Sprains / strains

Treatment of ligament sprain and muscle strain is: RICE
 
Rest / reduce painful activity to comfort level...
Ice/Hot packs (both work to improve blood supply at extreme temperatures)
Compression bandage
Sometimes POP plaster
Elevation of affected part
Gentle exercises
Gentle oil massage if comfortable.......after few days of injury...
Volini gel in severe pain only.
See the doctor for guidance

 




 




 
  

 
 

 



  

  

 

What is a sprain?

A sprain is an injury to a ligament. Ligaments are strong tissues around joints which attach bones together. They give support to joints. A ligament can be injured, usually by being stretched during a sudden pull. The ligaments around the ankle are the ones most commonly sprained. 

The recovery may take few days to even months depending on grade of injury, sensitivity of tissues (RSD) to injury, associated nerve damage and physiotherapy exercises. 

Some have pain for over one year as well requiring multiple antiinflammatory target injections and operations.

The severity of a sprain is graded into:

  • Grade I - mild stretching of the ligament without joint instability.
  • Grade II - partial rupture (tear) of the ligament but without causing joint instability.
  • Grade III - complete rupture (tear) of the ligament with instability of the joint.

A damaged ligament causes inflammation, swelling, and bleeding (bruising) around the affected joint. Movement of the joint is painful.

What is a strain?

A strain usually means a stretching or tearing of muscle fibres. Most muscle strains occur either because the muscle has been stretched beyond its limits or it has been forced to contract too strongly. The severity of a muscle strain is graded into:

  • First degree strain - a mild strain when only a few muscle fibres are stretched or torn. The injured muscle is tender and painful, but has normal strength.
  • Second degree strain - a moderate strain with a greater number of injured fibres. There is more severe muscle pain and tenderness. There is also mild swelling, some loss of strength, and a bruise may develop.
  • Third degree strain - this strain tears the muscle all the way through. There is a total loss of muscle function.

What is the aim of treatment?

Usually, the damaged ligament or muscle heals by itself over time. Some scar tissue is produced where there has been a tearing of tissues. The main aims of treatment are to keep inflammation, swelling, and pain to a minimum, and to be able to use the joint or muscle normally again as quickly as possible.

What is the treatment of a sprain or strain?

For the first 48-72 hours think of:Paying the PRICE - Protect, Rest, Ice, Compression, Elevation, and no Massage(for first 3-4 days)

Paying the PRICE

Protect the injured part from further injury. The site of the injury will determine how best to protect it.

Rest the affected joint or muscle for 48–72 hours following injury. For example, consider the use of crutches for an ankle, knee or leg injury.

Ice should be applied as soon as possible after injury for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin as it may cause 'ice-burn'.) A bag of frozen peas is an alternative. Gently press the ice pack onto the injured part. The cold from the ice is thought to reduce blood flow to the damaged ligament or muscle. This may limit pain and inflammation. After the first application, some doctors recommend re-applying for 15 minutes every two hours (during day time) for the first 48-72 hours. Do not leave ice on while asleep.

Compression with a bandage will limit swelling, and help to rest a joint. A tubular compression bandage is used for most joints. Mild pressure that is not uncomfortable or too tight, and does not stop blood flow, is ideal. A pharmacist will advise on the correct size. Remove before going to sleep. You may be advised to remove the bandage for good after 48 hours. This is because the bandage may limit movement of a joint which should normally be moving more freely after this time. However, bandages of the leg, knee or ankle are sometimes kept on for longer to help keep swelling down and to keep the affected joint more comfortable.

Elevation aims to limit and reduce any swelling. For ankle and knee sprains, keep the foot up on a chair to at least hip level when you are sitting. (It may be easier to lie on a sofa and to put your foot on some cushions.) When you are in bed, put your foot on a pillow. For hand or wrist sprains, use a sling with your hand and wrist higher than your elbow.

Avoid HARM for 72 hours after injury. That is, avoid:

Heat, for example, hot baths, saunas, heat packs. Heat has the opposite effect on the blood flow to ice. That is, it encourages blood flow. So, heat should be avoided when inflammation is developing. However, after about 72 hours, no further inflammation is likely to develop and heat can then be soothing.

Alcohol drinks which can increase bleeding and swelling and decrease healing.

Running or any other form of exercise which may cause further damage.

Massage which may increase bleeding and swelling. However as with heat, after about 72 hours, gentle massage may be soothing.

Other treatments

Your doctor, nurse or physiotherapist will advise. The advice may include:

For sprains
Do not stop moving the affected joint. Don't do anything that causes much pain, but gently get the joint moving again. Sometimes it means doing gentle exercises several times a day. The aim is to get the joint moving in all normal directions, and to prevent it becoming stiff. Physiotherapy may help for more severe sprains, or if symptoms are not settling. A physiotherapist can advise on exercises and may give heat, ultrasound, or other treatments. However, you should not play sport or do vigorous exercise involving the injured joint for at least 3-4 weeks after the injury.

