Sprains

A sprain is a stretch or tear of a ligament. Ligaments are strong bands of tissue around joints that connect one bone to another, and help to keep the bones together and stable.

In a sprain, one or more ligaments have been overstretched, twisted or torn. In a minor sprain, some of the fibres within the ligament are stretched. In more serious sprains, the ligament may be partially or completely torn.

A damaged ligament can cause inflammation, bruising and pain around the affected joint.

The most common locations for sprains are the ankle, thumb and wrist.

A sprain is caused by a ligament being overstretched, twisted or torn. This is most likely to happen if you:

- over-reach,
- change direction suddenly,
- slow down or speed up suddenly,
- fall and land awkwardly,
- collide with an object, or
- suffer a blow to a joint.
Many sprains are sports injuries, as the movements that often lead to sprains are common in many sports.

Ankle sprains are typically caused by going over on to the outside of your foot. This means that your whole body weight presses down suddenly on the outer ligament of your ankle, stretching or even tearing the ligament. Ankle sprains are often caused by walking or running over rough or uneven ground.

There are a number of factors that make you more likely to suffer a sprain:

- Poor conditioning - if you do not get regular exercise, your joints can become less flexible and more likely to sustain injury.


- Poor technique - the way you distribute your weight when running or walking, or the way you land from a jump when playing sports, can raise the risk of you injuring the ligaments in 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 are also less likely to control your body's movements accurately, making it more likely for you to stress or over-extend a joint.


- Not warming-up properly before exercise - warming-up loosens your muscles and increases the range of joint movement, making the ligaments less likely to suffer injury. Lack of warm-up before exercise will increase your risk of sprain.

The symptoms of a sprain include:

- pain around the affected joint,
- not being able to use the joint as normal,
- bruising, and
- inflammation.
The swelling from a sprain will occur soon after the injury but the bruising may not show until some time later, or may even not show at all. Bruising can appear some distance from the affected joint as blood from the damaged tissues seeps out along the muscles and other structures around the joint, before coming close to the skin.

Sprains are classified into three grades, depending on the severity of the injury:

- Grade I the ligament has been stretched or torn slightly, but is still attached to the bone. There will be pain and a small amount of swelling, but no real difficulty in moving the joint. Grade I sprains do not normally require medical treatment.


- Grade II the ligament has been partially torn. The pain will be moderate to severe, the joint will be swollen and difficult to move, and there will be some bruising which may make the joint discoloured. It will be difficult to take any weight on the joint. Some Grade II sprains may require medical treatment.


- Grade III one or more ligaments has been completely torn. There will be severe pain, swelling, and loss of movement in the joint. If the joint is the ankle, then you will usually be unable to walk. The joint will be extensively bruised and will probably be discoloured. Grade III sprains usually require medical treatment.
You should see a doctor for a sprain if:

- you hear a popping sound when you injure the joint,
- you have severe pain and cannot put any weight on the injured joint,
- the injured area looks crooked or has lumps or bumps, other than swelling, that would not be present on an uninjured joint,
- 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, or
- the pain has not improved after four days of self-treatment.

The key to diagnosing a sprain is the pain and discomfort in the injured area. Your doctor will ask you for a detailed description of how you injured the area, which may give a clue to the ligaments involved. They will physically examine the affected joint and look for signs of swelling, bleeding in the joint, and tenderness.

In severe cases, it may be difficult to distinguish a sprain from a fracture (break). Your doctor may ask you to have an X-ray to rule out a fracture or other bone injury. Occasionally, an MRI scan may be needed to distinguish between a partial and complete tear of the ligament.

Treatment for a Grade I or II sprain is usually in two stages - RICE therapy and rehabilitation. The first stage covers the 48 hours after the injury and aims to reduce swelling and pain. The second stage aims to rehabilitate the affected area and restore it to full function.

Immediate treatment of a sprain should follow RICE therapy. This stands for:

- Rest - stop the activity that caused the injury and rest the injured joint. Two days (48 hours) of rest is recommended.


- Ice - apply an ice pack to the area for between 10-30 minutes. The ice must not touch the skin directly as this may cause a cold burn, so place a towel over the injured part first.


- Compression - compress or bandage the injured site, to limit swelling and movement that could damage it further.


- Elevation - raise the injured area to an elevated but comfortable height (above heart height wherever practical) to reduce swelling, especially at night. Gravity helps reduce swelling by draining away excess fluid.
The symptoms from most Grade I or II sprains improve after a few days and the pain eases. However, the pain may take several weeks to disappear completely, especially when you use the injured joint. If necessary, you can relieve the pain with a painkiller such as paracetamol or ibuprofen. Ibuprofen is an anti-inflammatory, so it can also help to reduce swelling. However, ibuprofen is not recommended if you have a history of asthma, kidney or liver disease.

From 48 hours after the sprain, you should begin the second stage of treatment by gently beginning to use the injured area again. It is important to start moving the joint again early, to reduce the amount of scarring that will form in the damaged area. Rehabilitation of the joint using exercise to strengthen the ligament and surrounding muscles is also important to prevent the injury recurring.

Most Grade I and II sprains can be self-treated. RICE therapy and rehabilitation will usually be sufficient for the sprain to heal normally. You should see a steady, progressive improvement in the joint's ability to support your weight or your ability to move without pain. Mild and moderate sprains usually heal in 2-4 weeks, but if pain or swelling carries on beyond this point, you should visit your GP.

Grade III or more severe Grade II sprains may require additional treatment, depending on the joint involved and the severity of the injury. In some cases, surgery may be needed to sew the torn ligaments back together.

Other treatments for severe sprains may include:

- immobilising the area with a brace or splint and using crutches or a cane, so you can get around without putting pressure on the affected joint,
- immobilising the joint in a plaster cast if a flake of bone has been pulled away from the joint, and
-physiotherapy to encourage healing, strength and flexibility in the affected joint.
The amount of rehabilitation needed for more severe sprains can vary. For example, a moderate ankle sprain could require 2-3 months, whilst a severe sprain could take 8-12 months to return to full function. Surgically repaired ligaments will normally need a programme of rehabilitation, possibly lasting several months, to return the joint to full strength and function.

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

If you are prone to sprains, then taping, strapping or wrapping knees, ankles, wrists or elbows can help while you are recovering from injury and when you first get back into your regular activities. It is best for most people to regard taping, strapping or wrapping as a short-term protective measure. You can protect your joints in the long-term by working to strengthen and condition the muscles that are around the joint. The best brace you can give yourself is your own muscle brace.

You should always make sure you are wearing footwear that offers your feet and ankles support and protection, whether you are doing sport, work, or if you are just at home. In particular, if you are wearing high-heeled shoes, you are more likely to suffer a sprained ankle than if you are wearing flat shoes.

Other things you can do to help prevent sprains include:

- warm up properly before you exercise,
- avoid exercising or playing sport when you are tired,
- take precautions against falling - keep stairs, walkways, gardens and driveways free of clutter, and put sand or salt on icy spots outside your home in winter,
- avoid wearing shoes if the heel wears down on one side, and
- avoid uneven surfaces when you are running or walking. NHSDEC07