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Sprains and Strains

Sprains and strains

Definition

A sprain is damage to or tearing of ligaments or a joint capsule. A strain refers to damage to or tearing of a muscle.

Description

When excessive force is applied to a joint, the ligaments that hold the bones together may be torn or damaged. This action results in a sprain, and its seriousness depends on how badly the ligaments are torn. Any joint can be sprained, but the most frequently injured joints are the ankle, knee, and finger.

Strains are tears in the muscle. Sometimes called pulled muscles, they usually occur because of overexertion or improper lifting techniques. Straining the muscles of the back is common.

Demographics

Sprains and strains are common. Anyone can have them. Children under age eight are less likely to have sprains than are older people. Children's ligaments are tighter, and their bones are more apt to break before a ligament tears. People who are active in sports suffer more strains and sprains than less active people. However, being overweight and generally inactive also increases the chance of developing a strain or sprain. Repeated sprains in the same joint make the joint less stable and more prone to future sprains.

Causes and symptoms

Any unfamiliar activity that stresses a muscle or joint may cause a strain or sprain. Heavy lifting, falls, and playing a sport without warming up or conditioning are common causes. There are three grades of sprains.

Grade I sprains are mild injuries in which there is no tearing of the ligament and no joint function is lost, although there may be tenderness and slight swelling. Grade II sprains are caused by a partial tear in the ligament. These sprains are characterized by obvious swelling, extensive bruising, pain , difficulty bearing weight, and reduced function of the joint. Grade III, or third degree, sprains are caused by complete tearing of the ligament where there is severe pain, loss of joint function, widespread swelling and bruising, and the inability to bear weight. These symptoms are similar to those of bone fractures .

Strains can range from mild muscle stiffness to great soreness. Strains result from overuse of muscles, improper use of the muscles, or as the result of injury in another part of the body when the body compensates for pain by altering the way it moves.

When to call the doctor

Parents should call the doctor if their child experiences intense pain and swelling that does not improve within 24 to 48 hours; if their child cannot bear weight on the joint; if the child cannot use the muscle at all; or if there is a popping sensation in the joint when it is moved.

Diagnosis

Grade I sprains and mild strains are usually self-diagnosed. Grade II and III sprains are often seen by a physician, who x rays the area to differentiate between a sprain and a fracture. An MRI may be done to look for ruptured ligaments in a joint.

Treatment

Grade I sprains and mild strains can be treated at home. Basic first aid for sprains consists of RICE: Rest; Ice for 48 hours; Compression (wrapping in an elastic bandage); and Elevation of the sprain above the level of the heart. Over-the-counter pain medication such as acetaminophen (Tylenol) or ibuprofen (Motrin) can be taken for pain.

In addition to RICE, people with grade II and grade III sprains in the ankle or knee often need to use crutches until the sprains have healed enough to bear weight. Sometimes, physical therapy or home exercises are needed to restore the strength and flexibility of the joint.

Grade III sprains are usually immobilized in a cast for several weeks to see if the sprain heals. Pain medication is prescribed. Surgery may be necessary to relieve pain and restore function. Athletic people under age 40 are the most likely candidates for surgery, especially with grade III knee sprains. For complete healing, physical therapy usually follows surgery.

Alternative treatment

Alternative practitioners endorse RICE and conventional treatments. In addition, nutritional therapists recommend vitamin C and bioflavonoids to supplement a diet high in whole grains, fresh fruits, and vegetables. Anti-inflammatories such as bromelain (a proteolytic enzyme from pineapples) and tumeric (Curcuma longa ) may also be helpful. The homeopathic remedy arnica (Arnica montana ) may be used initially for a few days, followed by ruta (Ruta graveolens ) for joint-related injuries or Rhus toxicodendron for muscle-related injuries. If surgery is needed, alternative practitioners can recommend pre- and post-surgical therapies that enhance healing.

Prognosis

Moderate sprains heal within two to four weeks, but it can take months to recover from severe ligament tears. Until the early 2000s, tearing the ligaments of the knee meant the end to an athlete's career. Subsequent improved surgical and rehabilitative techniques offer the possibility of complete recovery. However, once a joint has been sprained, it never is as strong as it was before.

Prevention

Sprains and strains can be prevented by warming-up before exercising, using proper lifting techniques, wearing properly fitting shoes, and taping or bracing the joint.

Parental concerns

Parents should be aware that repeated spraining of a joint weakens it. It may be necessary for the child to do exercises to strengthen the joint after a serious sprain. Parents should allow plenty of time for strains and sprains to heal before allowing their child to return to strenuous athletics.

KEY TERMS

Ligament A type of tough, fibrous tissue that connects bones or cartilage and provides support and strength to joints.

