COMMON JOINT INJURIES & SPRAINS
Following a sprain or strain the usual advice is to pay the PRICE (Protection, Rest, Ice, Compression, and Elevation) and avoid HARM (Heat, Alcohol, Running, and Massage) for the first 48-72 hours after injury. Painkillers may be needed. Most sprains and strains heal within a few weeks. Physiotherapy may help. Extra treatment such as a brace or surgery may be needed for severe sprains where the ligament ruptures (tears badly).
Note: this leaflet does not advise on how to distinguish what injury you have. For example, if you have an injury, it is sometimes difficult to tell if you have a bone fracture, or other more serious injury. Therefore, see a doctor or nurse if you suspect that you have a fracture or other more serious injury. This leaflet assumes you know that you have a sprain or strain (for example, having been told by a doctor or nurse) and nothing more serious.
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 severity of a sprain is graded into:
1) Grade I - mild stretching of the ligament without joint instability.
2) Grade II - partial rupture (tear) of the ligament but without causing joint instability.
3) 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:
1) 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.
2) 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.
3) 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:
1) Paying the PRICE - Protect, Rest, Ice, Compression, Elevation, and
2) Do no HARM - no Heat, Alcohol, Running or Massage.
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 - the cold from the ice is thought to reduce blood flow to the damaged ligament or muscle. This may limit pain and inflammation.
Ice should be applied as soon as possible after injury. Wrap the ice in a damp towel and apply it to the injured area for 15-20 minutes. A bag of frozen peas is an alternative. Gently press the ice pack on to the injured part. This should be done every 2-3 hours during the day, for the first 2-3 days after the injury. (Do not put ice directly next to skin, as it may cause ice burn. Also, do not leave ice on while asleep, and do not apply it for more than 30 minutes, or it may damage the skin.)
Compression with a bandage will limit swelling, and help to rest a joint. A tubular elastic bandage or a simple elasticated bandage is suitable for most joints. A pharmacist will advise on the correct type and size.The bandage should feel snug, but not uncomfortable or tight, and should not stop blood flow. Remove before going to sleep. You may be advised to remove the bandage for good after 48 hours, so that the joint can move. However, sometimes it is advisable to kept the bandage on for longer, to help lessen the swelling and to keep the joint more comfortable.
Elegation 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.
Rinning 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.
Your doctor, nurse or physiotherapist will advise. The advice may include:
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.
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.
Severe sprains and strains
If the ligaments or muscles are badly torn, further treatment may be needed. Sometimes a brace or cast is used, to support the torn area while it heals. For example, a brace may be used for severe ankle sprains.
Torn ligaments sometimes require surgery to repair them. Your doctor will assess if this is necessary (but it is not needed in most cases).
For badly torn muscles, surgery is used very rarely - usually only if there is a complete tear in which the muscle is retracted (pulled back). Muscles are less easy to repair surgically than ligaments, because the muscle fibres do not hold stitches easily.
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.
These medicines are also called non-steroidal 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.
There has been debate about whether anti-inflammatory painkillers may delay healing. The logic is that some inflammation is a necessary part of the healing process. On the other hand, anti-inflammatory painkillers may be helpful for relieving the pain of a sprained ankle. Current advice from UK guidelines is to put off taking this type of painkiller until 48 hours after the actual injury. Further research is needed to clarify the use of anti-inflammatory painkillers following an injury.
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. 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 medicine that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects.
When to see a doctor:
A person with a sprain or strain is advised to seek further medical advice if there is:
1) Lack of expected improvement after trying basic home management (for example they have difficulty walking).
2) Worsening of symptoms (for example increased pain or swelling).
3) Concern regarding the nature and extent of the injury.
Consider reviewing a strain after a few days to assess muscle contractile function, depending on the severity of the injury.
Seek further medical advice if you are concerned about the injury or the injury is severe - in particular, if:
1) You suspect a bone may be broken or a ligament is ruptured.
2) You have a lot of tenderness over a bone.
3) The pain is severe, or if you cannot walk because of an injury.
4) Bruising is severe.
5) Symptoms and swelling do not gradually settle - or if symptoms get worse over time. 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.