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Overview |
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Definition |
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A sprain is an injury to a ligament or to the site of its attachment to bone,
most often the ankle, knee, elbow, or wrist, which usually results in painful
swelling.
- Grade 1—least severe type of sprain; minimal
or mild pain, swelling, and disability. Edema, tenderness, and function loss is
minimal to mild. Joint is stable. The ligament or muscle has less than 20% of
its fibers damaged.
- Grade 2—moderate pain, swelling, and
disability; moderate edema, tenderness and functional loss. Unstable joint, but
flexion of the ligament will result in a solid endpoint. Twenty to 70% tissue
fibers damaged.
- Grade 3—severe symptoms in all six
categories. Joint is unstable, and flexion of the ligament results in an absent
or mushy endpoint. Over 70% of the tissue fibers are damaged, or ligament or
muscle is completely ruptured.
A strain is a tear or other injury to muscle tissue or tendon, commonly
occurring in the muscles that support the neck, thigh, groin, and
ankle. |
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Etiology |
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Sprain—extrinsic load (i.e., twisting) to a joint,
which causes the ligaments to deform past their elastic limit. The extent to
which the bones depart from their normal alignment will determine the severity
of the injury to the tendon.
Strains—tension on a muscle that is stronger than
the tensile capacity of its weakest structural element. Usually occurs during
activities that require muscle activation and stretching simultaneously.
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Risk Factors |
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- Poor conditioning
- Ill-fitting sports equipment
- Inadequate warm-up before
activity
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Signs and Symptoms |
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- Pain
- Stiffness
- Swelling
- Joint instability
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Differential
Diagnosis |
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First, differentiation must be made between a sprain and a strain.
Sprains:
- Strain
- Avulsion fracture
- Hairline fracture
- Contusion
- Ecchymosis
- Tendon rupture (especially Achilles)
- Hematoma
- Septic joint
- Inflammatory arthropathies
- Tendinitis
Strains:
- Underlying tumor involving the muscle or its attachment
- Infectious and inflammatory muscle syndromes
- Sprain
- Contusion
- Tendinitis
- Fracture
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Diagnosis |
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Physical Examination |
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Pain and swelling in the affected area, usually acute within the first 48
hours of the injury |
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Pathology/Pathophysiology |
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Damage to the muscle, tendon, or ligament, depending on the severity and
grade of the injury |
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Imaging |
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X rays may be indicated when the patient suffers from a grade 2 or grade 3
sprain, or is experiencing pain over a bone. The attached ligament can pull a
piece of bone off during the injury, resulting in an avulsion fracture. X rays
are not useful for strains. Although rarely necessary, a magnetic resonance
image (MRI) will reveal complete tears of the ligament, as edema and bleeding
and muscle-tendon pathology (Achilles or rotator cuff tear).
Appropriate stress films show ligament instability. |
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Other Diagnostic
Procedures |
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Determine degree of injury for sprains (see Overview), and extent of
pain/tenderness in strains. |
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Treatment Options |
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Treatment Strategy |
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Over several days following injury, RICE
treatment—rest, ice, compression (tape, etc.), and
elevation of the affected joint.
Ice reduces pain, bleeding, and inflammation. It may also reduce secondary
damage to other parts of the joint. However, the overall clinical benefit is not
known. Bleeding and inflammation may play an important role in the healing
process. Wrap the affected area in elastic bandage in more severe cases. Cast
may be required to stabilize grade 3 injuries.
Activity that involves the affected area should be limited for an average of
seven days.
Physical therapy—Grade 1 injury: strapping/taping or
orthotic for two to three weeks. Grade 2: weight-bearing brace/orthotic/cast for
four to eight weeks. Grade 3: weight-bearing cast for three to six weeks
followed by orthotic or strapping for three to six weeks. Surgery may be
indicated. All to be followed by appropriate exercise regimen for return of
function. |
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Drug Therapies |
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Pain relief through analysis may allow the patient to mobilize the affected
area and resume activity. When injuries are more severe or chronic, however,
continued use of analgesics may lead to aggravation of the condition. Analgesics
should not be used to mask pain so that activity can be resumed without proper
immobilization. Reduction in the inflammatory response can also hasten the
mobilization of the injured area, but the role of inflammation in healing is
unknown and interference could theoretically slow tissue repair. Muscle spasms
often accompany sprains and strains and can interfere with rehabilitation.
Over-the-counter pain relievers and anti-inflammatory agents usually help;
however, product label dosage recommendations may be inadequate for moderate to
severe injuries.
- Aspirin—325 mg, one to two tablets every
four hours
- Naproxin—210 mg, two to three tablets every
8 to 12 hours
- Ibuprofen—200 mg, two to three tablets every
four to six hours
- Analgesic balms
- Acetaminophen—325 mg, one to two tablets
every four hours
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Complementary and Alternative
Therapies |
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Specific nutrients and herbs may help restore the integrity of connective
tissue, reduce inflammation, and provide pain relief. |
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Nutrition |
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- Vitamin C (1,000 to 1,500 mg tid) to reduce inflammation and support
connective tissue.
- Bromelain (250 to 500 mg tid between meals) is a proteolytic enzyme
that helps to reduce inflammation.
- Beta-carotene (50,000 IU/day) is needed for collagen
synthesis.
- Zinc (15 to 30 mg/day) supports immune function and
healing.
- Vitamin E (400 IU/day) has antioxidant effects.
