Clinical Topic A-Z Clinical Speciality

Sprains and strains

Sprains and strains
D013180Sprains and Strains
D016512Ankle Injuries
D017844Lateral Ligament, Ankle
D000842Ankle
D000843Ankle Joint
D001265Athletic Injuries
D013178Sports Medicine
D007718Knee Injuries
D012782Shoulder
D004550Elbow
D014954Wrist Injuries
D017006Rotator Cuff
D014953Wrist
InjuriesMusculoskeletal
2012-10-01Last revised in October 2012

Sprains and strains - Summary

A sprain is an injury to a ligament as a result of abnormal or excessive forces applied to a joint, but without dislocation or fracture.

A muscle strain (or 'pull') is stretching or tearing of muscle fibres caused by stretching the muscle beyond its limits or forcing it to contract too strongly.

Sprains and strains are common.

If a person with an ankle sprain has an uncomplicated recovery:

Walking is usually possible within 1–2 weeks.

Function is restored after 6–8 weeks.

Return to sporting activities occurs after 8–12 weeks (although time to recovery may depend upon the severity of the injury).

Pain and intermittent swelling are the most common residual problems.

The severity of symptoms and signs depends on the severity of the sprain (e.g. whether there has been a partial or complete ligament tear):

Common symptoms and signs include tenderness and swelling, bruising, and mechanical instability (if the sprain is severe).

The ankle and knee are commonly affected.

Marked bruising and swelling may indicate a complete ligament tear or fracture.

The clinical features of a muscle strain depend on the severity of the injury and the nature of the haematoma:

There may be a history of a strain or 'pulled muscle'.

Pain occurs in the affected muscle.

Large haematomas can occur as a result of tearing of the intramuscular blood vessels.

There may be obvious swelling, although small haematomas or those deep within the muscle are more difficult to diagnose clinically.

Muscle function may be affected, depending on the severity of the strain.

Management of a sprain or strain involves:

Assessing the severity of the injury (e.g. pain and swelling) and treatments already tried.

Assessing whether there are any complicating factors e.g. deformity of a limb or damage to nerve.

Advising the person to manage their injury using the protecting it from further injury, resting it for 48-72 hours after the injury, applying ice for the first 48–72 hours following the injury, using a simple compression bandage, and elevating it until the swelling is controlled (PRICE).

Advising the person to avoid heat, alcohol, running, and massage (HARM) in the first 72 hours after the injury.

Prescribing paracetamol or a topical nonsteroidal anti-inflammatory drug, if necessary. Codeine can be used as an 'add on' to paracetamol, if required and an oral NSAID (e.g. ibuprofen) can be considered 48 hours after the initial injury.

For sprains: immobilizing the joint for a few days only when sprains are severe.

For strains: immobilizing the injured muscle for the first few days after the injury.

Referral to an orthopaedic specialist should be made if there is locking of the joint, diagnostic uncertainty, slower than expected recovery, and symptoms out of proportion to the degree of trauma. Urgency of referral will depend on the severity of the injury and the clinical expertise of the primary care professional.

Referral for physiotherapy should be considered for strain injuries.

Have I got the right topic?

60months3060monthsBoth

This CKS topic covers the immediate management of acute ligament sprains of the ankle and knee, and muscle strains.

This CKS topic does not cover the management of completely ruptured tendons or ligaments, or soft-tissue problems that are chronic or recurrent, or problems that might be associated with a strain or sprain (such as fracture or dislocation).

There are separate CKS topics on Back pain - low (without radiculopathy), Neck pain - acute torticollis, Neck pain - cervical radiculopathy, Neck pain - non-specific, Neck pain - whiplash injury and Sciatica (lumbar radiculopathy).

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in October 2012

February 2014 — minor update. The prescribing information has been updated to reflect new information from the manufacturer of piroxicam gel regarding reports of renal problems with piroxicam gel use [ABPI Medicines Compendium, 2014].

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].

October 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. A change was made in the recommendations relating to specific management of severe sprains.

Previous changes

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

September 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has recently advised that topical ketoprofen is associated with a risk of photosensitivity reactions [MHRA, 2010]. Issued in September 2010.

June 2009 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has recently reminded prescribers of the risk of photosensitivity reactions for people using topical ketoprofen. Issued in June 2009.

