Approach
The main goals of the treatment are to relieve pain, maintain range of motion (ROM), maintain strength, return to preinjury activities or level, and prevent recurrence of injury.
General steps in management include:
Initiation of short-term treatment with RICE (rest, ice, compression, elevation).
Treatment with analgesics, if pain needs additional measures.
An oral nonsteroidal anti-inflammatory drug (NSAID) may be considered if rapid return to work or competitive sports is important.
Early mobilization, typically starting after 2 to 3 days of rest.
Advice on prognosis. Recovery to usual function at work and sports depends on the site and severity of the injury, as well as on levels of activity (e.g., with a severe sprained ankle: return to work can take a few weeks; full, active participation in sports can take several months).
Patients with a severe sprain or strain should be followed up when the swelling has largely subsided (after about 7-10 days) to assess for complete rupture and determine whether referral for further investigation and treatment is indicated.
Open, limited open, and percutaneous techniques are options for treating patients with acute Achilles tendon rupture.[41] There is inconclusive evidence for the use of grafting or biological adjuncts.
General approach to strains and sprains
Those presenting within the first 24 to 48 hours after injury with clinical features suggestive of incomplete rupture (grade 1: minimal loss of function, pain and swelling, no difficulty bearing weight, some bruising present; grade 2: some loss of function, moderate pain and swelling, usually difficulty bearing weight) should be treated with RICE followed by gentle mobilization. Analgesia in the form of acetaminophen or NSAIDs may be used adjunctively as required.
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Physical therapy may be started after 48 hours.
Patients should be reviewed after 1 week to assess for improvement. Those with worse pain 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. Surgical repair followed by rehabilitation with physical therapy is required for grade 3 rupture.
Strains presenting within the first 24 to 48 hours with confirmed complete rupture (grade 3) should undergo surgical repair followed by rehabilitation with physical therapy. Features suggestive of grade 3 rupture include severe bruising; lack of concordance between pain level and history of injury; severe functional limitation, for example inability to walk; severe local tenderness and x-ray showing no fracture; and significant swelling and pain. Ninety percent of patients with grade 3 rupture present in this way.
Rest, ice, compression, elevation (RICE)
Should be started as soon as possible.
Rest
Avoids pain from movement.
The affected part should be stabilized, protected, and rested for up to 48 hours after injury, depending on pain.
Complete immobilization (e.g., by a cast) is not indicated for sprains and strains treated in primary care.
Air-stirrup combined with elastic wrap is recommended for grade 1 and 2.[42][43] Even in grade 3 injury, functional splinting is strongly suggested over cast immobilization.[44]
Ice (i.e., cryotherapy)
Reduces pain.
The affected part should be immersed in ice water for up to 10 minutes, or a malleable ice pack (e.g., bag of frozen peas) should be applied for 10 to 30 minutes. Cold injury should be avoided, and the affected part should be allowed to warm up before the procedure is repeated, which may be as frequently as desired for 48 hours: for example, every 2 hours while the patient is awake.
Compression
Provides comfort by limiting movement and may restrict development of swelling.
Should be applied with care to avoid constricting blood flow. If tissues distal to the compression become blue or painful, the compression should be loosened and reapplied with less tension.
Should be used with caution if peripheral arterial disease is present or suspected (e.g., in older people, or people with diabetes).
Elevation
Helps to control swelling.
The injured part should be elevated above the level of the heart, if practical.
Medications: acetaminophen and/or NSAIDs
Acetaminophen 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 acetaminophen.[45]
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Topical NSAIDs have a more favorable benefit-harm ratio.[46][47]
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A Cochrane review evaluating the treatment of acute soft tissue injuries in adults <65 years found that, compared with acetaminophen, oral NSAIDs make no difference to pain at 1-2 hours and at 2-3 days, and may make no difference at day 7 or beyond.[45]
When thinking about prescribing an NSAID for musculoskeletal sprains and strains, note that:
NSAIDs may reduce the time sprains and strains take to heal.
NSAID prescription may be considered for people who need to return as soon as possible to full function at work or competitive sports.
Ibuprofen is recommended as the first choice oral NSAID; it has the lowest risk of adverse effects.
Gastroprotection (a proton-pump inhibitor or misoprostol) may be given to people at high risk of NSAID GI adverse effects, such as stomach upset, or upper GI bleeding in patients with a history of stomach ulcer or bleeding.
A combination of acetaminophen and NSAIDs can be used, but a combination of 2 NSAIDs is contraindicated.
Early mobilization
Mobilization as pain allows helps to prevent stiffness and maintain ROM. In the case of ankle sprain, using an external support with early mobilization may be beneficial.
Short-wave diathermy
Commonly used, but there is little evidence to promote its use to improve swelling, pain, and ROM.
Surgery
With complete rupture, or in patients who have persistent functional deficit with incomplete rupture, surgery may be required. However, studies comparing surgical repair with nonsurgical treatment have reported no difference in functional outcome; therefore, nonsurgical treatment has been increasingly preferred.[48][49][40] In one RCT of patients managed nonsurgically for Achilles tendon rupture, plaster casting was not found to be superior to early weight-bearing in a functional brace.[50]
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.[40]
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.
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