Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected

1st line – rest, ice, compression, and elevation followed by gentle mobilisation

Back
ACUTE
|
presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected
1st line – 

rest, ice, compression, and elevation followed by gentle mobilisation

Rest: protection of area assisted with, for example, semi-rigid boot or taping in gastrocnemius complex strain or use of crutches in groin strain for 48 hours.

Ice: helps to reduce swelling, improves outcome.

Compression and elevation in addition will help to reduce swelling. Compression should be applied with care to avoid constricting blood flow. Caution is required when using compression in people with, or suspected to have, peripheral arterial disease (e.g., older people or people with diabetes). If tissues distal to the compression become blue or painful, the compression should be loosened and reapplied with less tension.

The injured joint or area should be rested for 2 to 3 days.

Mobilisation can be started after 48 to 72 hours in accordance with patient's pain.

The patient should be reviewed in 1 week either by telephone or in clinic/surgery.

Consider – analgesia

Back
ACUTE
|
presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Paracetamol taken regularly is effective for pain relief and is the first choice in minor injuries. NSAIDs also provide effective pain relief, but the risk of gastrointestinal adverse effects associated with oral NSAIDs may be greater than with paracetamol.[41] [ Cochrane Clinical Answers logo ] NSAIDs may reduce the time sprains and strains take to heal.[48] NSAID prescription may be considered if rapid return to work or competitive sports is important. Ibuprofen is recommended as the first choice for an oral NSAID; it has the lowest risk of adverse effects.

Indometacin is useful for treatment of inflammation, but there is no evidence for its use in muscle strains.

In ligament sprains, piroxicam has been demonstrated to be of benefit.[48]

A combination of paracetamol and NSAID can be used, but a combination of 2 NSAIDs is contra-indicated.

Gastroprotection (a proton-pump inhibitor or misoprostol) may be given to people at high risk of NSAID gastrointestinal adverse effects, such as stomach upset, or upper gastrointestinal bleeding in patients with a history of stomach ulcer or bleeding.

Typically, 7 days of treatment should be satisfactory, although these medicines may be used on an "as required" basis thereafter.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

Tertiary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

piroxicam: 20 mg orally once daily when required

OR

indometacin: 25-50 mg orally three times daily when required

Consider – physiotherapy

Back
ACUTE
|
presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

Physiotherapy may be started after 48 hours and should take the form of a graded programme extending over 4 to 6 weeks.

In muscle strains, the programme consists of isometric, isotonic, then isokinetic exercises.

There is little evidence that ultrasound has any significant benefit in terms of symptom relief and it is therefore no longer recommended.

Short-wave diathermy is commonly used, but there is little evidence to promote its use to improve swelling, pain, and ROM.

In ligament sprains, physiotherapy would start with restoring motion and strength followed by endurance training. Patients should use semi-rigid supports when necessary, as in ankle sprains and wrist sprains, between sessions of physiotherapy.

presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)

1st line – physiotherapy or surgical repair

Back
ACUTE
|
presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)
1st line – 

physiotherapy or surgical repair

Features suggestive of grade 3 rupture in strains and sprains include the following: severe bruising; lack of concordance between pain level and history of injury; severe functional limitation, e.g., inability to walk; severe local tenderness and x-ray showing no fracture; significant swelling and pain.

Ninety percent of patients with grade 3 rupture present in this way.

With complete rupture, or in patients who have persistent functional deficit with incomplete rupture, surgery may be required. However, studies comparing surgical repair with non-surgical treatment have reported no difference in functional outcome; therefore, non-surgical treatment has been increasingly preferred.[44][45][46] In one RCT of patients managed non-surgically for Achilles tendon rupture, plaster casting was not found to be superior to early weight-bearing in a functional brace.[47]

In high-demand sporting individuals, or in cases that do not respond to thorough and comprehensive exercise-based treatment, surgical repair can be considered on a case-by-case basis following discussion with the patient.[46] Surgical repair, if required, is usually done within 1 week. The authors do not recommend operating within 24 hours of injury, due to the detrimental effect of swelling on repair.

Physiotherapists should be involved in the rehabilitation process.

Consider – analgesia

Back
ACUTE
|
presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Paracetamol taken regularly is effective for pain relief and is the first choice in minor injuries. NSAIDs also provide effective pain relief, but the risk of gastrointestinal adverse effects associated with oral NSAIDs may be greater than with paracetamol.[41] [ Cochrane Clinical Answers logo ] NSAIDs may reduce the time sprains and strains take to heal.[48] NSAID prescription may be considered if rapid return to work or competitive sports is important. Ibuprofen is recommended as the first choice for an oral NSAID; it has the lowest risk of adverse effects.

Indometacin is useful for treatment of inflammation, but there is no evidence for its use in muscle strains.

In ligament sprains, piroxicam has been demonstrated to be of benefit.[48]

A combination of paracetamol and NSAID can be used, but a combination of 2 NSAIDs is contra-indicated.

Gastroprotection (a proton-pump inhibitor or misoprostol) may be given to people at high risk of NSAID gastrointestinal adverse effects, such as stomach upset, or upper gastrointestinal bleeding in patients with a history of stomach ulcer or bleeding.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

Tertiary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

piroxicam: 20 mg orally once daily when required

OR

indometacin: 25-50 mg orally three times daily when required

ONGOING

with worse pain and/or without functional improvement at 1-week review

1st line – further investigation + consideration of surgical referral

Back
ONGOING
|
with worse pain and/or without functional improvement at 1-week review
1st line – 

further investigation + consideration of surgical referral

Patients who were initially managed with non-surgical treatment should be reviewed after 1 week following injury, to assess for improvement.

Those with worse pain and/or without functional improvement at 1-week review may possibly have a grade 3 rupture. At this stage, further evaluation with ultrasound and/or MRI is indicated.

Features suggestive of grade 3 rupture in strains and sprains include the following: severe bruising; lack of concordance between pain level and history of injury; severe functional limitation, e.g., inability to walk; severe local tenderness and x-ray showing no fracture; significant swelling and pain.

Traditionally, surgical repair followed by rehabilitation with physiotherapy was advocated, but a series of randomised controlled trials has shown that functional therapy is the preferred treatment except in high-demand sporting individuals, or in cases that do not respond to thorough and comprehensive exercise-based treatment, where surgical repair can be considered on a case-by-case basis following discussion with the patient. [46][37]

Consider – analgesia

Back
ONGOING
|
with worse pain and/or without functional improvement at 1-week review
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Paracetamol taken regularly is effective for pain relief and is the first choice in minor injuries. NSAIDs also provide effective pain relief, but the risk of gastrointestinal adverse effects associated with oral NSAIDs may be greater than with paracetamol.[41] [ Cochrane Clinical Answers logo ] NSAIDs may reduce the time sprains and strains take to heal.[48] NSAID prescription may be considered if rapid return to work or competitive sports is important. Ibuprofen is recommended as the first choice for an oral NSAID; it has the lowest risk of adverse effects.

Indometacin is useful for treatment of inflammation, but there is no evidence for its use in muscle strains.

In ligament sprains, piroxicam has been demonstrated to be of benefit.[48]

A combination of paracetamol and NSAID can be used, but a combination of 2 NSAIDs is contra-indicated.

Gastroprotection (a proton-pump inhibitor or misoprostol) may be given to people at high risk of NSAID gastrointestinal adverse effects, such as stomach upset, or upper gastrointestinal bleeding in patients with a history of stomach ulcer or bleeding.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day

Tertiary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

piroxicam: 20 mg orally once daily when required

OR

indometacin: 25-50 mg orally three times daily when required

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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