- Adequate protein intake is
important.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Flavonoids, a constituent found in dark berries and some plants, have
anti-inflammatory properties and strengthen connective tissue by promoting
collagen synthesis. The following are flavonoids that may be taken in dried
extract form as noted.
- Quercetin: 250 to 500mg tid
- Hawthorn (Crataegus monogyna): 500 mg tid
- Turmeric (Curcuma longa) potentiates the effect of bromelain.
Take 250 to 500 mg each of turmeric and bromelain, tid between
meals.
The following combination of antispasmodic, analgesic, and circulatory
stimulants may help to relieve congestion and provide pain relief. Black cohosh
(Cimicifuga racemosa), cramp bark (Viburnum opulus), Jamaica
dogwood (Piscidia piscipula), feverfew (Tanacetum parthenium),
poke root (Phytolacca americana), and valerian (Valeriana
officinalis). Combine equal parts in a tea (1 cup tid to qid), or tincture
(15 drops every 15 minutes for acute relief, up to eight doses; or 20 to 30
drops qid). |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arnica montana for acute injury with bruised sensation and
sensitivity to pressure
- Rhus toxicodendron for sprains and strains with great
restlessness
- Ruta graveolens for stiffness and pain from injury or chronic
overuse
Topical homeopathic creams containing leopard's bane (Arnica montana)
and/or St. John's wort (Hypericum perforatum) may provide pain relief. Do
not apply over broken skin.
Arnica oil may be applied topically for pain relief, provided the skin
is not broken. |
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Physical Medicine |
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Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory,
especially helpful for chronic or severe injury. Apply oil directly to skin,
cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat
source (hot water bottle or heating pad) over the pack and let sit for 30 to 60
minutes. For best results, use for three consecutive days. |
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Acupuncture |
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Acupuncture may provide pain relief and increase local
circulation. |
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Massage |
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Therapeutic massage is effective at increasing circulation and may relieve
spasm in surrounding muscle groups. |
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Patient Monitoring |
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Monitor for recurring sprains and strains. Once a muscle or tendon is
injured, it is susceptible to reinjury, especially if patient returns to full
activity too soon. |
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Other
Considerations |
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Prevention |
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Basic physical fitness and strength training are important preventive
measures.
Warm-up exercises increase energy output and increase the temperature of
muscles, improve coordination between the brain and muscles, reducing
uncontrolled muscle movements.
Warm-ups should begin with stretching movements of the large muscle groups
that are to be exercised more heavily. Jogging and exercise bikes are good
initial exercises, to be followed by exercises more specific to the activity to
be pursued. Lastly, the warm-up routine should include event-specific movements,
such as throwing a football or swinging a racket. Warm-ups should last 15 or 20
minutes.
Half of all athletic injuries are due to inappropriate training or inadequate
warm-up, and most of these errors result from a failure to follow the principle
of slow progression. Sudden increases in intensity or duration of an activity
often lead to over-use injuries such as sprains and strains.
Preventive training can take the form of muscle training, mobility and
flexibility training (flexibility of the joint is limited by tight connective
tissue), coordination and propioceptic training, and sport-specific training
that reinforces good technique in recurring, stress-inducing movements.
Improper technique often causes excess load on joints, so correction of
technique can prevent sprains and strains. Another method for reducing load is
to decrease the speed of the activity.
Patient should not return to full activity until the affected joint has
returned to 90% strength and flexibility. |
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Complications/Sequelae |
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- Strains: recurrent strains and complete muscle tears
- More chronic pain and joint instability
- Recurrent sprains
- Complete tear of muscle or tendon
- Stress fracture
- Degenerative arthritis from chronic joint
instability
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Prognosis |
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Inflammation occurs for up to 72 hours, followed by gradual reduction of
swelling.
Recovery time is as follows: grade 1, 4 to 6 weeks; grade 2, 2 to 3 months;
grade 3, 4 to 6 months. Patient may return to high-impact activity when range of
motion, strength, and function of the injured joint is nearly equal to the
uninjured side. |
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Pregnancy |
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High doses of vitamin C are contraindicated in pregnancy. Bromelain,
quercetin, and turmeric should be used with caution.
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References |
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Balch JF, Balch PA. Prescription for Nutritional Healing. Garden City
Park, NY: Avery Publishing Group; 1997.
Birrer RB, ed. Sports Medicine for the Primary Care Physician. Boca
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Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:429.
Brown DJ. Herbal Prescriptions for Better Health. Rocklin, Calif:
Prima Health; 1996.
Kibler WB, Herring S, Press J, Lee P. Functional Rehabilitation of Sports
and Musculoskeletal Injuries. Gaithersburg, Md: Aspen Publishers; 1998.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:38, 326, 330.
Null G. The Clinician's Handbook of Natural Healing. New York, NY:
Kensington Publishing Corp; 1997.
Olshevsky M, Noy S, Zwang M, Burger R. Manual of Natural Therapy. New
York, NY: Facts on File; 1989.
Strauss RH, ed. Sports Medicine. Philadelphia, Pa: WB Saunders Co;
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Ullmann D. The Consumer's Guide to Homeopathy. New York, NY: G.P.
Putnam's Sons; 1995.
Zachazewski JE, Magee DJ, Quillen WS. Athletic Injuries and
Rehabilitation. Philadelphia, Pa: WB Saunders Co;
1996. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |