Sprains and strains are a very common type of injury that affect the muscles and ligaments. Ligaments are strong bands of tissue around joints that connect one bone to another. They help to keep the bones together and stable.

Symptoms of sprains and strains include:

• pain
• swelling and inflammation
• loss of movement in the affected body part

Sprains

A sprain occurs when one or more of your ligaments have been stretched, twisted, or torn, usually as a result of excessive force being applied to a joint. The most common locations for a sprain to occur are:

• the knee - which can become strained when a person turns quickly during sports or other physical activities
• the ankle - which can become strained when walking or running on an uneven surface
• the wrist - which can become strained when a person falls onto their hand
• the thumb - which can become strained during intense and repetitive physical activity, such as playing a racquet sport

Strains

A strain occurs when the muscle fibres stretch or tear. They usually occur for one of two reasons:

• when the muscle has been stretched beyond its limits
• when the muscle has been forced to contract (shorten too quickly)

Strains can develop as the result of an accident, or during physical or sporting activities, such as running or playing football.

The most common types of strains are:

• hamstring strains - the hamstrings are muscles that run down the back of the leg and are connected to the hip and knee joints
• gastrocnemius and soleus strains - the gastrocnemius and soleus are the medical name for the muscles of the calf
• quadriceps strains - the quadriceps are muscles located at the front of the thigh
• lumbar strains - the lumbar muscles are found in the lower back

How common are sprains and strains?

It is hard to estimate exactly how common sprains and strains are because many people do not report minor injuries to their GP.

However, it is known that an ankle sprain is the most common type of sprain, accounting for an estimated 1-1.5 million visits to accident and emergency (A&E) departments each year in the UK.

Muscle strains are very common injuries that affect those who play a lot of sport, such as professional sportspeople . For example, it is estimated that 90% of professional footballers will experience at least one muscle strain during the course of a football season.

Outlook

The outlook for sprains is usually good and most people will be able to resume normal activities within six to eight weeks.

The outlook for people with muscle strains depends on the location and severity of the strain. For example, people a minor hamstring strain can usually resume normal activities within three weeks, whereas people with a severe quadriceps strain will probably have to wait several months.

Most sprains and strains can usually be treated with self-care techniques, such as using ice packs to help reduce inflammation.

Sprains

Common symptoms of a sprain include:

• pain around the affected joint
• being unable to use the joint normally or being unable to put weight on it
• bruising
• tenderness
• swelling
• inflammation

The swelling from a sprain will often occur soon after the injury. However, the bruising may not show until some time later or it may not show at all. Bruising can sometimes occur some distance from the affected joint, as blood from the damaged tissue seeps along the muscles and around the joint before coming close to the skin.

Strains

The symptoms of a muscle strain will depend on how severe the injury is. Symptoms can include:

• pain in the affected muscle
• swelling
• bruising
• muscle spasms (when the muscles contract tightly and painfully)
• loss of some, or all, of the function in the affected muscle
• blood collecting under the skin at the site of the strain - this is known as a haematoma and it looks like a large, dark-red bruise

Grading sprains and strains

There are two grading systems that are used to assess the seriousness of a sprain or strain. The grading systems are based on the extent of the damage to the muscles and ligaments.

The grading system that is used for sprains uses a series of grades from one to three:

• A grade one sprain - mild stretching of your ligament has taken place
• A grade two sprain - there has been a partial rupture (splitting) of your ligament but the joint it is associated with is still stable
• A grade three sprain - there has been a complete rupture of the ligament and the joint is unstable

The grading system that is used for muscle strains uses a series of degrees from first degree to third degree, as outlined below.

• First degree strain - mild straining of the muscles fibres has taken place but only a few fibres have been stretched or torn. The muscle will be painful and tender, but you should still be able to use it normally. However, if the pain in your muscle is very severe, you may decide not to use it until the muscle has healed.
• Second degree strain - moderate straining of the muscle fibres has taken place with a greater number of stretched or torn fibres. You will experience more severe pain and tenderness. There is also mild swelling, noticeable bruising and a distinct loss of strength in the affected muscle.
• Third degree strain - the muscle has been splint into two or torn away from its tendon (a band of tissue that connects a muscle to a bone). You will lose all use of the affected muscle.

When to seek medical help

You should visit your GP or another healthcare professional if you have a sprain or strain and:

• you have severe pain and cannot put any weight on the injured joint or muscle
• the injured area looks crooked or has lumps or bumps (other than swelling) that are not usually present
• you cannot move the injured joint
• the limb gives way when you try to use the joint
• you have numbness in any part of the injured area
• the pain has not improved after four days of self-treatment

Sprains or strains are most likely to occur if you:

• over-reach
• change direction suddenly
• slow down or accelerate suddenly
• fall and land awkwardly
• collide with an object
• experience a blow to a joint

Ankle sprains can occur if you 'go over' onto the outside of your foot. This causes your whole body weight to press down suddenly on the outer ligament of your ankle which can stretch or tear it. Ankle sprains sometimes occur when walking or running over rough or uneven ground.