March to July 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

There are no major changes to the recommendations.

October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006.

July 2006 — minor update to drug rationales. Issued in July 2006.

October 2005 — minor technical update. Issued in November 2005.

July 2005 — update to text discussing nonsteroidal anti-inflammatory drugs (NSAIDs) in the Medicines management and Prescribing points sections. Issued in July 2005.

January 2005 — reviewed. Validated in March 2005 and issued in April 2005.

September 2001 — rewritten, with previous guidance on different types of sprains consolidated into one guidance on sprains in general. Validated in November 2001 and issued in April 2002.

June 1998 — written.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2012.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2012.

Systematic reviews and meta-analyses

No new systematic reviews since 1 September 2012.

Primary evidence

No new randomized controlled trials published in the major journals since 1 September 2012.

New policies

No new national policies or guidelines since 1 September 2012.

New safety alerts

No new safety alerts since 1 September 2012.

Changes in product availability

No changes in product availability since 1 September 2012.

Goals and outcome measures

Goals

To ease pain, reduce swelling, and allow the person to return to their pre-injury level of function in the shortest possible time

To minimize the need for drug therapy

To refer promptly people who need special assessment or treatment

QIPP - options for local implementation

QIPP - options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).

If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008].

Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008; NICE, 2009a; NICE, 2009b].

Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.

[NICE, 2013]

Background information

Definition

What is it?

A sprain is an injury to a ligament as a result of abnormal or excessive forces applied to a joint, but without dislocation or fracture [Pugh, 2000].

A grading of severity has been applied to ankle sprains [Struijs and Kerkhoffs, 2010]:

Grade I — mild stretching of the ligament complex without joint instability.

Grade II — partial rupture of the ligament complex without joint instability.

Grade III — complete rupture of the ligament complex with instability of the joint.

A muscle strain (or 'pull') is stretching or tearing of muscle fibres. Most muscle strains happen for one of two reasons: either the muscle has been stretched beyond its limits or it has been forced to contract too strongly.

Muscle strains are graded depending on the severity of muscle fibre damage [Jarvinen et al, 2000]:

First degree strain — this is a mild strain when only a few muscle fibres are stretched or torn. Although the injured muscle is tender and painful, it has normal strength (but power may be limited by pain).

Second degree strain — this is a moderate strain, with a greater number of injured fibres and more severe muscle pain and tenderness. There is also mild swelling, noticeable loss of strength, and sometimes a visible bruise.

Third degree strain — this strain tears the muscle all the way through, sometimes producing a 'pop' sensation as the muscle rips into two separate pieces or shears away from its tendon. There is a total loss of muscle function.

Prevalence

How common is it?

Sprains and strains are common, but CKS was unable to find specific UK incidence or prevalence data.

Prognosis

What is the prognosis?

If a person with an ankle sprain has an uncomplicated recovery, walking is usually possible within 1–2 weeks, with function restored after 6–8 weeks, and a return to sporting activities after 8–12 weeks (although time to recovery may depend upon the severity of the injury) [de Bie et al, 2006].

With ankle sprains, pain and intermittent swelling (particularly on the lateral side of the ankle) are the most common residual problems [Struijs and Kerkhoffs, 2010].

A systematic review of the clinical course of acute ankle sprains found that after 1 year of follow-up, a high percentage of people experienced pain and subjective instability. Up to a third of people reported at least one re-sprain within a 3-year time period [van Rijn et al, 2008].

CKS could find no information on the prognosis for people with strains or knee sprains.

Diagnosis

Diagnosis of sprains and strains

Diagnosis of a sprain

How do I know my patient has a sprain?

The ankle and knee are commonly affected.

The severity of symptoms and signs depends on the severity of the sprain (for example whether there has been a partial or complete ligament tear). Common symptoms and signs include:

Tenderness and swelling.

Bruising.

Functional loss (for example pain on weight-bearing).

Mechanical instability (if the sprain is severe).

Marked bruising and swelling may indicate a complete ligament tear or fracture. For more information on when further investigation is required, see X-rays of ankle or knee injuries in Scenario: Assessment.