Resources

BOOKS

DeLee, Jesse C., and David Drez. DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed. Philadelphia: Saunders, 2003.

WEB SITES

Grayson, Charlotte. "Understanding Sprains and StrainsThe Basics." WebMD, March 1, 2002. Available online at <http://my.webmd.com/content/article/8/1680_54419.htm> (accessed October 14, 2004).

Wedro, Benjamin C. "Sprains and Strains." eMedicine Consumer Health, 2003. Available online at <www.emedicinehealth.com/fulltext/5715.htm> (accessed October 14, 2004).

Tish Davidson, A.M.

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Sprains and Strains

Sprains and Strains

Definition

Sprain refers to damage or tearing of ligaments or a joint capsule. Strain refers to damage or tearing of a muscle.

Description

When excessive force is applied to a joint, the ligaments that hold the bones together may be torn or damaged. This results in a sprain, and its seriousness depends on how badly the ligaments are torn. Any joint can be sprained, but the most frequently injured joints are the ankle, knee, and finger.

Strains are tears in the muscle. Sometimes called pulled muscles, they usually occur because of overexertion or improper lifting techniques. Sprains and strains are common. Anyone can have them.

Children under age eight are less likely to have sprains than are older people. Childrens' ligaments are tighter, and their bones are more apt to break before a ligament tears. People who are active in sports suffer more strains and sprains than less active people. Repeated sprains in the same joint make the joint less stable and more prone to future sprains.

Causes and symptoms

There are three grades of sprains. Grade I sprains are mild injuries where there is no tearing of the ligament, and no joint function is lost, although there may be tenderness and slight swelling.

Grade II sprains are caused by a partial tear in the ligament. These sprains are characterized by obvious swelling, extensive bruising, pain, difficulty bearing weight, and reduced function of the joint.

Grade III, or third degree, sprains are caused by complete tearing of the ligament where there is severe pain, loss of joint function, widespread swelling and bruising, and the inability to bear weight. These symptoms are similar to those of bone fractures.

Strains can range from mild muscle stiffness to great soreness. Strains result from overuse of muscles, improper use of the muscles, or as the result of injury in another part of the body when the body compensates for pain by altering the way it moves.

Diagnosis

Grade I sprains and mild strains are usually self-diagnosed. Grade II and III sprains are often seen by a physician, who x rays the area to differentiate between a sprain and a fracture.

Treatment

Grade I sprains and mild strains can be treated at home. Basic first aid for sprains consists of RICE: Rest, Ice for 48 hours, Compression (wrapping in an elastic bandage), and Elevation of the sprain above the level of the heart. Over-the-counter pain medication such as acetaminophen (Tylenol) or ibuprofen (Motrin) can be taken for pain.

In addition to RICE, people with grade II and grade III sprains in the ankle or knee usually need to use crutches until the sprains have healed enough to bear weight. Sometimes, physical therapy or home exercises are needed to restore the strength and flexibility of the joint.

Grade III sprains are usually immobilized in a cast for several weeks to see if the sprain heals. Pain medication is prescribed. Surgery may be necessary to relieve pain and restore function. Athletic people under age 40 are the most likely candidates for surgery, especially with grade III knee sprains. For complete healing, physical therapy usually will follow surgery.

Alternative treatment

Alternative practitioners endorse RICE and conventional treatments. In addition, nutritional therapists recommend vitamin C and bioflavonoids to supplement a diet high in whole grains, fresh fruits, and vegetables. Anti-inflammatories, such as bromelain (a proteolytic enzyme from pineapples) and tumeric (Curcuma longa ), may also be helpful. The homeopathic remedy arnica (Arnica montana ) may be used initially for a few days, followed by ruta (Ruta graveolens ) for joint-related injuries or Rhus toxicodendron for muscle-related injuries. If surgery is needed, alternative practitioners can recommend pre- and post-surgical therapies that will enhance healing.

Prognosis

Moderate sprains heal within two to four weeks, but it can take months to recover from severe ligament tears. Until recently, tearing the ligaments of the knee meant the end to an athlete's career. Improved surgical and rehabilitative techniques now offer the possibility of complete recovery. However, once a joint has been sprained, it will never be as strong as it was before.

Prevention

Sprains and strains can be prevented by warming-up before exercising, using proper lifting techniques, wearing properly fitting shoes, and taping or bracing the joint.

Resources

PERIODICALS

Wexler, Randall K. "The Injured Ankle." American Family Physician 57 (February 1, 1998): 474.

KEY TERMS

Ligament Tough, fibrous connective tissue that holds bones together at joints.

