Strains and sprains - Amazon AWS

Clinical setting, such as community pharmacies.

Module 1828

Strain

Strains and sprains From this module, you will learn: • The definition and diagnosis of sprains and strains • How to help patients manage an injury, including self-help and nonpharmacological approaches • The advice and support pharmacists can provide to their patients to help prevent future injury This is an updated and expanded version of module 1704 (published in June 2014)

KATHERINE GASCOIGNE The terms ‘sprain’ and ‘strain’ are often used interchangeably. They are common injuries that share similar symptoms – such as pain, swelling and a loss of movement. However, they are two distinct injuries: sprains affect ligaments (the short-band connective tissue between bones or cartilage), while strains affect muscle fibres.

Sprains often affect the ankle or knee joints, but can also be seen in the wrist and thumb. The ligaments around the ankle are the most commonly sprained, causing many visits to A&E departments. However, in most cases the injury is mild and can be managed in the primary care

Sprains A sprain is defined as an injury to a ligament as a result of abnormal or excessive forces applied to a joint, but without dislocation of the joint or fracture. The severity of a sprain is graded as follows: • Grade I (mild) – A slight stretching of the ligament complex, without joint instability. • Grade II (moderate) – Partial tearing of the ligament complex, causing mild tenderness and swelling around the ankle. There is not usually joint instability. • Grade III (severe) – Complete tear of the ligament complex, with instability of the joint. This will be accompanied by significant tenderness and swelling around the ankle.

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A muscle strain – or muscle pull – is a stretching or tearing of muscle fibres. This normally occurs because a muscle has been stretched beyond its limits or has been forced to contract too much. Muscle strains are also graded according to their severity: First-degree – A mild strain, where only a few muscle fibres are stretched or torn. The injured muscle is tender and painful, but still has normal strength – although power may be limited by pain. A muscle’s ‘power’ refers to its ability to generate as much force as possible, as quickly as possible, while muscle ‘strength’ is the amount of force a muscle can exert in a single transaction. Second-degree – A moderate strain. A greater number of muscle fibres are injured, causing more severe muscle pain and tenderness. There is mild swelling, as well as a noticeable loss of strength and power. In addition, there is sometimes a visible bruise. Third-degree – A severe strain that tears the muscle all the way through. There may be a

‘popping’ sensation as the muscle rips into two separate pieces or shears away from its tendon. Muscle function is lost entirely. Strains tend to be caused through sport of other physical activity. The most common types of strain affect the: • hamstrings (the muscles connecting the hip and knee joints) • calf muscles • quadriceps (thigh muscles) • lumbar muscles (muscles in the lower back).

Identifying a strain or sprain For both sprains and strains, the severity of the symptoms depends on the severity of the injury itself. Symptoms include: • tenderness and swelling • bruising • functional loss, for example pain when weight is applied • mechanical instability (movement beyond a joint’s normal range of motion can occur in severe cases). When a patient suffers from an injury and you are trying to determine if it is a strain, you can look for the following clinical attributes: • pain in the affected muscle • large haematomas – a solid swelling of clotted blood within the damaged muscle tissue – as a result of the tearing of intramuscular blood vessels • localised swelling • reduced muscle function – depending on the severity of the strain • a history of sprains or muscle pulls.

Conditions to rule out The following injuries can present with similar symptoms to that of a sprain or strain, and need to be ruled out when diagnosing a patient: Fracture It can be difficult to determine whether a joint is just sprained or whether a bone fracture has occurred. Signs of fracture can include:

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• pain when the affected area is touched, • • • •

pressed, moved or made to bear weight swelling, bruising or tenderness around the affected area the injured part looking deformed an audible snap or grinding noise at the time of injury the individual feeling faint, dizzy or sick through shock.

Tendon rupture What appears to be a bad sprain or strain could actually be a tendon rupture. This is indicated by an inability to use the limb served by that tendon’s muscle and/or a palpable gap in the tendon. Cartilage injury This most commonly affects the knee and involves a twisting injury with a tearing sensation, followed by severe pain. The area usually exhibits mild to moderate swelling within 24 hours of the injury. If the ligaments inside the knee are affected – as with the anterior cruciate ligament – swelling is usually immediate. If the sprain or strain is severe, or if any of the above injuries are suspected, you should advise the individual to attend the local A&E department for urgent medical attention. Patients should also be referred to a doctor if they are on anticoagulant therapy or have a history of neuropathy, bleeding disorders or deep vein thrombosis – even if their injury does not appear to be severe.

Management Patients may be reassured that most sprains and strains will heal by themselves with time. Scar tissue – that is weaker than original tissues – may be produced if the injury has involved some tearing of muscle or ligament tissue. The main aim of treatment is to reduce swelling, inflammation and pain, and to enable the normal use of the affected body part as quickly as possible. There are two acronyms – PRICE and HARM

– that may be employed as memory aids in the management of sprains and strains.

Price This acronym stands for protect, rest, ice, compression and elevation: Protect Preventing the injured part from further damage by using a support, or – if it is an ankle injury – recommending wearing shoes that provide ankle support. Rest Stopping the activity that caused the injury and resting the affected joint or muscle for up to 72 hours following injury. During this period the patient may require crutches to facilitate this rest. Ice As soon as possible after an injury occurs you should encourage patients to apply ice – wrapped in a damp towel – for 15-20 minutes at 2-3 hour intervals, for up to 72 hours after injury. It should not be applied for more than 30 minutes at time, and should not be used during the night – as prolonged exposure can damage the skin. A bag of frozen peas works well if no ice is available. The application of ice works by cooling the area, which causes a reduction in blood flow to the damaged ligament or muscle, thus limiting pain and inflammation. However, ice should never be placed directly against the skin, as it may cause an ice burn. Compression Using a tubular or simple elasticated bandage will compress the injury, leading to a reduction in swelling and helping to rest the joint by limiting its movement. The correct size should be recommended so that the bandage fits snugly, but is not uncomfortable or so tight that blood flow is stopped.


Advise the patient to remove the bandage overnight – and then completely after 48 hours – so that the joint can move. If there is still a risk of continued swelling or joint discomfort, you may recommend the bandage is kept on for longer. Elevation This aims to limit and reduce swelling that may occur. If the ankle or knee is affected, advise the patient to rest their foot on a chair – at least at hip level – while sitting. If lying on a sofa or when in bed, the foot should be elevated using cushions or an equivalent. If the hand or wrist is affected, a sling should be employed to elevate the affected joint higher than the elbow.

HARM As well as obeying the PRICE memory aid, you should advise patients to ‘do no HARM’ – with HARM standing for heat, alcohol, running and massage. Heat Heat has the opposite effect on blood flow to ice and as such should be avoided. Hot baths, saunas and heat packs are not to be recommended, as these will increase blood flow and cause more inflammation. However, once 72 hours has passed and further inflammation is deemed unlikely, patients may find the application of heat to the area soothing. Alcohol This should be avoided as it may increase bleeding and swelling, while decreasing healing. Running Any activity or exercise – such as running – that may cause further damage should be avoided. Massage This may increase bleeding and swelling in the injured body part, so should not be recommended initially. However, as with heat, after 72 hours it may be soothing.

Medicinal therapy As an adjunct to the PRICE and HARM techniques, a patient may require oral or topical pain relief. For sprains and strains, the analgesic of choice is paracetamol. It should be taken regularly over a few days at the maximum suitable dose. If paracetamol is not adequate, a combination of paracetamol with codeine or dihydrocodeine may be supplied over the counter for a maximum of three days’ use. Patients should be warned of the possibility of experiencing the common side effects of drowsiness and constipation. It is not appropriate to suggest that the patient take a non-steroidal anti-inflammatory (NSAID) initially, as their use is not recommended until 48 hours after the injury. This is because it is thought that NSAIDs may actually impair the healing process by affecting inflammation. This inflammation is necessary for the muscle to repair and regenerate, and for growth to start as soon as the sprain or strain occurs. After 48 hours have passed since the injury, ibuprofen – if appropriate for the individual patient – may be commenced. Ibuprofen is considered to be the NSAID with the lowest risk of adverse effects. Topical NSAIDs are also thought to be of some benefit in reducing the pain and inflammation associated with these injuries. Studies have produced varying results, but some claim that topical NSAIDs are as effective as oral NSAIDs at reducing the pain, with the added benefit that less of the drug is absorbed, meaning the risk of the patient experiencing side effects is reduced. After following the above advice for the two to three days immediately post-injury, the pain should reduce.

Longer-term advice The advice you provide on post-injury exercise differs between sprains and strains. Post-sprain advice Patients with mild to moderate injuries should


be advised to keep moving the affected joint. A doctor can recommend suitable, gentle exercises – that do not cause much pain – to be performed several times a day, with the aim of getting the joint moving in all normal directions. Sport or more vigorous exercise should be avoided for at least three to four weeks after the injury. A physiotherapist can advise on suitable exercises and may also provide heat, ultrasound or other treatments. For severe ankle sprains, a short period of immobilisation using a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Post-strains advice The injured muscle should be immobilised for the first few days after injury. A brace, cast or

splint may be supplied to encourage this. Once the individual has pain-free movement of the muscle and is able to stretch it as much as the healthy, contralateral muscle (equivalent muscle on uninjured limb), active mobilisation – a therapy aimed at improving joint use – may be reintroduced under the supervision of a physiotherapist or doctor. Surgery is occasionally needed to repair torn ligaments. Muscle fibres do not hold stitches well, so surgery is only used very rarely to repair a muscle that has torn completely.

after six to eight weeks. Muscle strains take longer to recover from, and the time it takes to return to sporting activities varies widely, from a matter of weeks to up to six months. You should advise patients to seek assessment by a doctor if: • the sprain or strain does not seem to be improving after a few days • there is an increase in pain or swelling • there is concern about the nature and extent of the injury.

Patient recovery

The best way to avoid the most common sprain or strain injuries is to ensure that the correct, properly fitted, footwear is worn for sporting or outdoor activities. You can also advise patients not to walk or run on uneven

Recovery time depends on how severe the injury is. Generally someone with a sprained ankle would be expected to be walking after one or two weeks, and back to full use of the affected ankle

Avoiding sprains and strains

surfaces where possible. Encourage patients to perform exercises that build up strength in muscles around vulnerable joints. This will help them reduce their risk of injury. Taping, strapping or wrapping susceptible or recovering joints will provide some strength, but this should usually only be seen as a short-term measure, and not a substitute for regular conditioning and strengthening exercises. It is essential you recommend that patients perform a warm-up before undertaking any exercise, while stretching or warming-down afterwards should be advised as a way to reduce the chance of a sprain or strain occurring. There is actually little evidence to support this, but it does seem that warming-up reduces soreness post-exercise.

Sprains and strains CPD

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Reflect What is the difference between a strain and a sprain? Why is ibuprofen not recommended for pain relief during the first 48 hours after a strain or sprain injury? How can strains and sprains be avoided?

1. The most commonly sprained ligaments are those around the knee. True or false

6. Heat and massage should be avoided until 72 hours after a strain or sprain injury. True or false

Plan This article contains information for pharmacists about strains and sprains. It defines the two injuries and discusses their severity, symptoms, diagnosis and treatment. Advice to give about how to avoid these types of injury is also included.

2. In a grade III sprain there is complete rupture of the ligament complex plus joint instability. True or false

7. For pain relief immediately following a sprain or strain, ibuprofen is the analgesic of choice. True or false

Act Read the Update article and the suggested reading (below), then take the-5 Minute Test online.

3. After a strain or sprain the joint should be rested for up to 72 hours following injury. True or false

8. Patients with a strain are advised to keep moving the injured muscle to aid mobility. True or false

4. Ice should be applied to a strain or sprain for a minimum of 30 minutes. True or false

9. For severe ankle sprains, a short period of immobilisation can result in a faster recovery. True or false

Find out more about the causes and treatment of strains and sprains from the NHS Choices website at bit.ly/sprainsstrains. Consider the range of bandages and ice packs that are kept in your pharmacy and which ones you would recommend. Find out about first aid leaflets for patients or courses they could attend that cover these types of injuries. Make sure that your counter staff know what to recommend and when to refer. Consider if any staff members could benefit from a first aid course. Evaluate Are you now confident in your knowledge of the symptoms and diagnosis of strains and sprains? Could you give advice to patients about their treatment?


5. Patients using compression to treat a strain or sprain are advised to remove the bandage at night. True or false

10. Surgery is commonly used to repair torn ligaments and muscles. True or false