Basis for recommendation

Basis for recommendation

This recommendation is based on guidelines from the New Zealand Guidelines Group, the Institute for Clinical Systems Improvement [NZGG, 2003; ICSI, 2006], and expert opinion in a review article [Wolfe et al, 2001].

Diagnosis of a muscle strain

How do I know my patient has a strain?

The clinical features of a muscle strain depend on the severity of the injury and the nature of the haematoma.

There may be a history of a strain or 'pulled muscle'.

Pain occurs in the affected muscle.

Large haematomas can occur as a result of tearing of the intramuscular blood vessels.

There may be obvious swelling, although small haematomas or those deep within the muscle are more difficult to diagnose clinically.

Muscle function may be affected, depending on the severity of the strain.

For more information on when further investigation is required, see X-rays of ankle or knee injuries in Scenario: Assessment.

Basis for recommendation

Basis for recommendation

This recommendation is based on expert opinion in a review article [Jarvinen et al, 2000].

Differential diagnosis

What else might it be?

Fracture:

Use the Ottawa ankle rules to assess the severity of damage to the ankle or foot and the likelihood of fracture.

The ankle assessment covers the ability to walk four steps immediately after the injury, and notes localised tenderness of the posterior edge or tip of either malleolus.

The mid-foot assessment covers the ability to walk and localised tenderness of the navicular or base of the fifth metatarsal.

The instrument is designed to rule out fractures of the malleolus and mid-foot.

Indicated by marked bruising, swelling, deformity, or bony tenderness, or the person is unable to bear weight. For more information on when X-rays are indicated for ankle or knee injuries (for example increased likelihood of fracture), see X-rays of ankle or knee injuries.

Tendon rupture:

Indicated by an inability to effect movement served by that tendon's muscle and/or a palpable gap in the tendon.

Cartilage injury:

Often affects the knee and involves a twisting injury with a tearing sensation, followed by severe pain. Mild to moderate swelling is expected within 24 hours. Swelling is often immediate for ligament strains inside the knee (most typically tears of the anterior cruciate ligament).

Basis for recommendation

Basis for recommendation

Fracture

The Ottawa ankle and knee rules are instruments for injury assessment developed in 1992 [Stiell et al, 1992; Stiell et al, 1997; Bachmann et al, 2003]

This information is based on a guideline from the Institute for Clinical Systems Improvement [ICSI, 2006].

Tendon rupture

This information is based on a guideline from the Royal Dutch Society for Physical Therapy [de Bie et al, 2006].

Cartilage injury

This information is based on expert opinion in a review article [Jackson et al, 2003].

Management

Management

Scenario: Assessment : covers the assessment of a sprain or strain (including when an X-ray is indicated), and the identification of complications.

Scenario: Management : covers the management of sprains and strains including advice, choice of analgesia, referral, and when to follow up.

Scenario: Assessment

Scenario: Assessment of sprains and strains

60months3060monthsBoth

Assessment

How should I assess a sprain or strain?

Assess the severity of the injury, including:

Pain, swelling, bruising, range of movement.

Ability to bear weight, balance, gait.

Treatment measures already tried.

Assess whether there are any complicating factors, including:

Presence of pain or bony tenderness elsewhere — may indicate a fracture. For more information on excluding fractures, see X-rays of ankle or knee injuries.

Deformity of a limb, or postural abnormality.

Damage to nerves or circulation.

Whether the person is taking medication (for example anticoagulants) which may affect the injury.

Any complicating illness (for example neuropathy, bleeding disorder, or history of deep vein thrombosis).

Possibility of abuse or domestic violence.

Basis for recommendation

Basis for recommendation

This recommendation on assessment is based on two guidelines on the management of ankle injuries [de Bie et al, 2006; ICSI, 2006] and a guideline on soft tissue knee injuries [NZGG, 2003]. Information from these guidelines was largely consistent, therefore it has been combined to offer a recommendation covering both ankle and knee sprains.

CKS could find no information on the assessment of strains, therefore recommendations have been extrapolated from those for sprains.

Complicating factors should be considered because [NZGG, 2003]:

Presence of pain elsewhere may indicate a fracture (for example ankle sprain with fracture of the proximal fibula).

Neuropathy or lack of sensitivity of the foot puts the person at increased risk of complications.

