Strains, Sprains, and Dislocations

CHAPTER 31

Strains, Sprains, and Dislocations

Muscle Strains

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• A strain is a tear of some or all of the fibers in a muscle.

• A strain is caused by a sudden, forceful change in the length of the muscle-tendon unit, most commonly an eccentric contraction against a significant load.

• Less frequently, strains result from a rapid or forceful stretch to a muscle or from repetitive overuse.

• Athletes who sprint, jump, leap, or kick are most susceptible to strain.

• Strains usually occur at the musculotendinous junction.

• Strains most commonly affect muscles in the lower extremity and those that cross 2 joints (ie, hamstrings, rectus femoris, gastrocnemius).

• The hamstrings are the most frequently strained muscle in the lower extremity; this can lead to significant disability.

SIGNS AND SYMPTOMS

• Acute-onset muscle pain during activity

• Some patients report a pop or tearing sensation.

• Weight bearing is usually painful.

• Physical examination reveals some or all of the following:

— Muscle tenderness

— Edema or ecchymosis

— Pain and weakness with contraction of the injured muscle

— Pain with passive stretch of the injured muscle

— Palpable defect in the muscle

DIFFERENTIAL DIAGNOSIS

• Apophyseal avulsion fracture

— Frequently mistaken for a muscle strain in the skeletally immature athlete

— If there is any bony tenderness or if pain is at the proximal or distal aspect of the muscle, rather than the midsubstance, radiographs should be obtained to rule out an avulsion fracture.

• Stress fracture

— A stress fracture may produce reactive edema in the adjacent muscle, mimicking a muscle strain.

DIAGNOSTIC CONSIDERATIONS

• The diagnosis is established clinically.

• Strains are graded into 3 categories (Table 31-1).

• Magnetic resonance imaging (MRI) may be performed to confirm location and degree of injury.

• Ultrasonography is an emerging imaging modality in the diagnosis of muscle injuries.

TREATMENT

• Initial treatment includes rest, ice, compression, and elevation (RICE).

— Ice can be applied for 10 to 15 minutes every few hours.

— Heat and vigorous stretching or massage should be avoided during the initial injury period.

• Crutches may be necessary until weight bearing is comfortable.

Table 31-1. Common Grading of Strains and Sprains

Grade	Characteristics
Strains
1	Stretch injury Some torn individual fibers, but comprising only a small percentage of overall muscle No loss of strength or motion
2	Partial tear of muscle Some degree of ecchymosis or swelling Some loss of strength or motion
3	Complete rupture of muscle Major hemorrhage and complete loss of function
Sprains
1	Stretching of ligament fibers Minimal to no swelling Stress tests demonstrate pain but no laxity.
2	Partial tear of one or more ligaments Moderate pain and swelling Some laxity on stress test
3	Complete disruption of ligament fibers Significant pain, swelling, and bruising Gross laxity on stress test of ligament

• Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is controversial.

— Studies demonstrate that NSAIDs can reduce inflammation and pain in the short term but may impair the muscle repair process in the long term, resulting in decreased muscle tensile strength and force production.

• A rehabilitation program of progressive stretching and strengthening exercises should be initiated as soon as pain begins to subside because early mobilization can help facilitate recovery.

• A compression sleeve for the injured muscle may help reduce pain and improve function during the healing process.

EXPECTED OUTCOMES/PROGNOSIS

• Return to play ranges from 2 to 3 days for mild strains to 3 to 12 weeks for severe strains.

• Hamstring strains have a high rate of recurrence (12%–31%) and can lead to prolonged disability if rehabilitation is inadequate or return to play is rushed.

• Hip adductor strains (groin pulls) take longer to heal and are also prone to reinjury.

WHEN TO REFER

• Rarely, muscle strains require management by a sports medicine physician or orthopaedic surgeon.

— Severe strains with significant loss of motion, strength, or function

— Large, tense, painful hematomas, which may be aspirated to reduce pain

PREVENTION

• Warming up (5-10 minutes of light jogging or calisthenics) before physical activity may reduce the risk of muscle strains by increasing blood flow to muscles, making them more pliable.

• Avoiding exercise while already fatigued may help reduce the risk of a muscle strain.

Joint Sprains

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• A sprain is a tear of some or all of the fibers in a ligament.

• A sprain is caused by a sudden, unnatural movement of a joint (eg, inversion or twisting of an ankle).

• Sprains are the most common injuries in sports for all age groups.

• Radiographs are frequently necessary to rule out fracture.

• Severity is graded into 3 categories (Table 31-1).

