> Table of Contents > Sprains and Strains
Sprains and Strains
Daniel L. Jones, MD
J. Herbert Stevenson, MD
image BASICS
DESCRIPTION
  • Sprains are complete or partial ligamentous injuries either within the body of the ligament or at the site of attachment to bone.
    • Classified as grade 1, 2, or 3 (AMA Ligament Injury Classification)
      • Grade 1: stretch injury without ligamentous laxity
      • Grade 2: partial tear with increased ligamentous laxity but firm endpoint on exam
      • Grade 3: complete tear with increased ligamentous laxity and no firm endpoint on exam
    • Usually secondary to trauma (e.g., falls, twisting injuries, motor vehicle accidents)
    • Physical exam is the key to accurate diagnosis.
  • Strains are partial or complete disruptions of the muscle, muscle-tendon junction, or tendon
    • Classified as
      • First degree: minimal damage to muscle, tendon, or musculotendinous unit
      • Second degree: partial tear to the muscle, tendon, or musculotendinous unit
      • Third degree: complete disruption of the muscle, tendon, or musculotendinous unit
    • Often associated with overuse injuries
Geriatric Considerations
More likely to see associated bony injuries due to decreased joint flexibility and increased prevalence of osteoporosis and osteopenia
Pediatric Considerations
  • Sprains and strains account for 24% of pediatric injuries.
  • 3 million pediatric sports injuries occur annually.
  • Must be concerned about physeal/apophyseal injuries in the skeletally immature patient
EPIDEMIOLOGY
Incidence
˜80% of all U.S. athletes experience a sprain or strain at some point.
Prevalence
  • Ankle sprains are among the most common injuries in primary care, accounting for ˜30% of sports medicine clinic visits. Most ankle sprains are due to inversion injuries (lateral sprains) involving the anterior talofibular ligament. Account for 650,000 annual ER visits in the United States (1)
  • Predominant age
    • Sprains: any age in physically active patient
    • Strains: usually 15 to 40 years of age
  • Predominant sex: male > female for most; female > male for sprain of acromioclavicular ligament
ETIOLOGY AND PATHOPHYSIOLOGY
  • Trauma, falls, motor vehicle accidents
  • Excessive exercise; poor conditioning
  • Improper footwear
  • Inadequate warm-up and stretching before activity
  • Prior sprain or strain
RISK FACTORS
  • Prior history of sprain or strain is greatest risk factor for future sprain/strain.
  • Change in or improper footwear, protective gear, or environment (e.g., surface)
  • Sudden increase in training schedule or volume.
  • Tobacco use
GENERAL PREVENTION
  • Appropriate warm-up and cool-down exercises
  • Use proper equipment and footwear.
  • Balance training programs improve proprioception and reduce the risk of ankle sprains (2)[B].
  • Semirigid orthoses or air casts may prevent ankle sprains during high-risk sports, especially in athletes with history of sprain (3)[A].
  • Proprioception and strength training decrease injury risk, stretching does not (4)[A].
COMMONLY ASSOCIATED CONDITIONS
  • Effusions, hemarthrosis
  • Stress, avulsion, or other fractures
  • Syndesmotic injuries
  • Contusions
  • Dislocations/subluxations
image DIAGNOSIS
PHYSICAL EXAM
  • Inspect for swelling, asymmetry, ecchymosis and gait disturbance.
  • Palpate for tenderness.
  • Evaluate for decreased range of motion (ROM) of joint and joint instability.
  • Evaluate for strength.
  • Sprains
    • Grade 1: tenderness without laxity; minimal pain, swelling; little ecchymosis; can bear weight
    • Grade 2: tenderness with increased laxity on exam but firm endpoint; more pain, swelling; often ecchymosis; some difficulty bearing weight
    • Grade 3: tenderness with increased laxity on exam and no firm end point; severe pain, swelling; obvious ecchymosis; difficulty bearing weight
DIFFERENTIAL DIAGNOSIS
  • Tendonitis
  • Bursitis
  • Contusion
  • Hematoma
  • Fracture
  • Osteochondral lesion
  • Rheumatologic process
DIAGNOSTIC TESTS & INTERPRETATION
  • Ankle
    • Anterior drawer test assesses integrity of anterior talofibular ligament.
    • Talar tilt test assesses integrity of calcaneofibular ligament.
    • Squeeze test assesses for syndesmotic injury.
    • Palpate fibular head.
  • Knee
    • Lachman test assesses integrity of anterior cruciate ligament. Posterior drawer assesses integrity of posterior cruciate ligament.
    • Valgus/varus stress tests assess integrity of medial and lateral collateral ligaments, respectively.
  • Shoulder
    • Positive apprehension test may indicate glenohumeral ligament sprain.
  • Radiographs help rule out bony injury; stress views may be necessary. Obtain bilateral radiographs in children to rule out growth plate injuries.
  • Use Ottawa foot and ankle rules (age 18 to 55 years) to determine if radiographs are necessary (5)[A].
  • Ankle films: required if pain in the malleolar zone and
    • Bone tenderness in posterior aspect distal 6 cm of tibia or fibula or
    • Unable to bear weight immediately or in emergency department
  • Foot films: required if midfoot zone pain is present and
    • Bone tenderness at base of 5th metatarsal or
    • Bone tenderness at navicular or
    • Inability to bear weight immediately or in emergency department
Follow-Up Tests & Special Considerations
  • CT scan if occult fracture is suspected
  • MRI is the gold standard for imaging soft tissue structures, including muscle, ligaments, and intraarticular structures. If tibiofibular syndesmotic disruption is suspected, MRI is highly accurate for diagnosis.