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Sprains and Strains

Sprains and Strains

Definition

A sprain is an injury to ligaments and/or the joint capsule that occurs in response to large stresses. A strain is disruption of the contractile elements in muscle and/or tendon. An easy way to remember the difference between sprain and strain is that strain is spelled with a "t," which can imply the associated word tendon.

Description

Sprains

Sprains are categorized into three levels of severity. In a mild sprain, or first degree sprain, few ligamentous fibers have been torn, and the ligament is not significantly weakened. There may have been some slight bleeding. In a moderate sprain, also known as a second degree sprain, there is more disruption of the ligamentous fibers (40–50% of the fibers are torn) and ligamentous weakness is present. Moderate bleeding occurs. In a severe sprain, also named a third degree sprain, there is complete disruption of the ligamentous fibers or joint capsule and there is no strength of the ligamentous tissue. Marked swelling, secondary to bleeding, is present. Many athletes have suffered a complete tear, or third degree sprain, of the anterior cruciate ligament (ACL) of their knee.

Strains

Strains are also referred to as first degree, second degree, or third degree strains. In a first degree strain there is usually mild damage to the muscle or tendon with only a few fibers torn. There is minimal bleeding. A second degree strain presents with moderate weakness as the contractile components are torn. There is more bleeding and swelling. In a third degree strain there is complete rupture of the muscle or tendon. A third degree strain is considered a complete tear, accompanied by bleeding, swelling, and loss of function of the associated muscle. An example of a third degree strain would be a rupture of the biceps tendon.

Causes and symptoms

Both sprains and strains are due to increased demand or large stresses placed on the involved structures, i.e., ligament, muscle, or tendon.

Sprains

In a first degree or mild sprain, there is minor weakness, minimal disability, and no muscle spasms of the surrounding musculature. In a second degree sprain, the individual may complain of moderate disability and report instability. For example, in a second degree sprain of the lateral ankle, the individual may report, "the ankle feels like giving way." In a third degree sprain the individual will complain of pain secondary to swelling. Furthermore, the individual will report having major impairment in function, e.g., weight bearing activities.

Strains

An individual with a mild strain may complain of mild irritation of the affected area with no appreciable change in function. A secondary strain will cause the individual to complain about swelling, some minimal stiffening, moderate disability, and moderate pain. In a severe strain, the individual will report a marked loss of function, swelling of the affected area, muscle spasms secondary to guarding, and significant weakness. Interestingly, because of the complete rupture in severe strains, there will be little or no pain on stretching or with movement. Any pain present is probably due to the severe swelling secondary to bleeding.

Diagnosis

Sprains

Functional testing and clinical observation are often sufficient to establish a diagnosis of sprain. In addition to the above symptoms, a variety of tests can be performed in an effort to evaluate the integrity and stability of the joint. For example, a clinician might test an injured knee by applying medial and lateral stress to the knee.

Four ligaments are important for the stability of the knee joint: the lateral collateral ligament, the medial collateral ligament, the anterior cruciate ligament, and the posterior cruciate ligament. The collateral ligaments are largely responsible for the stability of the knee joint in response to lateral and medial stress. Lateral force (also known as a valgus stress) pressures the medial ligament and medial force (also known as varus) pressures the lateral ligament. If a patient has sprained either ligament, the joint should be abnormally mobile—the more mobile, the more severe the sprain. Other tests to determine the status of the cruciate ligaments, such as the Lachman test and the posterior drawer test, may also be performed. Some of the more common knee injuries associated with football are tears of the medial collateral ligament (MCL) and/or the anterior cruciate ligament (ACL). Sometimes the forces that caused the injury are so severe that the MCL, ACL, and medial meniscus (cartilage) are all disrupted. This is termed an "unhappy triad."

Depending on factors like the severity of the sprain, the nature of the injury, and the severity of the sprain, x rays may also be indicated. X rays do not indicate the severity of the sprain, merely whether a fracture has occurred or not. Ultrasonography and magnetic resonance imaging (MRI) may be used to determine the severity of a sprain. MRI has the additional benefit of offering multiple types of information. For example, in cases of suspected neck sprain, MRI can show whether the injury is truly a sprain, a strain, or originates from abnormalities in the cervical (intervertebral) disks.

Strains

MRI is also an important tool in the evaluation of strain. Although not indicated in the majority of cases, MRI provides the most accurate diagnostic information of the imaging techniques available as of 2001. Other imaging techniques include ultrasound and computerized axial tomography (CAT scan), but their use is limited. In most cases, however, diagnosis is obtained from clinical observation and functional testing.

When evaluating a first degree strain, findings will show a mild loss of strength during resistance testing, a decreased range of motion, and minimal muscle guarding. In a second degree strain, the strength test will indicate moderate weakness, decreased range of motion, and moderate pain when stretching the tendon or muscle. In a third degree strain, findings will be more pronounced with significant swelling and major weakness compared to the uninvolved side. There will be marked loss of function and significant disability.

