History and exam

Key diagnostic factors

common

acute onset of symptoms

Can suggest sprain or strain.

mechanism of injury

The time, circumstances, and kind of trauma experienced, including its force and direction.

Eccentric exercise is likely to cause injury at musculotendinous junction. This type of exercise is associated with forcible lengthening of the contracting muscle (e.g., when lowering a weight).

severe pain

Pain that seems out of proportion to the injury and its mechanism can indicate grade 3 injury or complete rupture.

swelling

The amount depends partly on severity and partly on the time since the injury, as it can take up to 24 hours for the full extent of swelling to become apparent.

bruising

Muscle strain often results in a large hematoma.

In an intramuscular hematoma, bleeding is contained within the muscle sheath, resulting in pain and localized swelling. In an extramuscular hematoma, bleeding spreads through the intermuscular spaces; pain is less than that due to an intramuscular hematoma, and swelling is more diffuse.

palpable gap in normal position for Achilles tendon (Achilles tendon rupture)

May be detected in patients with Achilles tendon rupture.[26]

positive calf squeeze test (Achilles tendon rupture)

Also called Thompson/Simmonds test.

Clinical test with the highest sensitivity and specificity for Achilles tendon rupture. Performed by asking the patient to lie prone with his/her feet over the end of the examination couch. The examiner squeezes the patient’s calf, just distal to the thickest point. With an intact Achilles tendon, the foot should plantar flex. With a ruptured Achilles tendon, the foot may plantar flex a little (due to an intact plantaris) but should not plantar flex as much as the foot on the uninjured side.[26]

positive Matles test (Achilles tendon rupture)

To perform this test, the patient is asked to lie prone with his/her knees flexed to 90 degrees. In the presence of an Achilles tendon rupture, the foot on the injured side should assume a position that is more dorsiflexed than that of the uninjured side.[26]

positive biceps squeeze test (biceps tendon rupture)

Assesses intactness of the biceps tendon.[36]

positive Hook test (biceps tendon rupture)

A positive test is strongly suggestive for complete biceps tendon avulsion.

The patient actively supinates the arm with the elbow flexed to 90 degrees. The examiner then attempts to hook his/her index finger under the biceps tendon from the lateral side. This should be possible with an intact biceps tendon. However, with a distal avulsion of the biceps tendon, the examiner should not be able to feel a cord-like structure and therefore is unable to hook a finger under it.[27]

uncommon

pop sound

History of pop sound can suggest grade 3 strain.

deformity

More common with fractures than with sprain or strain.

Other diagnostic factors

common

previous injury

History of multiple minor injuries can point toward severe muscle sprain as opposed to fracture.

symptom duration more than a few days

Can suggest more severe grades of injury.

limited range of motion (ROM)

Limitation of ROM is more common in the acute phase. Failure to gain motion despite improvement in pain and swelling can suggest grade 3 strain.

weakness

More common in acute phase, due to painful inhibition of contraction.

Risk factors

strong

type of sports (basketball, ice skating, soccer, contact sports)

Incidence of ankle injury and ankle sprain may be higher in court games and team sports.[9]

Reported prevalence of ankle injury is highest in basketball, ice skating, and soccer.[18]

Contact sports may increase the risk of contusion.

anatomic variation

Anatomic variation of the foot, such as flatfoot or generalized joint laxity, may affect the risk of ankle injury.[19]

Limited ankle dorsiflexion in children may increase the risk of ankle injury.[20]

eccentric exercise

This type of exercise is associated with forcible lengthening of the contracting muscle (e.g., when lowering a weight).

Forces generated within eccentrically activated muscle are higher than in a concentrically activated muscle, thus increasing susceptibility to injury.[14]

pennate muscle architecture and type II muscle fibers (fast twitch)

More pennate muscles (muscles with a central tendon onto which the muscle fibers converge) were found to have a greater percentage of elongation before failure than less pennate muscle. Type II muscle fibers (fast twitch) are more commonly injured.[21][22]

muscle-tendon units that span 2 joints

Muscles such as the rectus femoris, semitendinosus, and gastrocnemius muscles are more commonly injured.[23][24]

weak

previous history of ankle sprain

A history of previous ankle sprain has been cited as a common risk factor in a prospective study of recreational basketball.[25]

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