I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a proponent of quick and repeated prescription of NSAIDS, I was disappointed to see the statement concluded that NSAIDS may "delay the natural healing process," based on a review commentary published 15 years ago in a non-peer reviewed journal, rather than basing this comment on at least one well-controlled study with evidence that NSAIDS do, in fact, delay the healing process (which I have never seen). Furthermore, when I examined the meta-analysis data on oral NSAIDS on Swelling (3 studies), I noticed that 2 out of 3 favored the placebo, and none of the studies had a significant difference as their confidence intervals all included zero. Only grouping oral with topical NSAIDS provided a favorable effect size. You can't have it both ways when it comes to making statements based on the literature by holding the evidence to different standards to support such statements.

We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].

We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].

It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.

We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.

We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in the context of gender inequity in SEM does not mitigate the role of other factors. We do not suggest that implicit bias is the sole driver of gender inequity, but that it is one that warrants attention.

Boynton et al. note, in the references that they cite arguing against implicit bias, that there may be phenomena such as individual choice that may result in such disparities. This may be true. In addition, we would add that at least one other phenomenon we did not mention is explicit bias. Each of the authors on this editorial can note multiple examples where these explicit biases have played out. The issue of ‘manels’ as a manifestation of gender disparities in SEM is merely the tip of the iceberg. Some of the authors of our editorial have written about other gender issues in different media [4]. Society at large, and the SEM community in particular, is still too disturbingly sexist to escape the conclusion that frank, explicit bias is a major driver of the disparities that concern us [5].

In regards to the issue of implicit bias, the body of literature supporting this concept is deep and underpins several of the resources we mention in our editorial. The LTE authors too easily dismiss this work as ‘ideological.’ We counter that, like any scientific theory, implicit bias is a ‘work in progress,’ and that noting a few references arguing against that theory does not tear down the entire body of evidence.

Gender disparities and contributory biases exist at many levels of our field. This is a problem, which could be seen as big or small depending on the observer. It is, nevertheless, a problem. We assert that it must be addressed.

We do agree, at least in part, with our dissenting colleagues, when challenging those of us interested in these issues to seek a ‘higher degree of evidence.’ While there is no lack of evidence for gender disparity in the SEM community, we applaud deeper investigations into these issues and a higher quality of evidence. Furthermore, we advocate for more research into the phenomena that may underpin these disparities.

For those parties interested in gender issues in sport and SEM, we would encourage them to consider looking more deeply into the problems we describe in our editorial and this response. We would like at the very least to see more documentation of gender (mis)representation among keynote speakers at SEM conferences; within academic divisions and departments; within teams (e.g. head team physicians among elite teams), etc. Moreover, analyses of the decision-making processes that lead to these disparities must also be included in future investigations.

Being of service to ourselves and our SEM community means meeting people where they stand. This is a more effective endeavor when we can be transparent about where we are starting from. To that end, we would encourage readers to consider these courses of action while we all continue this conversation:

i) consider taking the implicit bias test we reference [3]
ii) speak up when seeing significant gender disparities at conferences and other fora
iii) Men: mentor the female SEM trainees with which you work, and help them achieve higher levels in their field if they are motivated. And listen thoughtfully to what your female colleagues are saying about these issues
iv) Women: yes, ‘lean in,’ as the saying goes; but also continue to identify systemic biases and try to challenge them

References:
1. http://bjsm.bmj.com/content/early/2018/04/25/bjsports-2018-099084
2. http://bjsm.bmj.com/content/early/2018/03/17/bjsports-2018-099084.responses
3. www.implicit.harvard.edu
4. http://blogs.bmj.com/bjsm/2016/07/08/the-eva-carneiro-case-and-gender-in...
5. https://qz.com/1144504/the-world-is-relying-on-a-flawed-psychological-te...

Submitted by Sheree Bekker and James MacDonald, on behalf of all authors of the original editorial:
Sheree Bekker, Osman H Ahmed, Ummukulthoum Bakare, Tracy A Blake, Alison M Brooks, Todd E Davenport, Luciana De Michelis Mendonça, Lauren V Fortington, Michael Himawan, Joanne L Kemp, Karen Litzy, Roland F Loh, James MacDonald, Carly D McKay, Andrea B Mosler, Margo Mountjoy, Ann Pederson, Melanie I Stefan, Emma Stokes, Amy J Vassallo, Jackie L Whittaker