One common example of a strain is a hamstring strain, known more commonly as a pulled hamstring. In baseball, when a batter has just hit the ball in the infield, she or he will need to run quickly to first base. On approaching the first base bag, the batter may reach out and extend with the leg to touch the base. A common injury at the point of extension is a tear of one of the following muscles (more commonly known as the hamstrings): biceps femoris, semimembranosus, or semitendinosus (tearing of all three is rare). When the hamstrings are over-extended, such as when the baseball player over extends the leg, a muscle or tendon tear may occur.

Treatment

Sprains

In a mild sprain the goal in treatment is to decrease any swelling that is present and prevent loss of motion secondary to stiffness. Ice, elevation, and compression should be used before and after treatment sessions. Therapeutic exercise should include range of motion, stretching, and strengthening of the surrounding musculature. In a moderate sprain, treatment is more conservative and the clinician must minimize the risk of further injury. Modalities should be continued to decrease swelling and pain. The RICE (rest, ice, compression, and elevation) principle should continue throughout treatment. A general rehabilitation pathway of strengthening, range of motion, and flexibility all need to continue and progress as tolerated. In a severe sprain, there are usually two options: surgical and non-surgical. In the surgical option, the ligament is re-attached by the physician. The nonsurgical approach relies on bracing to minimize motion and allow for healing. The rehabilitation plan is complex in either of these approaches, but the goal is to initially minimize motion followed by slow progression into range of motion and strengthening.

Strains

Treatment of first and second degree strains is similar to treatment of sprains. It consists of utilizing the RICE principle and protecting the affected area from overstretching or overuse. Rehabilitation should focus on range of motion, decreasing swelling and pain, and gradual introduction of a strengthening program. Severe strains may require surgical repair, and protocols of rehabilitation are different for each affected area. Initial treatment could be immobilization followed by guarded range of motion, flexibility, and strengthening therapies.

Prognosis

Sprains

In a mild sprain, the individual can usually engage in normal activities within three to six weeks. In a moderate sprain, normal activities can usually resume in approximately eight to 12 weeks—ligamentous tissue requires approximately eight to 10 weeks to heal. By the third or fourth week, however, the individual with a moderate sprain will usually have a normal range of motion and be free of pain. Therefore, the key to recovery from a moderate strain is to prevent the patient from returning to normal activity before the ligament heals.

The prognosis for a complete rupture (severe sprain) varies. Success depends on the management of the injury, and the subsequent level of desired activity. A return to normal activity may require from six months to one year.

Strains

The prognosis for treating first or second degree strains is good. The major problem is stressing the affected area too soon. Overstressing the affected area too early in recovery may cause the strain to become chronic. A chronic strain could lead to further complications such as muscle spasm and possible myositis.

Health care team roles

It is appropriate that physicians, nurses, therapists, and other allied health partners be familiar with the prevention and care of sprains and strains. Moreover, nurses and allied health partners should be involved in patient education that focuses on minimizing the risk of overuse injuries.

Prevention

The best prevention for sprains and strains is to have optimal muscular strength, muscular flexibility, and endurance. Appropriate warm-up exercises before an activity may further minimize the potential for injury. Sprains may also be prevented by the use of a brace.

Sprains are caused by excessive stress to a ligament or capsule. Optimal strength, flexibility, and endurance help the muscles to accept and distribute forces that might otherwise be placed on the joint. If muscles are weak and not flexible, increased demand placed on the area will need to be absorbed by the ligaments or joint capsule. Increased demand on these structures will put them at greater risk for failure, i.e. tearing. Braces may absorb some of this extra demand. For example, persons wishing to avoid ankle injury may choose to tape their ankle or wear a lacing brace before engaging in activities with injury potential. Persons with prior ankle injuries may utilize an air stirrup.

Surfaces may also play a role in sprains and strains. A controversial example is the comparison of football injuries on natural grass and artificial turf. One study found an increased rate of anterior cruciate ligament sprains in football players playing on artificial turf compared to sprains on natural grass. A less controversial example might be the comparison of a manicured lawn to a field of wild prairie grass. The prairie grass might hide many dips in the field that would be apparent in a manicured lawn. Such a field would provide a greater likelihood of injury due to the unpredictability and unevenness of the surface, since there is a greater chance for unexpected excessive forces on a joint.

KEY TERMS

Immobilization— To keep a limb or joint free from movement and to maintain position. Movement is stopped by either bracing or casting.

Irritation— Minimal disruption of a structure that may cause bleeding. An irritation can present with minimal swelling and a feeling of discomfort to the individual. Usually, function is not impaired secondary to an irritation. An irritation can progress to a more severe impairment if healing is not allowed to appropriately take place.