Sport

Sprains and strains often occur during sporting activities. This is because many sports involve physical contact, sudden acceleration and deceleration, and have an increased risk of injury.

Sports injuries can occur when a person begins to take part in a sport for the first time and their muscles are not used to the physical stresses involved.

Alternatively, experienced athletes may injury themselves when they are at the peak of their training because the increased demands on their muscles can suddenly cause them to become strained.

Competitive athletes, such as sprinters, long-distance runners, gymnasts and footballers have a high risk of recurring muscle strains due to the intense nature of their training and the overuse of specific muscle groups.

Children are also at risk of getting sports injuries because they are still developing physically. For example, the female shape changes significantly during puberty (the gradual progression from a child to a sexually developed adult, which in girls is usually between ages 10 and 16). As the hips widen, exercise can put pressure on different parts of the legs and feet, which can sometimes lead to injury.

However, while sporting activities have an associated increased risk of injury, it is important to remember that they also have important health benefits and can help to increase a child’s confidence and self-esteem.

Risk factors

There are a number of factors that make you more likely to develop an injury. These are described below.

• Poor conditioning - a lack of regular exercise can make your joints less flexible and more likely to sustain injury.
• Poor technique - the way that you distribute your weight when walking or running, or the way that you land after jumping can increase your risk of injuring your knee or ankle.
• Fatigue - when your muscles are tired, they are less likely to provide good support for your joints. When you are tired you may also find it difficult to control your body's movements accurately, which increases your likelihood of stressing or over-extending a joint.
• Inadequate warm up - warming up before exercise helps loosens your muscles and increases your range of joint movement, lowering your risk of sustaining a ligament injury. Not warming up properly before exercising increases your risk of injury.

When diagnosing a strain or sprain, your GP will ask you about how you injured yourself. They will also ask you about any treatments that you have already tried, as well as any medication that you are currently taking that could affect the injury, such as anticoagulants (blood-thinning medication).

Your GP will examine the affected joint or muscle in order to assess how severe your injury is. For example, they will check for:

• pain, discomfort and tenderness in the injured area
• swelling and inflammation
• any lumps and bumps that are not usually present
• bruising or bleeding in the joint or muscle

Your GP will also assess:

• how much you can move the injured joint or muscle
• whether you are able to put your weight on it

If you have a severe sprain, your GP may check whether the ligaments are loose instead of tight. This is sometimes called joint instability, mechanical instability or ligamentous laxity.

X-rays

Most people with sprains and strains do not need to have X-rays. However, your GP may recommend that you have an X-ray if:

• you are unable to put any weight on your ankle, foot or leg
• there is tenderness of the bones at specific points on your ankle, foot or leg
• you have difficult moving your knee

Your GP may also recommend that you have an X-ray if you are over 55 years of age, and you have an acute knee injury (see below). The reason for this is that older people over the age of 55 have a higher risk of developing a fracture after this type of injury.

An acute knee injury is where the knee joint receives a sudden blow, or is damaged in some other way, such as being suddenly twisted out of position.

Most mild to moderate sprains and strains can be treated at home using:

• a self-care techniques called PRICE therapy, and
• by avoiding HARM

These are described in more detail below.

PRICE therapy

PRICE stands for protection, rest, ice, compression and elevation. Advice relating to each of these areas is outlined below.

• Protection - protect the injured area from further injury - for example, by using a support or, in the case of an ankle injury, wearing shoes that enclose and support your feet, such as lace-ups.
• Rest - stop the activity that caused the injury, and rest the injured joint or muscle. Avoid activity for the first 48 to 72 hours after injuring yourself. Your GP may recommend that you use crutches.
• Ice - for the first 48 to 72 hours after the injury, apply ice wrapped in a damp towel to the injured area for 15 to 20 minutes every two to three hours during the day. Do not leave the ice on while you are asleep, and do not allow the ice to touch your skin directly because it could cause a cold burn.
• Compression - compress or bandage the injured area to limit any swelling and movement that could damage it further. You can use a crepe bandage, a simple elastic bandage, or an elasticated tubular bandage. It should be wrapped snugly around the affected area but it should not be too tight. Remove the bandage before you go to sleep.
• Elevation - keep the injured area raised and supported on a pillow to help reduce the swelling. If your leg is injured, avoid having long periods of time where your leg is not raised.

Avoiding HARM

For the first 72 hours after a sprain or muscle strain you should avoid HARM. This means that you should avoid:

• Heat - such as hot baths, saunas or heat packs (applying a controlled amount of heat to affected joints)
• Alcohol - drinking alcohol will increase bleeding and swelling and decrease healing
• Running - or any other form of exercise that could cause more damage
• Massage - which may increase bleeding and swelling

Moving sprained joints

Most healthcare professionals recommend that you should not immobilise (stop using) a sprained joint because the injury will heal quicker if you begin to move the joint as soon as you are able to.

Your GP will be able to teach you a range of exercises that will help you to improve the function of the joint.

An exception to the above advice about immobilisation may be made in cases of severe ankle sprains.

Research conducted in 2009 found that people whose ankle joint was immobilised for 10 days with a cast placed under their knee, recovered normal ankle function more quickly than those who were treated using exercise soon after the injury occurred.

