Sprains and strains

What is a sprain?

A sprain is an injury to a ligament. It's a type of soft tissue injury. Ligaments are strong band-like structures around joints, which are a type of tissue that connects bones together and gives support to joints. A ligament can be injured, usually by being overstretched during a sudden abnormal movement. The ligaments at the side of the ankle are the ones most commonly sprained.

What does a sprained ankle look like?

A damaged ligament causes inflammation, swelling, and bleeding (which shows as bruising) around the affected joint. Moving of the joint is painful. The picture shows a sprained ankle with bruising. For more information, particularly about a sprained ankle, see the separate leaflet called Ankle Injury (Sprained or Broken Ankle).

Sprained ankle

By Boldie, Public domain, via Wikimedia Commons

The severity of a sprain is graded according to how badly the ligament has been damaged and whether or not the joint has been made unstable. The joint can become unstable when the damaged ligament is no longer able to give it the normal support:

• Grade I - mild stretching of the ligament (only a few fibres torn) without joint instability.

• Grade II - partial tear (rupture) of the ligament but without joint instability (or with mild instability).

• Grade III - a severe sprain: complete rupture of the ligament with instability of the joint.

How long does a sprain take to heal?

Mild sprains usually take about two weeks to heal. In more severe sprains, it can take up to 12 weeks for the ligament to heal.

What is a strain?

A strain is a non-medical term for a muscle injury. Sometimes it is used to describe the problem of overuse or awkward use of a muscle causing pain in that muscle but usually it refers to an overstretching or tear of muscle fibres (or very rarely of a tendon). A hamstring injury is the most common type of muscle strain. See the separate leaflet called Hamstring Injuries.

How do muscle strains happen?

Most strains occur either because the relevant part has been stretched beyond its limits, or it has been forced to pull (contract) too strongly, usually when playing sports. 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 which may develop.

• Third-degree strain - this strain tears the muscle all the way through. There is a total loss of muscle function.

Repetitive strain injury is a term used to describe several conditions that can affect the muscles and tendons. It isn't discussed here. See the separate leaflet called Repetitive Strain Injury (RSI).

Tendinopathy and tenosynovitis are other types of tendon injury. See the separate leaflet called Tendinopathy and Tenosynovitis (Tendinosis).

How long does a muscle strain last?

First-degree muscle strains usually heal within two weeks of the injury.

Second-degree muscle strains can take between four to eight weeks to heal.

Third-degree muscle strains can take several months to heal. They may require surgery to repair, which can require a lengthy rehabilitation time.

What is the aim of treatment?

The main aims of treatment are:

• To keep any inflammation and pain to a minimum and reduce swelling.

• To get you back to normal, and returning to your sport if appropriate, as quickly as possible.

Usually, the damaged ligament or muscle heals by itself over time. Some scar tissue may be produced where there has been a tearing of tissues.

How to treat a sprain or strain

The usual initial treatment is described as paying the PRICE (Protect, Rest, Ice, Compression, and Elevation), together with avoiding HARM (Heat, Alcohol, Running, and Massage).

These are commonly advised for the first 48-72 hours after a sprain or strain. This treatment must be balanced with early controlled use of the affected part of the body. This helps to keep the strength of the muscles and flexibility in the joints. Painkillers may be needed.

Pay the PRICE

• Protect from further injury (for example, protect the ankle by a support or high-top boots).

• Rest the joint for 48-72 hours following injury. For example, consider the use of crutches for a few days if it is your leg that you have injured.

• Ice should be applied as soon as possible after injury, for 15-20 minutes every two or three hours (during daytime) for the first 2-3 days. Make an ice pack by wrapping ice cubes in a plastic bag or towel, or by using a bag of frozen peas. Do not put ice directly next to skin, as it may cause ice burn. Gently press the ice pack on to the injured part. The cold is thought to reduce blood flow to the damaged ligament. This may limit pain, inflammation and bruising. Do not leave ice on while asleep.

• Compression with a bandage will limit swelling, and help to rest the joint or muscle. A tubular compression bandage or an elastic bandage can be used on a limb. The bandage should not be too tight - mild pressure that is not uncomfortable and does not stop blood flow is the aim. A pharmacist will advise on the correct size. Remove the bandage before going to sleep. You will usually be advised to remove the bandage for good after 48 hours.

• Elevation aims to limit and reduce any swelling. For example, keep your leg up on a chair to at least hip level when you are sitting, if it is your leg you have injured. Or if it is your arm, use a sling for a day or two.

Avoid HARM for 72 hours after injury

That is, avoid:

• Heat - for example, hot baths, saunas, heat packs. Heat encourages blood flow which will tend to increase bruising and inflammation. 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, - drinking alcohol can increase bleeding and swelling and decrease healing.

• Running - or any other activity that uses the affected part of the body, which may cause further damage.

• Massage - may increase bleeding and swelling. However, after 72 hours, gentle massage may be soothing.

For more information on using ice for treating pain and swelling, see the separate leaflet called Ice and Heat Therapy for Pain Relief.

Other treatments

Your healthcare professional will advise. The advice may typically include:

• Do not stop moving the affected joint or muscle. Avoid doing anything that causes much pain, but gently get your affected part moving again to prevent it becoming stiff.

• Consider wearing a joint support for a sprain until symptoms have gone. There are various forms of supports which can be used - from an elasticated bandage to a specialised brace. The aim is to give some support to the joint whilst the damaged ligament is healing, but to allow the joint to move to a reasonable degree.