Modalities— A term used to describe treatment modes that are applied to the individual. In rehabilitation, a few examples of a modality could be heat, ice, ultrasound, electrical stimulation, and traction.

Range of motion— The amount of motion that a joint has. There is active range of motion and passive range of motion. Active range of motion is the range the joint can traverse under voluntary contraction. The individual moves the limb using their muscle power. Passive range of motion is the range that the joint moves through while either a machine or individual moves the limb. In passive range of motion, the limb is usually moved for the individual with no muscle contraction.

Therapeutic exercise— A general term to describe a multitude of exercises, stretching, and general rehabilitation. Can include range of motion, resistive exercises such as weight training, postural correction exercises, and exercises that incorporate coordination and balance training.

Resources

BOOKS

Andrews, J.R., G. L. Harrelson, and K. E. Wilk. Physical Rehabilitation of the Injured Athlete. Philadelphia: W. B. Saunders Co., 1998.

Hall, C. M., and L. T. Brody. Therapeutic Exercise Moving Toward Function. Philadelphia: Lippincott, Williams and Wilkins, 1999.

Hertling, D., and R. M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore: Lippincott, Williams & Wilkins, 1996.

Magee, D. J. Orthopedic Physical Assessment. Philadelphia: W. B. Saunders Co., 1997.

PERIODICALS

Sitler, M., J. Ryan, B. Wheeler, J. McBride, R. Arciero, J. Anderson, and M. Horodyski. "The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point." American Journal of Sports Medicine 22, no. 4 (July/August 1994): 454-61.

Sitler, M., J. Ryan, B. Wheeler, J. McBride, R. Arciero, J. Anderson, and M. Horodyski. "An epidemiologic study of knee injuries." American Journal of Sports Medicine 20, no. 6 (November/December 1992): 686-94.

OTHER

"Facts and fallacies of diagnostic ultrasound of the adult spine." 〈http://www.chiroweb.com/archives/14/09/33.html〉.

Intelihealth. Knee. 〈http://www.intelihealth.com/IH/ihtIH?t=25430&p=∼br,IHW/∼st,24479/∼r,WSIHW000/∼b,∗/〉.

Intelihealth. Shoulder. 〈http://www.intelihealth.com/IH/ihtIH/WSSFG000/7165/8954/305248.html?d=dmtContent〉.

Knee Injury. 〈http://www.multisportsa.com/injuries/knee.htm〉.

Virtual hospital imaging of muscle injuries. 〈http://www.vh.org/Providers/Textbooks/MuscleInjuries/07MuscleTearStrain.html〉.

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Sprains and Strains

Sprains and strains

Definition

A sprain is an injury to ligaments and/or the joint capsule that occurs in response to large stresses. A strain is disruption of the contractile elements in muscle and/or tendon. An easy way to remember the difference between sprain and strain is that strain is spelled with a "t," which can infer the associated word tendon.

Description

Sprains

Sprains are categorized into three levels of severity. In a mild sprain, or first degree sprain, few ligamentous fibers have been torn, and the ligament is not significantly weakened. There may have been some slight bleeding. In a moderate sprain, also known as a second degree sprain, there is more disruption of the ligamentous fibers (40%–50% of the fibers are torn) and ligamentous weakness is present. Moderate bleeding occurs. In a severe sprain, also named a third degree sprain, there is complete disruption of the ligamentous fibers or joint capsule and there is no strength of the ligamentous tissue. Marked swelling, secondary to bleeding, is present. Many athletes have suffered a complete tear, or third degree sprain, of the anterior cruciate ligament (ACL) of their knee.

Strains

Strains are also referred to as first degree, second degree or third degree strains. In a first degree strain there is usually mild damage to the muscle or tendon with only a few fibers torn. There is minimal bleeding. A second degree strain presents with moderate weakness as the contractile components are torn. There is more bleeding and swelling. In a third degree strain there is complete rupture of the muscle or tendon. A third degree strain is considered a complete tear, accompanied by bleeding, swelling, and loss of function of the associated muscle. An example of a third degree strain would be a rupture of the biceps tendon.

Causes and symptoms

Both sprains and strains are due to increased demand or large stresses placed on the involved structures, i.e., ligament, muscle, or tendon.

Sprains

In a first degree or mild sprain, there is minor weakness, minimal disability, and no muscle spasms of the surrounding musculature. In a second degree sprain, the individual may complain of moderate disability and report instability. For example, in a second degree sprain of the lateral ankle, the individual may report, "the ankle feels like giving way." In a third degree sprain the individual will complain of pain secondary to swelling. Furthermore, the individual will report having major impairment in function, i.e., weight bearing activities.

