Taking the strain
Strains and sprains are common sports injuries. Mild acute injuries are amenable to self-management and with correct preparation can be avoided, says Steve Titmarsh…
Strains and sprains are among the most common injuries experienced by people participating in sports.1 A sprain is a stretch and/or tear of a ligament, whereas a strain is a stretch and/or tear of muscle fibres and/or the attached tendon.
Such injuries occur when excessive or abnormal force is applied to a joint in the case of a sprain, or when a muscle is stretched beyond its limits or forced to contract too strongly in the case of a strain (also referred to as ‘pull’).
Sprains typically involve the ankles, knees, wrists and thumbs, while strains usually affect the foot, hamstring and back.2
Some sports are associated with a higher risk of injury than others (see Box 1). Certain factors such as lack of regular exercise or preparation, being overweight, or using incorrect footwear may increase the risk of injury (see Box 2).3
Examples of sports with higher risk of injury3
Other sports involving extensive gripping
Risk factors for sports injuries3
• Lack of regular exercise – can result in poor strength, flexibility and co-ordination
• Poor exercise technique – may result in excessive pressure on specific muscles or joints
• Inappropriate footwear
• Inadequate warm up – it is important to warm up before exercising and cool down after as this help combat muscle fatigue giving better support for joints
• Increasing age
• Previous injury
• Sudden trauma such as a fall, twist or blow to the body
• Anatomical variations of the foot, ankle and knee — for example, generalised joint laxity or flatfoot, or joint misalignment
• Reduced balance and postural control, reduced joint proprioception, or neuropathy
• Drinking too much alcohol or taking drugs that cause drowsiness — may increase risk of ankle sprains and falls
• Being overweight or obese — may put excessive pressure on particular joints and muscles, increasing the risk of injury
• Being underweight — may increase the risk of ankle sprains.
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or diclofenac gel, or oral paracetamol or NSAIDs, can be recommended to relieve pain.4,5 A Cochrane review confirms that the efficacy of topical NSAIDS for treating pain symptoms is probably similar to that of oral NSAIDs.6
Another recent review and meta-analysis concluded that topical NSAIDs showed the greatest benefit to harm (ie side-effects) ratio for patients with acute non-low back pain and musculoskeletal injuries, followed by oral NSAIDs and paracetamol with or without diclofenac. Opioids were of no greater benefit than NSAIDs and were associated with more adverse effects.7
Analgesia forms but one part of the management of acute traumatic musculoskeletal injuries such as those sustained during strenuous activity such as sport. And analgesics should be taken in the lowest effective dosage for the shortest time possible.8
For mild acute injuries that do not need referral for medical attention the general self-management advice is to follow the PRICE (Protection, Rest, Ice, Compression, Elevation) strategy and avoid HARM (heat, alcohol, running, massage) for the first two to three days after injury.4,9
It may be beneficial to wear a joint support such as an elasticated bandage or specialised brace for a sprain until symptoms have cleared.9
Protection — protect from further injury (for example, by using a support or high-top, lace-up shoes to protect an ankle).
Rest — avoid exercise and reduce activity for the first 48–72 hours following injury.
Ice — apply an ice pack (or pack of frozen peas) wrapped in a damp towel for 15–20 minutes every 2–3 hours during the day for the first 48–72 hours following injury. This should not be left on during sleep.
Compression — an elastic bandage or elasticated tubular bandage, which should be a snug fit but not tight, worn during the day helps control swelling and supports the injury.
Elevation — keep the injured area elevated and supported on a pillow until the swelling is controlled. If a leg is injured, avoid prolonged periods with the leg not elevated. Immobilisation for a few days after injury may be needed for severe sprains and strains.
Heat – avoid hot baths, saunas, heat packs; these can increase blood flow, which, in turn tends to increase inflammation and bruising.
Alcohol – drink can worsen bleeding and swelling and decrease healing.
Running – further damage may result from using the affected part of the body.
Massage – may increase bleeding and swelling, but can be soothing 72 hours after injury.
When to refer for immediate medical attention4,9
People suspected to have, or showing signs of the following should be referred for immediate medical attention:
• Severe pain
• Inability to walk or bear weight or hold anything
• A fracture or dislocation – a limb may look out of shape, for example
• Damage to nerves or circulation, where a hand or foot is numb and cold with pale or bluish skin, for example
• Wound penetrating the joint or known bleeding disorder
• A serious complication such as haemarthrosis or septic arthritis
• Tendon rupture
• Complete tear, or tear of more than half the muscle belly
• Large intramuscular haematoma.
Generally, people can start to move again once the pain becomes tolerable when they do so.4 Movement should be gentle at first; stretching and strengthening exercises can be introduced as the pain becomes less and movement easier.10 Athletes can resume training once their pain has gone and muscle strength is back to normal.4
People who still have difficulty walking or whose symptoms are becoming worse after five days to a week following injury should be referred to their GP. People whose symptoms continue or do not improve as expected may need to be referred to a physiotherapist for advice about bracing or taping, for example. If there is no recovery or it is slow, an orthopaedics appointment may be advisable.4
1. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Strains and sprains: How common are strains and sprains? (https://cks.nice.org.uk/topics/sprains-strains/background-information/prevalence; accessed 1 February 2022).
2. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Strains and sprains: What is it? (https://cks.nice.org.uk/topics/sprains-strains/background-information/definition; accessed 1 February 2022).
3. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Strains and sprains: What are the risk factors? (https://cks.nice.org.uk/topics/sprains-strains/background-information/risk-factors; accessed 1 February 2022).
4. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Strains and sprains: Scenario: Management (https://cks.nice.org.uk/topics/sprains-strains/management/management; accessed 4 February 2022).
5. Qaseem A, McLean RM, O'Gurek D, et al. Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med 2020;173(9):739–48. (www.acpjournals.org/doi/10.7326/m19-3602; accessed 4 February 2022)
6. Derry S, Moore RA, Gaskell H, et al. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2015;6:CD007402 (www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007402.pub3/full; accessed 4 February 2022).
7. Busse JW, Sadeghirad B, Oparin Y, et al. Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries : A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med 2020;173(9):730–8.
8. de Sire A, Marotta N, Lippi L, et al. Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes. Medicina (Kaunas) 2021;57(11):1208.
9. Payne J, Bonsall A. Sprains and strains (https://patient.info/bones-joints-muscles/sports-injuries/sprains-and-strains#nav-7; accessed 4 February 2022).
10. NHS.UK. Treatment. Sports injuries (www.nhs.uk/conditions/sports-injuries/treatment; accessed 4 February 2022).
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