Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Sprains

Basics
Description
  • Sprains refer to damaged ligaments, and they are the result of overstretching of the tissues.
  • 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.
  • Classification: 3 grades are recognized :
    • Grade I: Interstitial injury with no disruption of fiber continuity
    • 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
  • Synonym: Ligament injury
General Prevention
Proper warm-up exercise is indicated before a workout or before participating in sports.
Epidemiology
  • No age-related factors.
  • Both genders are affected equally.
  • Sprains are common.
Risk Factors
  • Weekend athletes
  • Running, throwing, or jumping sports
  • Inadequate warm-up exercises
  • Anabolic steroids
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.

Diagnosis
Signs and Symptoms
  • Pain or swelling occurs in minor sprains.
  • Patients with incomplete ligament tears may have mildly increased laxity on stress examination.
  • Ecchymosis over the involved area or gross instability of the joint can be seen in cases of ligament disruption.
Physical Exam
  • Ecchymosis or tenderness over the area of the ligament strongly suggests the diagnosis.
  • Tenderness over the ligament occurs during testing for stability (stretching of the injured ligament).
  • Gross instability of the involved joint is diagnostic.
Tests
Lab
No laboratory tests aid in the diagnosis.
Imaging
  • Radiography:
    • Stress radiographs may show grade II and grade III injuries.
    • Obtain plain films to rule out associated fractures or dislocation.
  • MRI is best for assessing soft-tissues injuries, but not always necessary.
Pathological Findings
  • Grade I: Grossly intact ligament, but hemorrhages and tearing (seen microscopically) in small areas within the ligament
  • Grade II: Partial ligament injury with increased joint laxity
  • Grade III: Complete ligament disruption
Differential Diagnosis
  • Muscle strain
  • Contusion
  • Fracture
Treatment
General Measures
  • Initial treatments consist of the RICE protocol.
    • Ice minimizes swelling through local vasoconstrictive effects, dulls pain receptors, and decreases spasm.
    • Compression and elevation further limit soft-tissue swelling.
  • Grade I and grade II injuries:
    • Treat with initial immobilization and gradual, pain-free physical therapy to preserve ROM and to avoid disuse atrophy.
    • Normal activity can be resumed gradually once the pain and swelling subside.
  • Grade III injuries require longer immobilization to allow the ligament to heal, especially in nonoperative cases .
Special Therapy
Physical Therapy
  • Ice
  • Contrast treatment with hot and cold compresses
  • Massage
  • Ultrasound
  • Pain-free, protected, ROM exercises
  • Muscle strengthening
  • Proprioception training
Surgery
  • Most ligament injuries heal without surgical intervention.
    • Rupture of the ACL represents the notable exception and usually requires surgical reconstruction.
  • Repairs may be done by direct suture of the torn ligament.

Follow-up

Prognosis
Prognosis generally is excellent with nonoperative treatment in most patients with ankle and knee collateral ligament injuries.
Complications
  • Joint instability
  • Chronic pain
  • Stiffness
Patient Monitoring
Patients are followed at 2-3-week intervals to assess ROM.
Miscellaneous
Codes
ICD9-CM
  • 845.00 Ankle sprain
  • 848.9 Sprain/strain, site unspecified
Patient Teaching
  • Outline the treatment plan clearly.
  • 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.

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