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Sprains and Strains

BASICS

  • Sprains:
  • Ligament injuries (complete or partial) at ligament body or bony attachment.
  • Grade 1: Stretch injury, no laxity.
  • Grade 2: Partial tear, increased laxity but firm end point.
  • Grade 3: Complete tear, increased laxity, no firm end point.
  • Usually trauma-related: falls, twists, MVAs.
  • Strains:
  • Disruptions of muscle, musculotendinous junction, or tendon.
  • First degree: Minimal damage.
  • Second degree: Partial tear.
  • Third degree: Complete disruption.
  • Often from overuse injuries.

EPIDEMIOLOGY

  • Sprains/Strains: ~80% of athletes will experience.
  • Ankle sprains: ~30% of sports medicine clinic visits; most due to inversion/lateral sprain.
  • Predominant age:
  • Sprains: any age, active.
  • Strains: usually 15–40 years.
  • Sex: Male > Female for most sprains/strains, except ACL sprain (Female > Male).

ETIOLOGY & PATHOPHYSIOLOGY

  • Trauma, falls, accidents.
  • Overuse, poor conditioning, improper equipment/footwear.
  • Inadequate warm-up/stretching.
  • Prior injury increases risk.

RISK FACTORS

  • Previous sprain/strain (highest risk)
  • Change in footwear/equipment/surface.
  • Sudden increase in training/volume.
  • Tobacco, medications.

GENERAL PREVENTION

  • Proper warm-up/cool-down.
  • Good equipment/footwear.
  • Balance, proprioception, and strength training (reduces risk).
  • Semirigid orthoses during high-risk sports if prior injury.
  • Stretching alone does not prevent injuries.

COMMONLY ASSOCIATED CONDITIONS

  • Joint effusions, ecchymosis, hemarthrosis.
  • Stress/avulsion fractures.
  • Contusions, dislocations, subluxations.

DIAGNOSIS

HISTORY

  • Mechanism: activity, trauma, baseline fitness, prior MSK injuries.
  • Popping/snapping, swelling, pain.

PHYSICAL EXAM

  • Inspect: swelling, asymmetry, ecchymosis, gait.
  • Neurovascular exam.
  • Palpation: tenderness, instability.
  • ROM/strength testing.
  • Sprain grading:
    • Grade 1: Tender, no laxity, minimal swelling, can bear weight.
    • Grade 2: Increased laxity but firm end point, more swelling/ecchymosis, some weight difficulty.
    • Grade 3: Increased laxity, no end point, severe swelling/pain, cannot bear weight.

KEY EXAM TESTS

  • Ankle:
    • Anterior drawer (ATFL), talar tilt (CFL), squeeze (syndesmosis), malleoli palpation.
  • Knee:
    • Lachman/anterior drawer (ACL), posterior drawer/sag (PCL), valgus/varus (MCL/LCL).
  • Shoulder:
    • Load/shift, sulcus, apprehension/relocation/surprise tests.
  • Imaging:
    • X-ray to rule out fracture, especially with Ottawa rules.
    • US for dynamic assessment; MRI gold standard for soft tissue.
    • Bilateral x-rays in kids (growth plate injury).

DIFFERENTIAL DIAGNOSIS

  • Tendonitis, bursitis, contusion, hematoma, fracture, osteochondral lesion, rheumatologic disorders.

TREATMENT

GENERAL MEASURES

  • PRICEMM:
  • Protection, Relative rest, Ice, Compression, Elevation, Medications/Modalities
  • Grades 1/2 ankle sprain: Functional bracing (brace/orthosis/taping/elastic wrap).
  • Grade 3: Short immobilization (boot/crutches), early PT.
  • Early mobilization critical for most injuries.

MEDICATION

  • First line:
    • Acetaminophen (max 3 g/day)
    • NSAIDs: ibuprofen 200–800 mg TID, naproxen 250–500 mg BID, diclofenac 50–75 mg BID
    • Topical NSAIDs (diclofenac, ibuprofen, ketoprofen) effective for pain (gel/patch)
  • Second line:
    • PRP injections (strains; more studies needed)
    • Opioids: rare, only for severe acute pain

REFERRAL

  • ACL sprain in athletes
  • Salter-Harris fractures
  • Chronic instability
  • Tendon ruptures (Achilles, biceps, ACL)
  • Failure of conservative care

ADDITIONAL THERAPIES

  • Early physical therapy, proprioception retraining, core strengthening, eccentric exercises
  • Eccentric/lengthening exercises for hamstring strain—reduce reinjury risk
  • Rehab more effective than immobilization for most cases

SURGERY

  • Reserved for select partial/complete tears, failed conservative care, or high-level athletes.
  • Risks with surgery vs. conservative care are higher.
  • Chronic instability (10–20% after acute sprain) may need surgery.

ONGOING CARE

  • Advance activity as tolerated, using pain as a guide.
  • Monitor swelling, ROM, and strength.
  • Encourage early rehab to limit complications.

PATIENT EDUCATION

  • Proprioception/physical therapy for prevention.
  • ROM and strengthening restore function.
  • Injury prevention with balance and strength training.
  • Wean out of brace to avoid atrophy.

PROGNOSIS

  • Favorable with rest and proper rehab; varies by severity/location.
  • Early PT speeds recovery, limits chronic issues.

COMPLICATIONS

  • Chronic instability
  • Arthritis
  • Muscle contracture
  • Chronic tendinopathy

ICD-10

  • S93.6: Sprain of foot
  • S93.4: Sprain of ankle
  • S93.5: Sprain of toe

CLINICAL PEARLS

  • PRICEMM for acute injury:
    • Protection
    • Relative rest
    • Ice
    • Compression
    • Elevation
    • Medications/Modalities
  • Early mobilization > immobilization for most cases.
  • Proprioceptive/core training and gradual return to activity prevent recurrence.
  • Chronic instability after sprain may need surgery if conservative care fails.