Strains

An individual with a mild strain may complain of mild irritation of the affected area with no appreciable change in function. A secondary strain will cause the individual to complain about swelling, some minimal stiffening, moderate disability, and moderate pain. In a severe strain, the individual will report a marked loss of function, swelling of the affected area, muscle spasms secondary to guarding, and significant weakness. Interestingly, because of the complete rupture in severe strains, there will be little or no pain on stretching or with movement. Any pain present is probably due to the severe swelling secondary to bleeding.

Diagnosis

Sprains

Functional testing and clinical observation are often sufficient to establish a diagnosis of sprain. In addition to the above symptoms, a variety of tests can be performed in an effort to evaluate the integrity and stability of the joint. For example, a clinician might test an injured knee-by applying medial and lateral stress to the knee.

Four ligaments are important for the stability of the knee joint: the lateral collateral ligament, the medial collateral ligament, the anterior cruciate ligament and the posterior cruciate ligament. The collateral ligaments are largely responsible for the stability of the knee joint in response to lateral and medial stress. Lateral force (also known as a valgus stress) pressures the medial ligament and medial force (also known as varus) pressures the lateral ligament. If a patient has sprained either ligament, the joint should be abnormally mobile—the more mobile, the more severe the sprain. Other tests to determine the status of the cruciate ligaments, such as the Lachman test and the posterior drawer test, may also be performed. Some of the more common knee injuries associated with football are tears of the medial collateral ligament (MCL) and/or the anterior cruciate ligament (ACL). Sometimes the forces that caused the injury are so severe that the MCL, ACL, and medial meniscus (cartilage) are all disrupted. This is termed an "unhappy triad."

Depending on factors like the severity of the sprain, the nature of the injury, and the severity of the sprain, x-rays may also be indicated. x-rays do not indicate the severity of the sprain, merely whether a fracture has occurred or not. Ultrasonography and magnetic resonance imaging (MRI) may be used to determine the severity of a sprain. MRI has the additional benefit of offering multiple types of information. For example, in cases of suspected neck sprain, MRI can show whether the injury is truly a sprain, a strain, or originates from abnormalities in the cervical (intervertebral) disks.

Strains

MRI is also an important tool in the evaluation of strain. Although not indicated in the majority of cases, MRI provides the most accurate diagnostic information of the imaging techniques currently available (as of 2001). Other imaging techniques include ultrasound and computerized axial tomography (CAT scan), but their use is limited. In most cases, however, diagnosis is obtained from clinical observation and functional testing.

When evaluating a first degree strain, findings will show a mild loss of strength during resistance testing, a decreased range of motion, and minimal muscle guarding. In a second degree strain, the strength test will indicate moderate weakness, decreased range of motion, and moderate pain when stretching the tendon or muscle. In a third degree strain, findings will be more pronounced with significant swelling and major weakness compared to the uninvolved side. There will be marked loss of function and significant disability.

One common example of a strain is a hamstring strain, known more commonly as a pulled hamstring. In baseball, when a batter has just hit the ball in the infield, she or he will need to run quickly to first base. On approaching the first base bag, the batter may reach out and extend with the leg to touch the base. A common injury at the point of extension is a tear of one of the following muscles (more commonly known as the hamstrings): biceps femoris, semimembranosus, or semi-tendinosus (tearing of all three is rare). When the hamstrings are over-extended, such as when the baseball player over extends the leg, a muscle or tendon tear may occur.

Treatment

Sprains

In a mild sprain the goal in treatment is to decrease any swelling that is present and prevent loss of motion secondary to stiffness. Ice, elevation, and compression should be used before and after treatment sessions. Therapeutic exercise should include range of motion, stretching, and strengthening of the surrounding musculature. In a moderate sprain, treatment is more conservative and the clinician must minimize the risk of further injury. Modalities should be continued to decrease swelling and pain. The RICE (rest, ice, compression, and elevation) principle should continue throughout treatment. A general rehabilitation pathway of strengthening, range of motion, and flexibility all need to continue and progress as tolerated. In a severe sprain, there are usually two options: surgical and non-surgical. In the surgical option, the ligament is re-attached by the physician. The non-surgical approach relies on bracing to minimize motion and allow for healing. The rehabilitation plan is complex in either of these approaches, but the goal is to initially minimize motion followed by slow progression into range of motion and strengthening.

Strains

Treatment of first and second degree strains is similar to treatment of sprains. It consists of utilizing the RICE principle and protecting the affected area from overstretching or overuse. Rehabilitation should focus on range of motion, decreasing swelling and pain, and gradual introduction of a strengthening program. Severe strains may require surgical repair, and protocols of rehabilitation are different for each affected area. Initial treatment could be immobilization followed by guarded range of motion, flexibility, and strengthening therapies.