Bleeding disorders may contribute to increased swelling, or haemarthrosis.

X-rays of ankle or knee injuries

When is an X-ray of an ankle or knee injury indicated?

Immediate referral to an Emergency Department for an X-ray of the ankle following an acute ankle injury is recommended if the person has pain in the malleolar zone AND one of the following:

Inability to bear weight (walk four steps) immediately after the injury and when examined.

Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.

Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

Immediate referral to an Emergency Department for an X-ray of the foot is recommended if there is pain in the midfoot zone AND one of the following:

Inability to bear weight (walk four steps) immediately after the injury and when examined.

Bone tenderness at the base of the fifth metatarsal.

Bone tenderness of the navicular bone.

Immediate referral to an Emergency Department for a knee X-ray is recommended for people with an acute knee injury AND one or more of the following:

Age 55 years or more.

Tenderness at the head of the fibula.

Isolated tenderness of the patella.

Inability to flex the knee to 90 degrees.

Inability to bear weight (walk four steps) at the time of injury and when examined.

Use clinical judgement when managing people who are less than 18 years of age, intoxicated, pregnant, or those with multiple painful injuries, head injury, or diminished sensation due to neurological deficit.

Basis for recommendation

Basis for recommendation

The recommendation on when to X-ray the ankle or foot is based on the Ottawa Ankle Rules [Stiell et al, 1995a].

Use of these rules is also recommended in Canadian guidelines (which suggest the groups of people for whom clinical judgement should be used) [Alberta Medical Association, 2007] and Dutch guidelines on management of an acute ankle sprain [de Bie et al, 2006].

Evidence suggests that the Ottawa ankle rules are highly sensitive for identifying fractures and may reduce unnecessary radiography and waiting times [Bachmann et al, 2003; Perry and Stiell, 2006].

The recommendation on when to X-ray the knee is based on the Ottawa knee rule [Stiell et al, 1995b; Stiell et al, 1996].

This method of determining whether X-rays are required was also recommended in a New Zealand guideline for general practitioners on the diagnosis and management of acute knee injuries [Robb et al, 2007].

A US review of the evaluation of acute knee pain in primary care found that of five decision systems for deciding when to use plain films in suspected knee fracture, the Ottawa knee rules have the strongest supporting evidence [Jackson et al, 2003].

Evidence suggests that the Ottawa knee rules are highly sensitive for identifying fractures and may reduce unnecessary radiography and waiting times [Bachmann et al, 2004; Perry and Stiell, 2006].

Scenario: Management

Scenario: Management of sprains and strains

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Advice

How should I advise a person with a sprain or strain?

Advise the person to manage their injury using PRICE:

Protection — protect from further injury (for example by using a support or high-top, lace-up shoes).

Rest — avoid activity for the first 48–72 hours following injury and consider the use of crutches.

Ice — apply ice wrapped in a damp towel for 15–20 minutes every 2–3 hours during the day for the first 48–72 hours following the injury. Do not leave ice on while asleep.

Compression — with a simple elastic bandage or elasticated tubular bandage, which should be snug, but not tight. Remove before going to sleep.

Elevation — advise the person to rest with their leg elevated and supported on a pillow until the swelling is controlled, and to avoid prolonged periods with the leg not elevated.

Advise the person to avoid HARM in the first 72 hours after the injury:

Heat (for example hot baths, saunas, heat packs).

Alcohol (increases bleeding and swelling and decreases healing).

Running (or any other form of exercise which may cause further damage).non

Massage (may increase bleeding and swelling).

Use analgesia if necessary.

For sprains:

The Ottawa ankle rules are a ubiquitous instrument of assessment.

For severe sprains, a short period of immobilization can result in quicker recovery.

For less sever sprains, it is advisable not to immobilize the joint. Begin flexibility (range of motion) exercises as soon as they can be tolerated without excessive pain.

For strains:

Immobilize the injured muscle for the first few days after the injury. Consider the use of crutches in severe injuries.

Start active mobilization after a few days if the person has pain-free use of the muscle in basic movements and the injured muscle can stretch as much as the healthy contralateral muscle.

