Sprains and Strains
A strain refers to a painful condition brought about by inflammation, overuse (or using in an unbalanced way), and overstretching/tearing of muscles or tendons or joints.
A sprain is an injury to the band (ligament) which connects two or more bones to a joint. A sprain is usually caused by the joint being forced suddenly outside its usual range of movement. A severe sprain may look and feel like a break (fracture), and it can be difficult for health professionals to tell the difference between the two.
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. Most sprains and strains heal within a few weeks.
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 band-like structures around joints, which attach bones together and give support to joints. A ligament can be injured, usually by being overstretched during a sudden pull. The ligaments at the side of the ankle are the ones most commonly sprained.
A damaged ankle ligament causes inflammation, swelling, and bleeding (which shows as bruising) around the affected joint. Moving of the joint is painful. The picture shows a badly sprained ankle with fairly extensive bruising.
The severity of a sprain is graded according to how badly the ligament has been stretched and whether or not the ankle 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 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.
What is a strain?
A strain may be brought about by inflammation, overuse or simply awkward (or unbalanced) use. It includes inflammation of muscles and tendons such as the Achilles tendon at the back of the heel. It also includes overstretching or tearing of muscle fibres. Most strains occur either because the relevant part has been stretched beyond its limits, or it has been forced to pull (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?
The main aims of treatment are:
- To keep inflammation, swelling, and pain to a minimum.
- To be able to use the ankle joint normally again as quickly as possible.
Usually, the damaged ligament heals by itself over time. Some scar tissue may be produced where there has been a tearing of tissues.
What is the treatment of a sprain or strain?
The usual initial treatment is described as PRICE (Protect, Rest, Ice, Compression, and Elevation), together with avoiding HARM (Heat, Alcohol, Running, and Massage). RICE has been updated by the National Institute for Health and Care Excellence (NICE) to PRICE - adding in P for Protection at the start.
These are commonly advised for the first 48-72 hours after a sprained ankle. This treatment must be balanced fairly early with early controlled weight-bearing and ensuring as normal a gait pattern as possible. This assists in retaining the power and balance of the muscles of the upper and lower legs and in maintaining a healthy posture. Painkillers may be needed.
For the first 48-72 hours think of:
- RICE - Rest, Ice, Compression, Elevation. P for Protection has been added to this.
- Do no HARM - no Heat, Alcohol, Running or Massage.
- Protect from further injury (for example, protect the ankle by a support or high-top high-lace shoes).
- Rest the joint for 48-72 hours following injury. For example, consider the use of crutches when wanting to be mobile. You need to protect the injured ankle from further injury. For example, use a bandage and/or ankle support, or a boot with high sides. It is important that the ankle is not rested for too long as this may delay recovery. In most cases, early controlled weight-bearing with the ankle well supported is preferable to complete rest.
- 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, 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. Some doctors recommend re-applying for 15 minutes every two hours (during daytime) for the first 48-72 hours. Do not leave ice on while asleep.
- Compression with a bandage will limit swelling, and help to rest the joint. A tubular compression bandage or an elastic bandage can be used. 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 may be advised to remove the bandage for good after 48 hours, so that the joint can move.
- Elevation aims to limit and reduce any swelling. For example, 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.
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, which can increase bleeding and swelling and decrease healing.
- Running, which may cause further damage.
- Massage, which may increase bleeding and swelling. However, after 72 hours, gentle massage may be soothing.
Your healthcare professional will advise. The advice may typically include:
- Do not stop moving the joint. Avoid doing anything that causes much pain, but gently get the joint moving again. The aim is to get the joint moving in normal directions, and to prevent it becoming stiff.
- Consider wearing a joint support 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 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. 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 will happen again.
- Improving proprioception. This means the ability of your brain to sense the position and movement of your joints. Good proprioception helps you to make immediate, unconscious minor adjustments to the way you walk when walking over uneven ground. This helps to prevent further sprains, and is achieved through special exercises.
- You should not play sport or do vigorous exercise involving the injured part for at least 3-4 weeks after a sprain.
Severe sprains and strains
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 a few weeks.
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 points of damage might have been difficult to detect.
For badly torn muscles, surgery is used very rarely - usually only if there is a complete tear in which the muscle is pulled back (retracted). 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 stronger painkillers such as 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. 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.
There has been debate about whether anti-inflammatory painkillers may delay healing. This is partly because some inflammation is a necessary part of the healing process, and partly because they may very slightly increase bleeding. Current advice from UK guidelines is to put off taking this type of painkiller until 48 hours after the actual injury, when bleeding should have completely stopped.
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 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 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.
- The leg or joint 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 foot (a numb, cold foot with pale or bluish skin). If this occurs, treatment is urgent.
- The pain is severe.
- You cannot walk or weight bear because of the injury.
- 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 improve after a few days, although the pain often takes several weeks to go completely, especially when you use the injured joint.
Preventing ankle sprains
The ankle is the most commonly sprained joint as it faces great challenges for weight bearing and balance, particularly when moving fast over uneven ground. You can help to prevent ankle sprains by wearing boots that give ankle support rather than shoes when hiking across country or rambling over hills and uneven ground.
Exercises to build up the muscles around the ankle and to improve proprioception (described earlier under 'Other treatments') help to prevent ankle sprains. A physiotherapist can advise on these exercises.
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 happen again (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.
Further reading & references
- Ivins D; Acute ankle sprain: an update. Am Fam Physician. 2006 Nov 15;74(10):1714-20.
- Pescasio M et al; Clinical management of muscle strains and tears. The Journal of Musculoskeletal Medicine. Vol. 25 No. 11
- Sprains and strains; NICE CKS, October 2012 (UK access only)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Mary Lowth
Dr John Cox