Diagnostic Procedures/Surgery
Surgery may be required for some partial and complete sprains depending on location, mechanism, and chronicity.
image TREATMENT
GENERAL MEASURES
  • Acute: Protection, relative rest (activity modification), ice, compression, elevation, medications, modalities (PRICEMM) therapy
  • Ankle sprains: Compression stockings didn't affect pain, swelling, or time to pain-free walking but did show decreased time to return to sport (6)[B].
  • Grade 1, 2 ankle sprain: functional treatment with brace, orthosis, taping, elastic bandage wrap
    • Ankle braces (lace-up, stirrup-type, air cast) are a more effective functional treatment than elastic bandages or taping (7)[A].
  • P.985

  • Grade 3 ankle sprain: Short period of immobilization may be needed.
  • Refer for early physical therapy (8)[A].
  • For high-level athletes with more extensive damage (e.g., biceps or pectoralis disruption), consider surgical referral.
MEDICATION
First Line
  • Acetaminophen: not to exceed 3 g/day
  • NSAIDs
    • Ibuprofen: 200 to 800 mg TID
    • Naproxen: 250 to 500 mg BID
    • Diclofenac: 75 mg BID
  • Opioids may be needed acutely for severe pain.
  • Acetaminophen and NSAIDs have similar efficacy in reducing pain after soft tissue injuries with less GI side effects, NSAIDs were better than narcotics (9)[B].
  • Topical diclofenac, ibuprofen, ketoprofen are effective for pain related to strains and sprains, especially in gel form or patch (10)[A].
  • Platelet-rich plasma injections may aid recovery in treatment of muscle strains, but more studies are needed.
ISSUES FOR REFERRAL
  • ACL sprain in athletes/physically active
  • Salter-Harris physeal fractures
  • Joint instability especially chronic
  • Tendon disruption (i.e., Achilles, biceps, ACL)
  • Lack of improvement with conservative measures
ADDITIONAL THERAPIES
  • Physical therapy is a useful adjunct after a sprain, particularly if early mobilization is crucial.
    • Proprioception retraining
    • Core strengthening
    • Eccentric exercises
    • Thera-Band exercises
  • After hamstring strain, frequent daily stretching and progressive agility and trunk stabilization exercises may speed recovery and reduce risk of reinjury (11)[A]. Rehab protocols emphasizing eccentric/lengthening exercises are more effective than conventional exercises (12)[B].
SURGERY/OTHER PROCEDURES
  • Casting and surgery are reserved for select partial and complete sprains. Need for surgery depends on the neurovascular supply to the injured area as well as the ability to attain full ROM and stability of the affected joint. The need for surgery also depends on activity level and patient preference.
  • For primary management of acute lateral ankle sprains, there is no difference between surgical versus conservative therapy. Risks are increased with surgical intervention (1)[A].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
If the affected joint has full strength and ROM, the patient can advance activity as tolerated using pain as a guide for return to activity.
Patient Monitoring
After initial treatment, consider early rehabilitation. Limit swelling and provide pain-free, full ROM.
DIET
Weight loss if obese
PATIENT EDUCATION
  • Injury prevention through proprioceptive training and physical therapy
  • ROM and strengthening exercises to restore functional capacity
PROGNOSIS
Favorable with appropriate treatment and rest. Duration of recovery depends on the severity of injury.
REFERENCES
1. Kerkhoffs GM, Handoll HH, de Bie R, et al. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;(2):CD000380.
2. Sefton JM, Yarar C, Hicks-Little CA, et al. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011;41(2):81-89.
3. Handoll MM, Rowe BH, Quinn KM, et al. Withdrawn: interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2011;(5):CD000018.
4. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and metaanalysis of randomised controlled trials. Br J Sports Med. 2014;48(11):871-877.
5. Bachmann LM, Kolb E, Koller MT, et al. Accuracy of the Ottawa ankle rules to exclude fractures of the ankle and mid-foot: a systematic review. BMJ. 2003;326(7386):417.
6. Bendahou M, Khiami F, Saïdi K, et al. Compression stockings in ankle sprain: a multicenter randomized study. Am J Emerg Med. 2014;32(9):1005-1010.
7. Lardenoye S, Theunissen E, Cleffken B, et al. The effect of taping versus semi-rigid bracing on patient outcome and satisfaction in ankle sprains: a prospective, randomized controlled trial. BMC Musculoskelet Disord. 2012;13:81.
8. Bleakley CM, O'Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
9. Jones P, Dalziel SR, Lamdin R, et al. Oral nonsteroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2015;(7):CD007789.
10. Derry S, Moore RA, Gaskell H, et al. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;(6):CD007402.
11. Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database Syst Rev. 2012;(12):CD004575.
12. Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2014;48(7):532-539.
Additional Reading
&NA;
  • Hamilton BH, Best TM. Platelet-enriched plasma and muscle strain injuries: challenges imposed by the burden of proof. Clin J Sport Med. 2011;21(1): 31-36.
  • Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is the best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-135.
See Also
&NA;
Tendinopathy
Codes
&NA;
ICD10
  • S93.409A sprain of unsp ligament of unspecified ankle, init encntr
  • S96.919A Strain of unsp msl/tnd at ank/ft level, unsp foot, init
  • S43.50XA Sprain of unspecified acromioclavicular joint, initial encounter
Clinical Pearls
&NA;
For acute injury, remember PRICEMM:
  • Protection of the joint
  • Relative rest (activity modification)
  • Apply ice
  • Apply compression
  • Elevate joint
  • Medications for pain
  • Other modalities as needed