For strains
It is best to immobilise the injured muscle for the first few days after the injury. You may be advised to use crutches in severe injuries. After a few days you can usually gradually start to use the muscle again. Again, this may be under the supervision of a physiotherapist or other health professional.

Badly ruptured (torn) ligaments or muscles
These sometimes require surgery. Your doctor will assess if this is necessary (but it is not needed in most cases).

What about medication?

You may not need any medication if the injury is mild and you can tolerate the pain. If needed, painkiller options include the following:

Paracetamol and codeine

Paracetamol is useful to ease pain. It is best to take paracetamol regularly, for a few days or so, rather than every now and then. An adult dose is two 500 mg tablets, four times a day. If the pain is more severe, a doctor may prescribe codeine which is more powerful, but can make some people drowsy and constipated.

Anti-inflammatory painkillers

These drugs are also called nonsteroidal anti-inflammatory drugs (NSAIDs). They relieve pain and may also limit inflammation and swelling. There are many types and brands. You can buy two types (aspirin and ibuprofen) at pharmacies without a prescription. You need a prescription for the others. Side-effects sometimes occur with anti-inflammatory painkillers. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers. So, check with your doctor or pharmacist before taking them to make sure they are suitable for you.

But note: Clinical Knowledge Summaries, a well known source of guidance for doctors in the UK (cited below), do not recommend that anti-inflammatory painkillers should be used in the first 48 hours after the injury. This is because of concerns that they may delay healing. The logic is that some inflammation is a necessary part of the healing process. So, it may be that decreasing inflammation too much by taking these drugs may impair the healing process. This may be a theoretical concern as no trials have proven this point. Also, this view is in contrast to what is said in the article from the 'American Family Physician' (cited below). This states that "some studies have shown that patients with ankle sprain showed that, compared with placebo (dummy tablet), NSAIDs were associated with improved pain control and function, decreased swelling, and more rapid return to activity." Further research is needed to clarify the use of these drugs following an injury.

Rub-on (topical) anti-inflammatory painkillers

Again there are various types and brands. You can buy one containing ibuprofen at pharmacies without a prescription. You need a prescription for the others. There is debate as to how effective rub-on anti-inflammatory painkillers are compared to tablets. Some studies suggest that they may be as good as tablets for treating sprains. Some studies suggest they may not be as good. However, the amount of the drug that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects.

Exercises of the joint affected to stretch muscles and reduce spasmodic pain which otherwise affect mobility of the joint

General measures 

Exercise

If possible, exercise regularly. This helps to strengthen the muscles around affected joints, to keep you fit, and to maintain a good range joint movement. Swimming is ideal for most joints, but any exercise is better than none. Many people can manage a regular walk.

Weight control

If you are overweight, try to lose some weight as the extra burden placed on back, hips, and knees can make symptoms worse. Even a modest weight loss can make quite a difference.

  • Wearing a Lubar belt or knee brace.

These measures slightly alter the distribution of weight and pressure on the knee joint, which is why they are thought to ease symptoms in some cases. A podiatrist or physiotherapist can advise exactly how to use them.

Braces or supports may also be helpful for other joints affected. For example, a support around the thumb for painful thumb.

Daily walking for 30 to 45 minutes with or without Walking aids

Diet. Getting too little calcium over your lifetime can increase your risk. 

Fruits, Salads, green vegetables/leaves, Curd/Yoghurt -250 grammes, Lemon juice with little salt/sugar, daily upto 250-500 grammes is mandatory

Water -5-6 lit per day or more, daily slow sustained yoga type physiotherapy exercises as given in website is essential for good health of bones and body.

Daily brisk/speed walking for 1 hour, getting enough vitamin D from your diet, sunlight will decrease your risk.

Physical activity. Not exercising and being inactive or staying in bed for long periods can increase your risk.

Smoking. Smokers harm their blood circulation, damage all tissues in body by free radicals of smoke and absorb less calcium from their diets.

Medications. Some commonly used medicines can cause loss of bone mass. These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone.

Low body weight. Women who are very thin – and small-boned – are at greater risk for osteoporosis.

Physiotherapy help if unable to follow correct exercises

Sometimes advice or treatment from a physiotherapist is helpful. For example:

  • For advice on which exercises to do to strengthen the muscles above the knee (quadriceps). Strengthening the 'quads' has been shown to improve symptoms.
  • For advice on how to keep active and fit.
  • For advice on shoes insoles, knee braces, taping to the knee, and how to use walking aids properly (to make sure you have one of the correct height).

Manipulation and stretching around affected joints may be helpful. This is something that physiotherapists may also be able to help with.

Occupational therapy

An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by OA. Special devices, such as tap turners to help with turning on a tap, may mean that you can carry out tasks around the house more easily.

