Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Sprains
Sprains
John H. Wilckens MD
BasicsDescription
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Sprains refer to damaged ligaments, and they are the result of overstretching of the tissues.
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Injuries to the ligamentous structures of
movable joints are among the most common complaints seen in primary
care medicine, as well as in the subspecialty areas of orthopaedic
surgery. -
Sprains can occur in any movable joint.
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Classification: 3 grades are recognized (1):
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Grade I: Interstitial injury with no disruption of fiber continuity
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Grade II: Partial tear of the ligament
with mild laxity but no instability of the involved joint; preservation
of the ligament’s continuity -
Grade III: Complete tear of injured ligament
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Synonym: Ligament injury
General Prevention
Proper warm-up exercise is indicated before a workout or before participating in sports.
Epidemiology
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No age-related factors.
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Both genders are affected equally.
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Sprains are common.
Risk Factors
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“Weekend” athletes
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Running, throwing, or jumping sports
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Inadequate warm-up exercises
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Anabolic steroids (2)
Etiology
Abrupt, overstretching of the ligament from an
externally applied force or a force generated by the periarticular
muscles can lead to various degrees of ligamentous injuries.
externally applied force or a force generated by the periarticular
muscles can lead to various degrees of ligamentous injuries.
DiagnosisSigns and Symptoms
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Pain or swelling occurs in minor sprains.
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Patients with incomplete ligament tears may have mildly increased laxity on stress examination.
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Ecchymosis over the involved area or gross instability of the joint can be seen in cases of ligament disruption.
Physical Exam
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Ecchymosis or tenderness over the area of the ligament strongly suggests the diagnosis.
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Tenderness over the ligament occurs during testing for stability (stretching of the injured ligament).
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Gross instability of the involved joint is diagnostic.
Tests
Lab
No laboratory tests aid in the diagnosis.
Imaging
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Radiography:
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Stress radiographs may show grade II and grade III injuries.
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Obtain plain films to rule out associated fractures or dislocation.
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MRI is best for assessing soft-tissues injuries, but not always necessary.
Pathological Findings
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Grade I: Grossly intact ligament, but hemorrhages and tearing (seen microscopically) in small areas within the ligament
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Grade II: Partial ligament injury with increased joint laxity
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Grade III: Complete ligament disruption
Differential Diagnosis
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Muscle strain
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Contusion
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Fracture
TreatmentGeneral Measures
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Initial treatments consist of the RICE protocol.
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Ice minimizes swelling through local vasoconstrictive effects, dulls pain receptors, and decreases spasm.
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Compression and elevation further limit soft-tissue swelling.
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Grade I and grade II injuries:
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Treat with initial immobilization and gradual, pain-free physical therapy to preserve ROM and to avoid disuse atrophy.
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Normal activity can be resumed gradually once the pain and swelling subside.
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Grade III injuries require longer immobilization to allow the ligament to heal, especially in nonoperative cases (3).
Special Therapy
Physical Therapy
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Ice
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Contrast treatment with hot and cold compresses
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Massage
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Ultrasound
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Pain-free, protected, ROM exercises
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Muscle strengthening
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Proprioception training (4)
Surgery
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Most ligament injuries heal without surgical intervention.
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Rupture of the ACL represents the notable exception and usually requires surgical reconstruction.
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Repairs may be done by direct suture of the torn ligament.
P.419
Follow-upPrognosis
Prognosis generally is excellent with nonoperative treatment in most patients with ankle and knee collateral ligament injuries.
Complications
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Joint instability
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Chronic pain
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Stiffness
Patient Monitoring
Patients are followed at 2–3-week intervals to assess ROM.
References
1. Davis PF, Trevino SG. Ankle injuries. In: Baxter DE, ed. The Foot and Ankle in Sport. St. Louis: Mosby-Year Book, 1995:147–169.
2. Freeman BJC, Rooker GD. Spontaneous rupture of the anterior cruciate ligament after anabolic steroids. Br J Sports Med 1995;29:274–275.
3. Frey C. Ankle sprains. Instr Course Lect 2001;50: 515–520.
4. Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res 2002;402:76–94.
MiscellaneousCodes
ICD9-CM
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845.00 Ankle sprain
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848.9 Sprain/strain, site unspecified
Patient Teaching
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Outline the treatment plan clearly.
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Patient compliance is important in achieving a good outcome.
Prevention
Proper warm-up exercise is indicated before a workout or before participating in sports.
FAQ
Q: When can a patient with a grade I ankle sprain safely return to activity?
A:
Patients with minor ankle sprains can return to activity when the ankle
achieves full ROM, good muscle strength, and minimal pain. Until a
patient has complete return of strength and proprioception, an ankle
splint should be worn during activities to prevent reinjury.
Patients with minor ankle sprains can return to activity when the ankle
achieves full ROM, good muscle strength, and minimal pain. Until a
patient has complete return of strength and proprioception, an ankle
splint should be worn during activities to prevent reinjury.