiffness and tissue atrophy can impair healing and hinder the return to normal gait mechanics and sport.
Elevation: Elevating your limb above your heart can help reduce fluid accumulation at the ankle. Going to Costco the next day wasn’t ideal, but life happens! (It was more swollen the following morning as a result). Do as I say, not as I do.
Avoiding Anti-Inflammatories: There is ongoing debate regarding whether NSAIDs and icing impair ligamentous tissue healing. However, both are effective for managing pain, so if pain is a major limiter, individuals don't need to abide by a rigid rule. I personally didn’t feel either was necessary, so I opted out. I also prefer heat to increase blood flow because, research aside, promoting vascularization makes logical sense for tissue repair.
Compression: I always recommend graded compression socks (20–30 mmHg) for potential ankle swelling. They help flush lymphatic fluid upward toward the knee rather than letting it pool dependently in the foot.
Exercise: I started double-leg calf raises later that night and passively stretched my foot in a pain-free range. I introduced isometric exercises the following day, and by day four, I was performing single-leg heel raises in multiple directions.
Load: When ready, add weight to your exercises! My goal in physical therapy is to make a patient’s exercises more challenging than the loads they experience in daily life. More capacity equals a higher injury ceiling.
Optimism: Research is remarkably consistent in this realm: the more optimistic you are about recovering, the faster your healing timeline tends to be. The moment I briefly worried I might have a Grade II sprain or a fracture, my perception of pain increased. It is amazing how much the brain can help or hinder the recovery process.
Vascularization: My favorite way to improve blood flow and deliver oxygen to healing tissues is via a hot tub, sauna, or warm bath. I am fortunate to have access to a hot tub, so I performed active ankle mobility exercises in the warm water daily for a week, which was extremely helpful in reducing tightness and regaining pain-free range of motion.
Exercise: I love that exercise is listed twice in this framework. So often, people brush off sprained ankles, which can lead to chronic ankle instability and worse outcomes down the road. This experience was a great reminder for me that even as the ankle starts feeling better, I shouldn't stop targeted exercises. Furthermore, sprained ankle rehabilitation should never stop at resistance bands—that is a disservice to the patient. Adding stability exercises and plyometrics is key to returning to sport and handling the unexpected movements of daily life.
I am still in the midst of healing, but I plan to return to play in two weeks—provided I pass my return-to-sport testing.
When I brought up my injury to two of my college teammates, I learned that Meg hasn’t been able to play for over nine months due to knee pain, and Emily broke her wrist during her first game back. As much as it can be a blow to our egos, soccer—or any sport you used to play consistently—demands a lot from the body. Pre-season training, including strength training, cardio, jumping, and lateral movements, is vital to preparing for match play. Unfortunately, anyone over the age of 35 is classified as a "Masters Athlete." The people I see most in the clinic are Masters Athletes who ask a great deal of their bodies without always accounting for what it takes to perform at that level. I am now in this category myself, and I truly empathize with the frustration of wanting your body to do one thing when it has other plans.
Pickleball, skiing, mountain biking—you name the activity. As much as we would love to just go out and fly, our bodies deserve a runway.
If you have any questions about the above, or want to train for your next Masters Athlete competition, give me a holler!