Basis for recommendation

Basis for recommendation

PRICE measures

The recommendation on the use of protection, rest, ice, compression, and elevation (PRICE) was based on New Zealand guidelines on the diagnosis and management of soft tissue knee injuries [NZGG, 2003], a US guideline on ankle sprains [ICSI, 2006], and a review of the literature on the management of strains [Jarvinen et al, 2000]. Since there was considerable agreement between recommendations in both guidelines, CKS has used these sources to make general recommendations for the management of a sprain or strain.

The use of protection was suggested in guidelines on ankle sprains [ICSI, 2006]; CKS has extrapolated this to also include knee sprains and muscle strains, as it seems pragmatic advice.

The New Zealand guideline discusses the lack of evidence in the literature to support the use of RICE measures, but describes them as 'commonly accepted practice' for the management of a mild soft tissue knee injury [NZGG, 2003].

For strains, RICE measures are recommended to minimize bleeding from ruptured blood vessels and prevent a large haematoma forming, which will minimize the amount of scar tissue formation [Jarvinen et al, 2000]. The lack of recent literature on the management of strains has necessitated CKS to extrapolate information on how to carry out PRICE from a review of the management of ankle sprains [ICSI, 2006] and a guideline on the management of soft tissue knee injuries [NZGG, 2003].

Avoiding HARM

The recommendation on HARM was based on New Zealand guidelines on the diagnosis and management of soft tissue knee injuries [NZGG, 2003]. This has been extrapolated by CKS to also cover ankle sprains and muscle strains.

Mobilization:

For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in quicker recovery than tubular compression bandaging alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape [Seah and Mani-Babu, 2011].

For sprains, the recommendation not to immobilize the affected joint is from an article on the management of ankle sprains [Wolfe et al, 2001]. It is thought that functional stress stimulates collagen replacement [Wolfe et al, 2001].

For strains, the optimal length of immobilization depends on the grade of the injury and should allow the scar to bear the pulling forces without re-rupture. If mobilization occurs immediately after the strain injury, re-ruptures can occur at the original injury site. Short immobilization allows granulation tissue to gain enough strength to withstand the forces caused by the contracting muscle. However, longer term immobilization can cause healthy myofibres to atrophy, and reduces the muscle's tensile strength. Active mobilization after a few days provides a better outcome [Jarvinen et al, 2000].

Choice of analgesia

Which analgesic should I prescribe?

Prescribe paracetamol, or a topical nonsteroidal anti-inflammatory drug (NSAID).

Codeine can be used as an 'add on' to paracetamol, if required.

Consider prescribing an oral NSAID (for example ibuprofen) 48 hours after the initial injury.

Basis for recommendation

Basis for recommendation

Oral analgesia:

CKS could find no good quality evidence that oral NSAIDs or paracetamol are effective for treating pain associated with sprains and strains. However guidelines recommend taking paracetamol or NSAIDs as adjunctive treatment to PRICE measures for the acute management of sprains and strains [ICSI, 2006].

Oral NSAIDs:

Oral NSAIDs should not be used in the first 48 hours after the initial injury because of concerns that they may delay healing. Feedback from our expert reviewers recommended that the use of oral NSAIDs should be delayed until 48 hours after the initial injury [Orchard et al, 2008]. Early use of NSAIDs coincides with muscle repair, regeneration, and growth. Inflammation is a necessary part of the healing process, therefore decreasing inflammation may impair the healing process [Braund and Haxby Abbot, 2007]. CKS could find no published randomized controlled trials assessing the effect of oral NSAIDs on delaying the healing process. Additional research is needed to define any effect of oral NSAIDs on healing rate [Stovitz and Johnson, 2003].

There is no published evidence that NSAIDs facilitate a more rapid restoration of function [McGriff-Lee, 2003].

Ibuprofen is the recommended NSAID, as it has the lowest risk of adverse effects [CSM, 1994; Henry et al, 1996; CSM, 2002].

Topical NSAIDs:

Evidence suggests that topical NSAIDs are effective for treating the pain associated with sprains and strains.

Referral

When should I refer a sprain or strain?

Immediately refer to an Emergency department if any of the following are suspected:

Fracture (see X-rays of ankle or knee injuries).

Dislocation.

Damage to nerves or circulation.

Tendon rupture.

Wound penetrating the joint.

Known bleeding disorder.