• Physiotherapy (physical therapy) may help for more severe sprains or strains, or if symptoms are not settling. A physiotherapist can advise on exercises. The aim of physiotherapy includes:
  

  • To get the joint back to a full range of normal movement.

  • To improve the strength of the surrounding muscles. The stronger the muscles, the less likely it is that a sprain or strain will happen again.

  • Improving proprioception. This means the ability of your brain to sense the position and movement of your joints and is important following sprains. Good proprioception helps you to make immediate, unconscious minor adjustments to the way you move - for example, when walking over uneven ground. This helps to prevent further sprains and is achieved through particular types of exercises which a physiotherapist or sports therapist can show you.

• You will probably not be able to play sport or do vigorous exercise involving the injured part for at least 3-4 weeks after a sprain or serious strain. However, this does depend on how bad the injury was.

What is the treatment for a severe sprain or strain?

Severe sprain

Extra treatment may be needed for severe sprains (where the ligaments are badly torn (ruptured) or the joint is unstable).

There is some evidence that these types of sprain may heal more quickly if treated with a short period of immobilisation. This means wearing a brace or a plaster cast for 10 days or so.

In some cases, if ligaments are very badly torn or the joint is too unstable, surgery may be advised. Your doctor will assess if this is necessary (but it is not needed in most cases).

If the sprain is still very painful six weeks after the original injury, you may be advised to have additional tests on the joint, such as a further X-ray or scan. Sometimes there are torn ligaments or small breaks (fractures) which do not show up when the injury first happens. The joint may initially have been very swollen and small additional areas of damage might have been difficult to detect.

Severe strain

For severe strains (badly torn muscles or tendons), surgery is used very rarely - usually only if there is a complete tear in which the muscle is completely torn or has become unattached to the bone (for example, a severe hamstring injury). Muscles are less easy than ligaments to repair surgically because the muscle fibres do not hold stitches easily.

What about medication for a sprain or strain?

You may not need any medication if the injury is light, such as a mild sprain or strain, and you can tolerate the pain. If needed, paracetamol is the safest choice, especially immediately after the injury. Painkiller options include the following:

Paracetamol

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 stronger painkillers such as codeine, which is more powerful but can make some people drowsy and constipated.

Anti-inflammatory painkillers

These medicines are also called non-steroidal anti-inflammatory drugs (NSAIDs). They relieve pain and may also limit inflammation and swelling. Some clinicians recommend that they shouldn't be taken for the first 48 hours after an injury.

This is partly because some inflammation is a necessary part of the healing process, and partly because they may very slightly increase bleeding. However, the evidence for this is old and not of very good quality. More recent studies suggest the benefits of taking NSAIDs for the first few days of an injury, outweigh the risks.

You can buy some types (eg, ibuprofen) at pharmacies, without a prescription. You need a prescription for some others - eg, naproxen. Side-effects sometimes occur. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, chronic kidney disease, 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.

If you take anti-inflammatory medication, ibuprofen is recommended as the one least likely to cause side-effects.

Rub-on (topical) anti-inflammatory painkillers

Again, there are various types and brands of topical anti-inflammatory painkillers. You can buy one containing ibuprofen or diclofenac 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. Other studies suggest they are no better than an embrocation. However, the amount of the medicine that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects.

When to worry about a sprain or strain

A person with a sprain or strain is advised to seek medical advice if there is:

• Lack of expected improvement after trying basic home management (for example, they have difficulty walking).

• Worsening of symptoms (for example, increased pain or swelling).

You should see a doctor if there is any concern about the injury, or if the injury is severe. In particular, see a doctor if:

• You suspect a bone may be broken or a ligament is ruptured.

• You have a lot of tenderness over a bone.

• Your arm or leg looks out of shape (deformed) rather than just swollen. This may mean there is a break (fracture) or dislocation which needs urgent treatment.

• There is loss of circulation in the hand or foot (it is numb and cold with pale or bluish skin). If this occurs, treatment is needed urgently.

• The pain is severe.

• You cannot walk or weight bear because of the injury or you cannot hold anything, if you have a wrist sprain..

• Bruising is severe.

• The joint does not seem to work properly or feels unstable after the pain and swelling have gone down. This may be a sign of an additional injury such as a torn tendon.

• Symptoms and swelling do not gradually settle. Most sprains and strains improve after a few days, although the pain often takes several weeks to go completely, especially for sprains.

Preventing sprains and strains

It isn't always possible to prevent injury - sometimes it's just bad luck. However, you are less likely to get a sprain or strain when exercising if:

• Your muscles are strong.

• You warm up with gentle aerobic exercise to gradually get the heart beating a bit quicker and get the body ready for exercise.

• You cool down after exercise.

• You use proper equipment and appropriate footwear.

• You don't exercise or play sport when tired or unwell (especially contact sports).

Also by avoiding falls, if possible:

• Ensure rugs and carpets can't slip.

• Clear away ice and snow from paths.

• Avoid getting drunk.

• Take extra care if you are taking medications that cause drowsiness.

The ankle is the most commonly sprained joint. For information on preventing ankle sprains, see the separate leaflet called Ankle Injury (Sprained or Broken Ankle).

The hamstrings - muscles at the back of the thigh - are the most common muscles to strain. To read about hamstring injury prevention exercises, see the separate leaflet called Hamstring Injuries.

Dr Mary Lowth is an author or the original author of this leaflet.