Prognosis

Sprains

In a mild sprain, the individual can usually engage in normal activities within three to six weeks. In a moderate sprain, normal activities can usually resume in approximately eight to 12 weeks—ligamentous tissue requires approximately eight to 10 weeks to heal. By the third or fourth week, however, the individual with a moderate sprain will usually have a normal range of motion and be free of pain. Therefore, the key to recovery from a moderate strain is to prevent the patient from returning to normal activity before the ligament heals.


KEY TERMS


Immobilization —To keep a limb or joint free from movement and to maintain position. Movement is stopped by either bracing or casting.

Irritation —Minimal disruption of a structure that may cause bleeding. An irritation can present with minimal swelling and a feeling of discomfort to the individual. Usually, function is not impaired secondary to an irritation. An irritation can progress to a more severe impairment if healing is not allowed to appropriately take place.

Modalities —A term used to describe treatment modes that are applied to the individual. In rehabilitation, a few examples of a modality could be heat, ice, ultrasound, electrical stimulation, and traction.

Range of motion —The amount of motion that a joint has. There is active range of motion and passive range of motion. Active range of motion is the range the joint can traverse under voluntary contraction. The individual moves the limb using their muscle power. Passive range of motion is the range that the joint moves though while either a machine or individual moves the limb. In passive range of motion the limb is usually moved for the individual with no muscle contraction.

Therapeutic exercise —A general term to describe a multitude of exercises, stretching and general rehabilitation. Can include range of motion, resistive exercises such as weight training, postural correction exercises, and exercises that incorporate coordination and balance training.


The prognosis for a complete rupture (severe sprain) varies. Success depends on the management of the injury, and the subsequent level of desired activity. A return to normal activity may require from six months to one year.

Strains

The prognosis for treating first or second degree strains is good. The major problem is stressing the affected area too soon. Overstressing the affected area too early in recovery may cause the strain to become chronic. A chronic strain could lead to further complications such as muscle spasm and possible myositis.

Health care team roles

It is appropriate that physicians, nurses, therapists, and other allied health partners be familiar with the prevention and care of sprains and strains. Moreover, nurses and allied health partners should be involved in patient education that focuses on minimizing the risk of over-use injuries.

Prevention

The best prevention for sprains and strains is to have optimal muscular strength, muscular flexibility, and endurance. Appropriate warm-up exercises before an activity may further minimize the potential for injury. Sprains may also be prevented by the use of a brace.

Sprains are caused by excessive stress to a ligament or capsule. Optimal strength, flexibility and endurance help the muscles to accept and distribute forces that might otherwise be placed on the joint. If muscles are weak and not flexible, increased demand placed on the area will need to be absorbed by the ligaments or joint capsule. Increased demand on these structures will put them at greater risk for failure, i.e. tearing. Braces may absorb some of this extra demand. For example, persons wishing to avoid ankle injury may choose to tape their ankle or wear a lacing brace before engaging in activities with injury potential. Persons with prior ankle injuries may utilize an air stirrup.

Surfaces may also play a role in sprains and strains. A controversial example is the comparison of football injuries on natural grass and artificial turf. One study found an increased rate of anterior cruciate ligament sprains in football players playing on artificial turf compared to sprains on natural grass. A less controversial example might be the comparison of a manicured lawn to a field of wild prairie grass. The prairie grass might hide many dips in the field that would be apparent in a manicured lawn. Such a field would provide a greater likelihood of injury due to the unpredictability and unevenness of the surface (there is a greater chance for unexpected excessive forces on a joint).

Resources

BOOKS

Andrews J.R., G.L. Harrelson, K.E. Wilk. Physical Rehabilitation of the Injured Athlete. Philadelphia: W.B. Saunders Co., 1998.

Hall C.M., L.T. Brody. Therapeutic Exercise Moving Toward Function. Philadelphia: Lippincott, Williams and Wilkins, 1999.

Hertling D., R.M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore: Lippincott, Williams & Wilkins, 1996.

Magee D.J. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders Co., 1997.

PERIODICALS

Sitler M., J. Ryan, B. Wheeler, J. McBride, R. Arciero, J. Anderson, and M. Horodyski. "The efficacy of a semi-rigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point." American Journal of Sports Medicine (July/August 1994) 22 no. 4: 454-61.

Sitler M., J. Ryan, B. Wheeler, J. McBride, R. Arciero, J. Anderson, and M. Horodyski. "An epidemiologic study of knee injuries." American Journal of Sports Medicine (November/December 1992) 20 no. 6: 686-94.

OTHER

"Facts and fallacies of diagnostic ultrasound of the adult spine." <http://www.chiroweb.com/archives/14/09/33.html>.