Signs of septic arthritis (for example fever, joint swollen and warm to the touch) or haemarthrosis (for example very painful and tender joint swelling immediately after injury).

Large intramuscular haematoma.

Complete tear, or tear of more than half the muscle belly.

Refer to an orthopaedic specialist if there is:

Locking of the joint.

Diagnostic uncertainty.

Recovery that is slower than expected.

Symptoms out of proportion to the degree of trauma.

Urgency of referral will depend on the severity of the injury and the clinical expertise of the primary care professional.

Routine referral for physiotherapy is not recommended for sprains of the ankle or knee.

Consider referral for physiotherapy for strain injuries.

Basis for recommendation

Basis for recommendation

The recommendation on when to refer combines information from a US article on the management of ankle sprains [Wolfe et al, 2001], New Zealand guidelines on the diagnosis and management of soft tissue knee injuries [NZGG, 2003], and a review of the literature on muscle strain injuries [Jarvinen et al, 2000]. In an emergency, CKS has recommended referral to Accident and Emergency (rather than directly to an orthopaedic specialist) if serious complications are suspected, as this is common practice in the UK.

A summary of the New Zealand guideline on the diagnosis and management of soft tissue knee injuries found no evidence relating to the appropriateness and timing of referral to specialists for people with knee injuries, but suggested that the need for referral will be influenced by the nature and extent of injury as well as the practitioner's training and experience [Robb et al, 2007].

A review of the use of physiotherapy in acute lateral ligament sprains of the ankle [Shaw, 2005] found six RCTs and one systematic review. There were methodological limitations to a number of the trials and a lack of evidence of the effectiveness of passive manipulation, ultrasound, short-wave diathermy, or exercise regimens. The review authors commented that on the basis of this evidence, active physiotherapy offers no additional benefit to home mobilization with simple instructions.

CKS could find no evidence specifically relating to the use of physiotherapy for other sprain injuries therefore CKS has extrapolated this to also apply to sprains of the knee.

CKS has not recommended referral of all muscle strains, because conservative management will result in a good outcome in most cases [Jarvinen et al, 2000]. However, expert feedback suggests that appropriate rehabilitation reduces the likelihood of restrain and residual symptoms so referral to physiotherapy may be justified.

Follow up

How should I follow up a sprain or strain?

Advise a person with a sprain or strain to seek further 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).

Concern regarding the nature and extent of the injury.

Consider reviewing a strain after a few days to assess muscle contractile function, depending on the severity of the injury.

Basis for recommendation

Basis for recommendation

The recommendation on follow up of sprains is based on a US guideline from the Institute for Clinical Systems Improvement on ankle sprains [ICSI, 2006]. Advice has been extrapolated from this to also cover knee sprains as CKS found no guidelines or evidence relating specifically to the follow up of knee injuries.

The recommendation to review a strain to assess muscle contractile function is based on a review of muscle strain injuries [Jarvinen et al, 2000].

CKS was unable to find further information regarding the follow up of strains, so has made pragmatic recommendations for what advice to give regarding seeking further medical advice based on those for the follow up of sprains.

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Codeine

What issues should I be aware of before prescribing codeine?

Codeine has the potential to cause gastrointestinal problems (for example constipation), and central nervous system toxicity (for example sedation) [BNF 64, 2012]. People should be warned to avoid activities where drowsiness may be detrimental.

Oral NSAIDs

What issues should I be aware of before prescribing an oral NSAID?

For a detailed discussion on the contraindications, adverse effects, monitoring issues, and interactions of nonsteroidal anti-inflammatory drugs (NSAIDs), see the CKS topic on NSAIDs - prescribing issues, as this is beyond the scope of this CKS topic.

Do not use ibuprofen in:

People with a history of hypersensitivity to NSAIDs (for example bronchospasm, asthma, rhinitis, or urticaria known to have been precipitated by an NSAID).

People with peptic ulcers or who are at high risk of gastrointestinal bleeding or ulceration.

People taking ciclosporin, lithium, methotrexate, or other NSAIDs.

If possible, avoid ibuprofen in:

People with hypertension, heart failure, or renal impairment. Ibuprofen can worsen or precipitate these conditions.

Pregnant (particularly in the third trimester) or breastfeeding women.