Immobilising strained muscles

The advice for muscle strains is different. For the first few days after the injury you are advised to immobilise your injured muscle and keep it still.

You may be given a brace, cast or splint to help keep the muscle as still as possible. As most strains involve the leg muscles, you may need to use crutches for a few days. However, the length of time that you should keep your muscle immobile will depend on how severe your injury is.

The aim of immobilising the muscle is to allow it to start healing so that you can move it without tearing or pulling it again in the same place. After a few days you will probably be advised to start using the muscle again.

Treating pain

If you experience pain from a strain or sprain, paracetamol is the first type of painkiller that will usually be recommended. If paracetamol does not help to relieve your pain, a stronger painkiller, such as codeine which is only available on prescription, may be required.

Oral non-steroidal anti-inflammatory drugs (NSAIDs) can also help to reduce swelling and inflammation. However, NSAIDs should only be considered for use 48 hours after the injury has occurred because if they are used before this time they may adversely affect the healing process.
Ibuprofen is not recommended if you have a history of asthma or kidney disease, or if you have, or have had in the past, stomach problems such as a peptic ulcer.

If your pain is severe, your GP may prescribe you a stronger painkiller, such as codeine, to be used alongside paracetamol. Codeine can cause drowsiness and it is advisable not to drink alcohol when you are taking it.

Your GP may also prescribe an NSAID cream or gel, such as ibuprofen or ketoprofen, to help treat pain. You should gently apply the cream or gel to the injured area and wash your hands immediately afterwards.

Ketoprofen can make your skin sensitive to light (photophobia). Avoid exposing areas of your skin to which you have applied cream or gel to direct sunlight or artificial sources of light, such as sunlamps or sun beds.

Follow up

If you have a sprain or strain, your GP may ask to see you again a few days after your initial diagnosis to assess how well your injury is healing and whether any further treatment is required.

It is also recommended that you contact your GP if:

• your sprain or strain does not improve as expected - for example, you still find walking difficult
• your symptoms get worse, such as increased pain or swelling

Recovery

Following a sprain or a strain, the length of time that it will take for you to recover will depend on the severity of the injury.

Depending on the severity of your injury, after an ankle sprain you will probably be able to walk one to two weeks after the injury. You may be able to use your ankle fully after six to eight weeks and you will probably be able to return to sporting activities after eight to 12 weeks.

In cases of muscle strains, the time it can take to return to sporting activities can range widely, from two weeks to six months.

Strengthening and conditioning

Regular stretching and strengthening exercises as part of an overall physical conditioning programme can help to reduce your risk of getting sprains and strains. Regular exercise will help your joints stay flexible and reduce the likelihood of injury.

If you are prone to getting sprains and strains, taping, strapping or wrapping your knees, ankles, wrists or elbows can help while you are recovering from injury and when you first get back into regular activities.

However, for most people, it is best to regard taping, strapping or wrapping as a short-term protective measure. You can protect your joints in the long-term by strengthening and conditioning the muscles around them.

Correct footwear

You should always make sure that you wear footwear that supports and protects your feet and ankles whether you are:

• doing sport
• at work
• at home

If you wear high-heeled shoes, you are more likely to sprain your ankle than if you wear flat shoes.

Preventative advice

You can help prevent sprains and strains by following the advice listed below.

• Warm up properly before you exercise and cool down properly afterwards
• Avoid exercising or doing sporting activities when you are tired
• Take precautions against falling - keep stairs, walkways, gardens and driveways free of clutter, and in winter put sand or salt on icy spots outside your home
• Do not wear shoes that have a worn heel on one side
• Avoiding running or walking on uneven surfaces

Fractures

If you have a sprain or strain with a lot of bruising and swelling it may indicate that the bone is fractured (broken). Other signs of a fracture can include:

• lumps and bumps that are not usually there
• being unable to bear weight
• pain or tenderness in a different place - for example, if you have sprained your ankle but also have pain in your leg

Dislocated joints can also be a complication of sprains and strains.

Pain and recurring swelling can be common complications after an ankle sprain, particularly on the outer (lateral) side of the ankle.

If you are unable to use or tighten a strained muscle it may mean that a tendon that is attached to the muscle is ruptured.

If you twist your knee and feel a tearing sensation followed by severe pain, it could be a cartilage injury.

Referral to hospital

If your injury has complications, your GP may refer you to:

• the accident and emergency (A&E) department of your local hospital
• an orthopaedic specialist (a doctor who specialises in conditions that involve the skeleton, joints and muscles)

You may be referred to A&E or a specialist if you have:

• a suspected fracture or dislocation
• nerve or circulation damage
• a ruptured tendon
• a wound entering into the joint
• a bleeding disorder or a history of deep vein thrombosis (DVT)
• signs of bacterial infection in a joint (septic arthritis), bleeding into a joint (haemarthrosis), or a large blood clot in a muscle (intramuscular haematoma)
• a completely torn muscle, or more than half of it is torn

Your GP may also refer you to an orthopaedic specialist if your condition does not improve as expected.