Intellihealth. Knee. <http://www.intelihealth.com/IH/ihtIH?t=25430&p=~br,IHW|~st,24479|~r,WSIHW000|~b,*|>.

Intellihealth. Shoulder. <http://www.intelihealth.com/IH/ihtIH/WSSFG000/7165/8954/305248.html?d=dmtContent>.

Knee Injury. <http://www.multisportsa.com/injuries/knee.htm>.

Virtual hospital imaging of muscle injuries. <http://www.vh.org/Providers/Textbooks/MuscleInjuries/07MuscleTearStrain.html>.

Mark Damian Rossi, Ph.D., P.T.

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Sprains and Strains

Sprains and Strains

Sprains and strains are common soft tissue athletic injuries. These two terms are often used interchangeably, when in fact each is a distinct injury both in causation and effect.

A sprain is an injury to a ligament, the connective tissue that joins two bones together in a joint. The injury is the result of the ligament fibers being overstretched, often causing a micro-tear, as opposed to the severing or the rupture of the fibers. The overstretching is most often caused by a movement of one beyond the possible range of motion of the joint, either through a hyperextension (overextension), or by a twisting action. Hyper-extended and twisted knees are examples of knee sprains. Ligaments are composed of a type of collagen, which is formed from specific amino acids ingested in the body through dietary protein. Collagen is a naturally elastic substance found in various formations in all of the connective tissue within the body. Collagen provides the overstretched fibers that constitute a ligament sprain with the ability to heal through the action of the body's restorative processes; vitamin C is essential to ligament strength and elasticity.

A strain is an injury that occurs to a muscle or a connecting tendon. A muscle strain is an injury caused to the fibers of skeletal muscle; the other types of muscle, cardiac muscle and smooth organ muscles are not susceptible to strain because they are not controlled by voluntary nervous system impulse. Skeletal muscle is composed of long, thin, cylindrical fibers that are arranged in bundles; a strain is an overstretching or micro-tear of the fiber. Tendons are also formed from a type of collagen, although a tendon is generally a less elastic tissue than a ligament.

Sprains commonly result from a twisting motion in a joint that creates either overextension or over-flexion of the supporting ligaments. A common example of this injury mechanism is a sprained knee caused by contact in sports such as soccer, American football, or rugby. These sprains result from circumstances where the athlete is moving in a forward direction, when the knee is twisted, either through physical contact with an opponent or through a sudden change of direction by the athlete, sometimes accompanied by irregularity or unevenness on the playing surface. The forces that directed the knee forward are suddenly directed laterally, creating torque (a force that causes rotation in the joint), causing the ligaments to stretch. The same mechanism, with a greater degree of force applied, will result in the more serious tear or rupture injury to the ligament.

Another common sprain is to the individual fingers or the wrist, due to an object such as a ball forcefully striking the body and bending the specific structure past its normal range of motion.

A muscle strain, often referred to as a pull, is most often caused by either repetitive motion that overtaxes the muscle, or through an imbalance in a set of muscles. Almost all joints in the body operate through the function of a muscle pair: one muscle, the extensor providing the joint with the ability to extend or straighten, the other, the flexor, permitting the joint to bend. The knee, with the extensor quadriceps and the flexor hamstring is such a joint. A general ideal ratio of strength between the four muscles of the quadriceps and the hamstring is 3:2; muscle and tendon strains are common in both muscle groups when there is an imbalance, which creates additional stress on the weaker of the pair when the forces of motion are applied.

The groin, given its location within the body, is a set of tissues connecting to the abductor muscles of the upper thigh and the lower abdominals, is a common site for a strain injury, as imbalances between the groin and the muscle groups connected to the groin can lead to injury. Groin pulls are very common in sports requiring sudden lateral movement.

Ligament injuries are most often a result of the nature of the physical movement associated with a particular sport, and as such these injuries are not always preventable. Muscle strains are more often caused by a preexisting structural imbalance. A focused and whole body stretching and flexibility regime, where the muscle groups throughout the body are balanced with one another, is the most effective way to minimize muscle and tendon strains.

The overriding goal in the treatment of sprains and strains is the avoidance of a recurring injury. For both injuries, the application of the RICE (rest/ice/compression/elevation) treatment for the first 48 to 72 hours after the occurrence will reduce swelling in the injury and will facilitate healing. Most strains and sprains will not require any external support other than wrapping; crutches may sometimes be necessary when the athlete has sustained a significant strain of a knee or ankle ligament that is short of being torn or ruptured.

see also Groin pulls and strains; Hamstring pull, tear, or strain; Musculoskeletal injuries; Quadriceps pulls and tears; Tendinitis and ruptured tendons.

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