People taking antihypertensives, digoxin, oral corticosteroids, or warfarin.

Topical NSAIDs

What issues should I be aware of before prescribing topical NSAIDs?

Topical non steroidal anti-inflammatory drugs (NSAIDs) may result in systemic effects. Skin reactions, hypersensitivity, and asthma may occur [BNF 64, 2012].

Topical ketoprofen has been associated with a risk of photosensitivity reactions [MHRA, 2010].

Advise people using topical ketoprofen to keep the area treated with topical ketoprofen protected from sunlight during the treatment period, and for 2 weeks afterwards. They should also carefully wash their hands after every application.

Topical piroxicam — there have been reports of interstitial nephritis, nephrotic syndrome, and renal failure. However a causal relationship has not been established [ABPI Medicines Compendium, 2014].

Compression bandages

What issues should I be aware of before prescribing compression bandages?

Crepe, cotton crepe, and cotton, polyamide, and elastane bandaging all provide support without exerting undue pressure.

Elasticated tubular bandaging may be more convenient for people to use. This can be prescribed, but is also available over-the-counter.

A range of other products are marketed as providing additional comfort, support, and compression. These are not available on an FP10 prescription, but are available over-the-counter.

Evidence

Evidence

Supporting evidence

The 'PRICE' approach to management

Evidence on the 'PRICE' approach to management

CKS could find no clinical trials that assessed the efficacy of protection, rest, ice, compression, and elevation (PRICE), however PRICE is a commonly accepted practice for managing sprains and strains [Jarvinen et al, 2000; NZGG, 2003; ICSI, 2006].

Using the Ottawa rules

Evidence on using the Ottawa rules

The Ottawa ankle and knee rules are able to accurately exclude fractures in adults who present with a knee injury. Their application may lead to a reduction in the use of radiography and the time spent in Emergency departments.

A systematic review of six trials (n = 4249) analysed the evidence to support the use of the Ottawa knee rules [Bachmann et al, 2004].

The mean sensitivity of the Ottawa knee rules for identifying a fracture was found to be 98.5% (95% CI 93 to 100). The mean specificity was 49% (95% CI 43 to 51). For adults, assuming a fracture prevalence of 7%, the probability of fracture after a negative test result was 0.37% (95% CI 0.15 to 1.48).

One study found that for children, sensitivity was 92% (95% CI 64 to 100) and specificity 50% (95% CI 42 to 56), with a probability of fracture after a negative test result of 2% (95% CI 0.3 to 12). The authors of the review concluded that, for paediatric care, there is insufficient evidence to advise on clinical practice.

A systematic review included 27 studies (n = 15,581) in a meta-analysis to assess the accuracy of the Ottawa ankle rules [Bachmann et al, 2003].

The sensitivity of the Ottawa ankle rules for identifying a fracture ranged from 96.4–99.6%. Specificity ranged from 26.3–47.9%. The post-test probability of fracture varied according to the prevalence of fracture. Overall, less than 2% of people in most subgroups were found to have a fracture after a negative Ottawa result.

In studies assessing the Ottawa ankle rules in children, there was a 1.2% chance of a fracture after a negative Ottawa result.

A review of the impact of the Ottawa ankle and knee rules on clinical care of traumatic injuries was carried out [Perry and Stiell, 2006].

Two studies demonstrated a relative reduction in radiography rates of around 25% where the Ottawa ankle rules were used, and a reduction in time spent in the Emergency department of around half an hour. One of the studies reported no missed fractures using the Ottawa rules.

A separate study of the use of the Ottawa knee rules found a similar reduction in radiography rates and time spent in the Emergency department with no missed fractures.

Economic analyses discussed in the review concluded that both the Ottawa ankle rules and Ottawa knee rules are cost effective.

Efficacy of oral analgesics

Evidence on efficacy of oral analgesics

No good quality trials have been published that have compared oral nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol with placebo for sprains and strains. However it is common practice to use paracetamol or oral NSAIDs as adjunctive treatment to protection, rest, immobilization, compression, and elevation (PRICE) in the acute management of sprains and strains [ICSI, 2006]. CKS found evidence that paracetamol is as effective as oral NSAIDs.

