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.

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.

• Poor conditioning
• Ill-fitting sports equipment
• Inadequate warm-up before activity

• Pain
• Stiffness
• Swelling
• Joint instability

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

Pain and swelling in the affected area, usually acute within the first 48 hours of the injury

Damage to the muscle, tendon, or ligament, depending on the severity and grade of the injury

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.

Determine degree of injury for sprains (see Overview), and extent of pain/tenderness in strains.

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.

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

Specific nutrients and herbs may help restore the integrity of connective tissue, reduce inflammation, and provide pain relief.

• 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.

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).

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.

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.

Acupuncture may provide pain relief and increase local circulation.

Therapeutic massage is effective at increasing circulation and may relieve spasm in surrounding muscle groups.

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.

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.

• 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

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.

High doses of vitamin C are contraindicated in pregnancy. Bromelain, quercetin, and turmeric should be used with caution.

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