Strain and Sprain

Aside from the other traumatic soft tissue injuries like contusions, sprain and strain are the two most common acute soft tissues injuries that involve muscles, tendons, and ligaments. These injuries often occur with our daily simple or complex activities like occupation, hobby, recreation, sports and exercise activities. These soft tissue injuries have two categories, the acute injuries and overuse injuries. Sprain and strain, together with contusions, belongs to the sudden traumatic acute injuries of the soft tissues. The overuse injuries, such as the tendinitis and bursitis, occur gradually over time and constantly injuring the soft tissue without allowing enough time to heal between occurrence.

            mild 2nd degree sprain, rotated inwards. (Photo credit: Wikipedia)
 

SPRAIN

A sprain is a sudden trauma involving one or more ligaments around a joint. The ligaments, similar to tendon and fascia which are connective tissues, are tough and fibrous connective tissues that connect one bone to another bone to maintain stability and resist mechanical stresses. Sprains can occur in any joint but are most common in the knee, ankle, wrist, and thumb. The injury can be minor that resolves in a few days or it can be a major injury requiring surgical intervention and a period of immobilization. Pain and rapid swelling follow after a sprain. In most cases, the severity of sprain depends on the pain and swelling. The greater it is, the more severe the injury is.

Causes

Risk factors that increase the occurrence of sprain include:

• Twisting, stretching or any excessive forces being applied to the joint that go beyond the functional range of motion 
• Fatigue of muscles predisposes to injury. A tired muscle doesn't give enough support to a joint
• A fall and landing on an outstretched arm, landing on the side of their foot, or twisting a knee with the foot planted firmly on the ground.
• Individuals with sedentary lifestyle, usually less or no physical activity
• Inadequate or no warm-up and cool-down regimen in an exercise or an activity  
• Bumping into a hard object or person such as contact sports
• Poor conditioning and poor techniques to an exercise or an activity

Signs and symptoms

• Pain around the affected joint
• Muscle pain and spasm
• Swelling follows soon after the injury
• Bruising may appear later sometimes at some distance from the affected joint (hematoma) or it may not appear at all
• Joint instability depends on the severity of the injury
• Sometimes may hear a popping sound or feel a tear 
• A loss of the ability to move and use of the affected extremity or to bear weight may lead to joint stiffness

Diagnosis

• Physical examination to demonstrate clinical presentation and method of injury
• X-ray for possible bone fracture
• Magnetic Resonance Imaging (MRI) performed for a detailed look at surrounding soft tissues and the ligament

Grading of injury

Grade I  

• Mild pain and swelling 
• Little to no instability, Little to no tear of the ligament 
• Stretched but intact with no loss of function

Grade II  

• Moderate pain and swelling, 
• Minimal instability of the joint 
• Partial tearing of the ligament from a third to almost all its fibers 
• Decrease in the ROM 

Grade III  

• Severe pain and swelling
• Significant instability of the joint
• Complete rupture of the ligament
• Significant decrease in ROM

                                                                        STRAIN                                                 

A strain is an injury involving the musculotendinous unit that involves a muscle, tendon or their attachment to bone.  Functionally, the tendons and muscles  tightly integrated to move bones.Tendons are fibrous cords of tissue with one end of the tendon connects to muscle and the other end of the tendon connects to a bone. The same with a sprain injury, any excessive forces that stretch or tear the muscle and/or tendons produce an injury. Muscle strains are particularly common in the legs and back, such as hamstring strains and lumbar (lower back) strains.

Causes

A strain caused by an excessive twisting or a pulling action to a muscle or tendon. This is common to contact sports and other sports that require extensive gripping and quick starts. 
The injury can be acute or chronic, just like in a sprain injury 

4 days after a pulled hamstring. Two images of the same leg. One of the pictures was shot through a mirror (Photo credit: Wikipedia)

Sign and Symptoms

• The severity is dependent on the extent of the injury.
• Pain and muscle spasm
• Localized swelling
• Loss of muscle function
• Limited joint range of motion

Grading of injury

Grade I  

• Localized pain, minimal swelling, and tender to touch

Grade II  

• Localized pain, moderate swelling, tenderness, and impaired motor function

Grade III  

• A palpable defect of the muscle, Severe pain, and poor motor function

Treatment of Sprain and Strain

In the acute phase, the focused is on the reduction of pain and swelling and further injury

• PRICE stands for protection, rest, ice, compression, and elevation 24 hours up to 72 hours to reduce pain and swelling or until swelling improves
• No heating such as hot baths or hot packs
• Refrain alcoholic beverages because it will increase bleeding and swelling, and slow down the healing process
• Massage may increase bleeding and swelling in the acute phase
• Don't avoid instead a reduction regular exercise or activities  
• Protection may include a non-weight bearing on the injured site using a crutch may help. A splint or brace may also be helpful for moderate injuries while a surgical repair required for severe injuries
• Apply an ice pack or a cold pack for 15 to 20 minutes to prevent frostbite, 6 to 8 times a day.
• Compression bandages to help reduces swelling
• Elevation of the injured extremity above heart level help also reduces swelling
• Prescription medication or over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB) and acetaminophen (Tylenol)  may be helpful to manage pain and inflammation during the healing process

Start the physical therapy programs early to prevent or minimize the effects of deconditioning. Depending on the patient's rate of recovery such as diminished pain and swelling, incorporate a series of exercises in the rehabilitation to help reduce swelling, prevent joint stiffness, and restore normal, pain-free range of motion. Exercises include: 

• Weight-bearing and balancing exercises
• Strengthening, endurance, and flexibility exercises to increase strength and regain flexibility
• Treatment modalities such as an Ultrasound, a soft-tissue massage or techniques, and a manual therapy techniques(Joint oscillation) help reduce pain and inflammation
• A  continuous passive motion (CPM) machine to maintain or promote flexibility of the joint.

As pain decreases and function improves, progression to functional training based on patient's occupation and/or recreational goals. Patient education and training/retraining for instrumental activities of daily living (IADL). A full recovery may allow a patient to return to full daily activities, including sports. Remind patient the potential danger in accelerating the rehabilitation program as it may lead to serious consequences.

Preventive measures

• Avoid exercising or doing sporting activities when you feel tired or in pain.
• Maintain a healthy, well-balanced diet to keep muscles strong and full of energy
• Wearing appropriate footwear designed for a specific activity such as sports shoes or a protective equipment. A high-heeled is more likely to sprain your ankle than if you wear flat shoes. 
• Practice safety measure to help prevent falls such as slippery floors, cluttered areas, and others
• Run on or walk on even surfaces may help
• A taping, strapping or wrapping your knees, ankles, wrists to protect joints. 
• Do regular stretching and strengthening exercises daily to maintain a healthy weight and promote general well-being
• Be in proper physical condition and in a high spirit to play a sport.
• A short warm-up and cool-down regimen that include stretching may help reduce injuries before engaging in any sports or exercise