NSAIDs compared with placebo:

One systematic review (search date: 1993) identified seven randomized controlled trials (RCTs) that compared oral NSAIDs with placebo in people with soft tissue injuries of the ankle. The trials identified were of poor quality and the authors were unable to pool data, however they concluded that oral NSAIDs were associated with less pain [Ogilvie-Harris and Gilbart, 1995].

Paracetamol compared with oral NSAIDs:

A systematic review (search date: December 2006) identified two randomized controlled trials (RCTs) that compared paracetamol with oral NSAIDs in people with sprains or strains. These RCTS found evidence that paracetamol was as effective as an oral NSAID for treating pain associated with sprains and strains.

The first RCT (n = 300) randomized people with painful limb injuries to take paracetamol 4 g, diclofenac 75 mg, indometacin 75 mg, or paracetamol 4 g plus diclofenac 75 mg, daily for a period of 3 days. There was no significant or clinically relevant difference in pain reduction between the four groups (on a 100 mm visual analogue scale) [Woo et al, 2005].

The second RCT (n = 260) randomized people with lateral ankle sprains to take either paracetamol 3.9 g, or ibuprofen 1200 mg, daily for 9 days. There was no significant difference in pain reduction on walking between the groups after 4 and 9 days (on a 100 mm visual analogue scale [0 = no pain; 100 = very severe pain]; day 4 mean change from baseline: –37 with paracetamol vs. –35 with ibuprofen; p = 0.24; day 9 mean change from baseline: –56 with paracetamol vs. –57 with ibuprofen; p = 0.73) [Dalton and Schweinle, 2006].

Topical NSAIDs

Evidence on topical NSAIDs

CKS found evidence to suggest that topical nonsteroidal anti-inflammatory drugs (NSAIDs) were effective for treating pain associated with sprains and strains.

One meta-analysis (search date: April 2003) identified 36 randomized controlled trials (RCTs) that assessed the efficacy of topical NSAIDs for pain associated with sprains and strains [Mason et al, 2004]. The trials were often small, the outcomes measured were not consistent, and there was clinical heterogeneity. Different preparations were used, with different application schedules, different concentrations of active agent, and different formulations. The authors also stated that there may have been selective publication of trials showing topical NSAIDs to be effective, and suppression of trials where there was no difference between topical NSAID and placebo.

The outcome analysed in the meta-analysis was 50% pain reduction after 1 week of treatment. Topical NSAIDs studied included felbinac, ibuprofen, indometacin, and ketoprofen. The main results were:

Topical NSAIDs compared with placebo:

Pooled data from 26 RCTs (n = 2853) suggest a relative benefit of 1.6 (95% CI 1.4 to 1.7). The results from this pooled data suggest that you need to treat 3.8 people with a topical NSAID for 1 week for one person to achieve a 50% pain reduction (NNT = 3.8 [95% CI 3.4 to 4.40]). The p-value was not reported.

Topical NSAIDs compared with oral NSAIDs:

Pooled data from three RCTs (n = 433) suggest that the rates of treatment success were similar for topical NSAIDs (57%) and oral NSAIDs (62%), with no statistically significant difference (relative benefit 0.9; 95% CI 0.8 to 1.1). The p-value was not reported.

Topical NSAIDs compared with each other:

Different NSAIDs had different efficacy, with ketoprofen being significantly better than all others in an indirect comparison, while indometacin was barely distinguished from placebo.

Pooled data from three RCTs (n = 716) which directly compared topical piroxicam with topical indometacin showed improvement in 52% of people using piroxicam and 39% on indometacin. The relative benefit was 1.3 (95% CI 1.1 to 1.5).

Harms:

Local adverse events, systemic adverse events, or withdrawals due to an adverse event were rare, and there was no difference between topical NSAIDs and placebo.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of sprains and strains.

Search dates

July 2008 - September 2012

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp "Sprains and Strains"/, exp Ankle Injuries/, exp Collateral Ligaments/, exp Ankle/, (ankle OR ankle joint OR sports OR athletic injuries OR sports medicine OR knee injuries OR athlete).tw., exp Ankle Joint/, exp Shoulder/, exp Elbow/, exp Wrist Injuries/, exp Wrist/, exp Wrist Joint/, exp Rotator Cuff/

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

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