PRINCIPLES OF TREATMENT

• PRICEM: protection, rest, ice, compression, elevation, and mobilization

— Protection

■Crucial for early ligament healing

■Provides needed stability for moderate and severe sprains

■ Continued until

❖ Weight bearing is pain-free for lower extremity injuries

❖ Functional motion is pain-free for upper extremity injuries

— Rest

■Reduce activities to a pain-free level.

— Ice

■15 to 20 minutes at a time

■Can be done as frequently as once an hour

■Do not apply ice directly to skin.

■Heat should be avoided during the first few days because it will worsen swelling.

— Compression

■An elastic bandage should be wrapped distal to proximal.

■Remove for sleeping

— Elevation

■Above the heart as much as possible

— Mobilization

■Early mobilization, which is appropriate for most mild and moderate sprains, can help facilitate recovery.

■For all but the mildest of sprains, a rehabilitation program to restore range of motion, flexibility, strength, and proprioception will speed recovery and should be initiated as early as tolerated by the athlete.

• NSAIDs

— Reduce pain and inflammation, which may shorten recovery time by allowing rehabilitation to progress more quickly

— May increase early ligament strength

— Ibuprofen 10 mg/kg 3 times a day or naproxen 5 to 7 mg/kg twice a day for 7 to 10 days

• Criteria for return to sports (see Chapter 30, Preparticipation Physical Evaluation, Box 30-1)

— Little to no pain

— Full range of motion

— Near-normal strength

— Able to perform sport-specific drills with no pain or instability

■A functional brace or taping technique may be used to achieve this.

Ankle Sprains

• Ankle sprains account for up to 28% of all sports-related injuries.

• Athletes between 15 and 19 years of age are most frequently affected.

• Basketball, soccer, American football, and volleyball are the most commonly involved sports.

• Eighty-five percent are lateral (Figure 31-1)

— The anterior talofibular and calcaneofibular ligaments are the most frequently injured.

— Usual mechanism is excessive inversion of a plantar flexed ankle

• Ten percent are syndesmotic (high ankle sprains) (Figure 31-1).

— Injury to the syndesmosis complex (interosseous membrane and inferior tibiofibular ligaments)

— Usual mechanism is excessive external rotation on a dorsiflexed ankle

Figure 31-1. A, Lateral ankle ligaments (posterior talofibular ligament, anterior talofibular ligament, and calcaneofibular ligament) and inferior tibiofibular ligaments. B, Location of lateral ankle ligaments drawn on patient’s ankle.

Panel A from Sprains and strains. National Institute for Arthritis and Musculoskeletal and Skin Diseases Website. https://www.niams.nih.gov/Health_Info/Sprains_strains/default.asp. Published July 2012. Accessed November 11, 2013. Panel B from Sullivan JA, Anderson SJ, eds. Care of the Young Athlete. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2000:415.

• Five percent are medial.

— Injury to deltoid ligament

— Mechanism is excessive eversion, usually from a high-impact injury.

— More commonly associated with fibula fractures

SIGNS AND SYMPTOMS

• Pain after a twisting injury to the ankle

• Some report a pop at the time of injury.

• Weight bearing is usually painful.

• Swelling and bruising may be mild, moderate, or severe.

• Range of motion is often limited because of pain.

• The injured ligament is tender to palpation (Figure 31-1, B).

• Anterior drawer test (see Chapter 4, Physical Examination, Figure 4-39) and talar tilt test (Figure 31-2)

— Can confirm the diagnosis of lateral ankle sprain and grade injury severity

— Sensitivity (96%) and specificity (84%) for detecting a ligament tear is best at 5 days after the injury.

— Less reliable during the acute phase because patient guarding can cause false-negative result

Figure 31-2. Talar tilt test is performed by stabilizing the distal tibia-fibula with the non-dominant hand while the dominant hand is cupped around the calcaneus. The examiner then inverts the ankle (arrow) and grades the amount of translation/laxity compared to the uninjured ankle, as well as noting any pain with this maneuver.

From Anderson SJ, Harris SS, eds. Care of the Young Athlete. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.

• Reverse talar tilt test

— Grades severity of medial ankle sprains

• External rotation test

— Forced external rotation of the ankle

— Painful with syndesmotic sprains, but also with fractures

• Squeeze test

— Compression of tibia and fibula at mid-calf

— Causes pain at the ankle with syndesmosis sprains, but also with fractures

DIFFERENTIAL DIAGNOSIS

• Ankle fracture

— Skeletally immature patients with tenderness over the physis but normal radiographic findings should be treated for a Salter-Harris type 1 injury (see Chapter 42

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