Other therapies

  • Some people have found that TENS (Transcutaneous Electrical Nerve Stimulator) machines help to ease pain from OA. A TENS machine delivers small electrical pulses to the body via electrodes placed on the skin.
  • Acupuncture may also help to ease symptoms in some cases.
  • Some people find that they can also get some pain relief from using hot or cold packs on the affected joint(s). This is also called thermotherapy. You can use a hot water bottle filled with either hot or cold water and apply it to the affected area. Or, special hot and cold packs that can either be cooled in the freezer, or heated in a microwave, are also available.

Medicines used 

Paracetamol

Paracetamol is the common medicine used to treat OA. It often works well to ease pain. It is best to take it regularly to keep pain away, rather than 'now and again' when pain flares up. A normal adult dose is two 500 mg tablets, four times a day. It usually has little in the way of side-effects, and you can take paracetamol long-term without it losing its effect.

Anti-inflammatory painkillers

You may find that a topical preparation of an anti-inflammatory painkiller that you rub onto the skin over affected joints is helpful instead of, or in addition to, paracetamol tablets. This may be particularly helpful if you have knee or hand OA. Compared to anti-inflammatory tablets, the amount of the drug that gets into the bloodstream is much less with topical preparations, and there is less risk of side-effects (see below).

Anti-inflammatory painkillers that are taken by mouth are not used as often as paracetamol. This is because there is a risk of serious side-effects, particularly in older people who take them regularly. However, one of these medicines is an option if paracetamol or topical anti-inflammatories do not help. Some people take an anti-inflammatory painkiller for short spells, perhaps for a week or two when symptoms flare up. They then return to paracetamol or topical anti-inflammatories when symptoms are not too bad. There are many different brands of anti-inflammatory painkillers. If one does not suit, another may be fine.

Side-effects may occur in some people who take anti-inflammatory painkillers:

  • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are over 65, or have had a duodenal or stomach ulcer, or if you are also taking low-dose aspirin. Stop the medicine and see a doctor urgently if you develop indigestion, upper abdominal pain, or if you vomit or pass blood. Read the leaflet that comes with the medicine for a list of other possible side-effects. You doctor can prescribe another medicine that can help to protect your stomach if you are taking anti-inflammatory painkillers in the long-term. You should discuss this with them.
  • Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers.

Codeine

Codeine is sometimes combined with paracetamol for added pain relief. Constipation is a common side-effect from codeine. To help prevent constipation, have lots to drink and eat a high fibre diet.

Capsaicin cream

This cream is made from chilli peppers and it works by blocking the nerve signals that send pain messages to the brain. It may be helpful if you have knee or hand OA. It takes a while for the effects of this cream to build up and may take around one month to get the maximum benefit. You should rub in a pea-sized amount of cream around the affected joint four times a day, and not more often than every four hours.

Don't use this cream on broken or inflamed skin. You may notice some burning after you apply the cream but this tends to improve the longer you have used it. Avoid having a hot bath or shower, before, or after, applying the cream because it may make the burning sensation worse. Also, be careful to wash your hands after applying the cream. Because it is made from chilli peppers, it can cause burning if it gets into your eyes, mouth or around your genital area.

An injection of antiinflammatory medicine


An injection directly into a joint is useful if a joint becomes badly painful / inflamed.

See a doctor if:

You are concerned about the injury or the injury is severe. In particular, if:
  • You suspect a bone may be broken or a ligament is ruptured.
  • You have a lot of tenderness over a bone.
  • The pain is severe, or if you cannot walk because of an injury.
  • Bruising is severe.
  • Symptoms and swelling do not gradually settle. Most sprains and strains improve after a few days, and the pain gradually eases. However, the pain often takes several weeks to go completely, especially when you use the injured joint or muscle.

Preventing ankle sprains

You can help to prevent ankle sprains, the most common sprain, by wearing boots that give ankle support rather than shoes when hiking across country or rambling over hills and uneven ground. Boots are often best for manual labourers too.

After having an ankle sprain, it is best to build up the muscles around the joint with exercises. A physiotherapist can show you which are the best exercises to do. This is because the stronger the surrounding muscles, the less likely a sprain will recur. Also, some exercises are designed to improve proprioception. This is the ability of your brain to sense movement and position of your body parts and joints such as the ankle. So, for example, good proprioception helps you to make immediate and unconscious minor adjustments to the way you walk when walking over uneven ground. This helps to prevent you overstretching ligaments and causing sprains.

References

  • Sprains and strains, Clinical Knowledge Summaries (July 2008)
  • Ivins D; Acute ankle sprain: an update. Am Fam Physician. 2006 Nov 15;74(10):1714-20. [abstract]

Precautions when using heat and ice

Do not use cold packs or heat:-

  • over areas of skin that are in poor condition.
  • over areas of skin with poor sensation to heat or cold.
  • over areas of the body with known poor circulation.
  • if you have diabetes.
  • in the presence of infection.

Also, do not use ice packs on the left shoulder if you have a heart condition. Do not use ice packs around the front or side of the neck.

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