General Information About Sprains

INTRODUCTION

A sprain is an injury to a ligament, with partial or complete rupture, caused by stretching.

A ligament is a band-like fibrous tissue that connects the bones that form a mobile joint, and its main function is to provide STABILITY.

When we talk about a joint, we should think of the union of the bones that form our body; some joints, very few, have no movement or very little movement and therefore have no ligaments.

All mobile joints, which are the majority, have ligaments around them that, as already mentioned, connect the ends of the bones that form the joint and give the joint stability by preventing excessive movements; this allows us to carry out our everyday and sports activities.

All joints with a great deal of movement are at risk of suffering a sprain; however, it is more frequent in the ANKLE, KNEE, CERVICAL SPINE, AND WRIST.

WHAT IS JOINT STABILITY?

A joint is said to be stable when it resists the “physiological” loads to which it is subjected, meaning the loads it normally supports when performing activities of daily living.

Joint stability depends on three combined factors:

• The shape of the joint. A joint formed by a spherical bone introduced into the concavity of another, such as the hip, is more stable than one with a flat surface, such as the knee.
• The ligaments that connect the bones that form it. Ligaments are essential for stability, and they are more important when the joint surfaces are flat.
• The muscles that surround it and participate in its mobility. Muscular action and power also participate in joint stability. Weak muscles do not efficiently protect the joint during its movements, and the joint is more prone to dislocation.

Therefore, it is understandable that, if a ligament ruptures, the affected joint will have more movement than normal, which will prevent us or make it difficult for us to perform our activities.

When there is abnormal movement of a joint, in intensity or direction, the ligaments are stretched and three types of injury may occur: (figure 2)

• A sprain. It is generally the first injury that occurs when the force is not very intense, varying in severity from mild stretching to rupture.
• A dislocation. As the stretching force on the ligament increases, it ruptures and may cause a dislocation, which is the loss of the normal relationship between the bones that form the joint, the bone “comes out” of place.
• A fracture. If the ligament resists the force, which is not rare, the bone fractures at the site where the ligament inserts. This situation is common in the ankle, and both injuries may coexist, fracture-dislocation.

Finally, a ligament injury may lead to an unstable joint with excessive mobility and abnormal load support, and to a process of joint degeneration, wear of the joint, which causes chronic pain.

TYPES OF SPRAIN

TYPES OF SPRAIN (figure 3)

Not all sprains are the same; some are less serious than others, which will depend on the intensity of the force that caused them. To differentiate them, they are divided into three grades of injury. (1)

First degree, mild. If it only undergoes stretching without visible tearing, with microscopic injury, the ligament fibers are distended but intact.

Second degree, moderate. If it ruptures partially; some ligament fibers are torn.

Third degree, severe or serious. The ligaments are completely torn and are not functional, complete rupture.

First-degree sprains do not cause significant discomfort and allow activities to continue, although with some pain. Discomfort and difficulty performing activities increase with the severity of the sprain.

Risk factors

Although a sprain can happen to anyone due to trauma while practicing a sport, jumping, falling, or simply walking on uneven ground, it is more frequent in athletes, people with overweight, or those with some weakness or fatigue.

The use of high-heeled shoes, especially very narrow ones, is an important factor for suffering an ankle sprain. (figure 4). Knee sprains are more common due to trauma to the knee during sports activities. (figure 5)

A sprain that has been poorly treated increases the risk of recurrence, and if the sprain was severe, it may lead to chronic instability of the injured joint.

When joint instability exists, abnormal movements occur during activities, with greater amplitude or in an abnormal direction, in which the joint does not normally move, and it is more prone to injury compared with a normal joint.

CAUSES OF SPRAIN

The sprain is produced by sudden and strong stretching of the ligament when the joint moves abruptly and intensely, increasing normal movement in a certain direction or forcing the joint in a direction in which it normally does not move.

This may occur when receiving direct trauma to the joint in sports, when falling and suffering deviation or torsion of the joint, or due to automobile accidents. (figures 6 and 7)

Cervical spine sprain typically occurs through an acceleration-deceleration mechanism during a frontal collision; the head moves rapidly backward and forward, subjecting the ligaments to sudden stretching. (figure 7)

HOW TO IDENTIFY A SPRAIN

The discomfort that occurs after suffering a sprain will depend on its intensity: (figure 8)

In a first-degree sprain, pain, edema, and inflammation are mild; it allows weight bearing and there is no mechanical instability, so gait is normal, only with mild pain.

In a second-degree sprain, pain and edema are moderate, as is functional disability; ecchymosis, presence of bruising, and limitation of movement occur. Pain is more intense with movement and when walking, requiring some type of external support. Instability tests are negative or suspicious and painful when performed.

In a third-degree sprain, there is intense pain, edema, and severe ecchymosis, and blisters may appear; it is accompanied by loss of function and movement, with inability to bear weight on the affected area. There are clinical signs of mechanical instability.

MANEUVERS TO DETERMINE POSSIBLE INSTABILITY

MANEUVERS TO DETERMINE POSSIBLE INSTABILITY (figure 9)

Except for the cervical spine, due to the risk of neurological injury, it is generally possible to rule out an unstable injury through examination tests by moving the joint in the opposite direction to the injured area, attempting to separate the bones that form it; these general maneuvers are the gapping sign and the anterior and posterior drawer tests, and they are feasible to perform in any joint; when pain prevents the maneuvers from being carried out adequately, anesthesia is required. Specific maneuvers and tests will be discussed in the topics corresponding to each region.

REQUIRED STUDIES

Radiographs. In the presence of a mild sprain, radiographic studies are not necessary; in the rest, they are useful to rule out an avulsion fracture at the ligament insertion site. Severe sprains may be clinically confused with an ankle fracture.

In cases of clinical instability or suspicion of it, dynamic radiographs with a gapping maneuver may be requested, with which the diagnosis is confirmed or ruled out. If the studies are necessary and pain prevents the maneuvers from being performed, they are carried out under anesthesia.

Magnetic resonance imaging. It is rarely used, only in severe sprains for evaluation of bone and articular cartilage that may be injured, or when pain persists chronically.

SPRAIN TREATMENT

Regardless of the injured area, sprain treatment includes two essential points: the RICE method during the first 48 hours and physical therapy.

In the acute stage, the RICE method is used: (2,3)

1. Rest. The injured area should be kept immobile.
2. Ice. The use of cold, cryotherapy, is considered essential in the initial treatment.
3. Compression. Apply an elastic bandage to compress and prevent or decrease edema.
4. Elevation. Keep the injured area elevated with the same objective as compression.

The literature also refers to the “PRICE” method, referring to the need for protection with a rigid splint or orthosis.

It is always necessary to add analgesic and anti-inflammatory medication in the acute phase.

CRYOTHERAPY. (4)

Cryotherapy is a treatment method for acute soft-tissue injuries whose purpose is to minimize the hemorrhage and inflammation that accompany them and interfere with their healing, as well as to reduce pain. The following actions have been attributed to it: vasoconstriction, reduction in cellular metabolism and blood flow, decreased nerve conduction velocity, and decreased muscular neurological activity; the action of all of these leads to improvement of hypoxic injury with decreased muscle spasm and pain.

The protocol for its use is not standardized, with highly variable recommended times of use and rest.

One way to use cryotherapy may be:

• Maintain cooling continuously whenever possible during the first 2 hours after the injury, changing the application every 30 minutes.
• During the following 3 to 6 hours, continue cooling for 30 minutes, with another 30 minutes of rest.
• Afterward, and during the first 48 hours, 20 to 40 minutes every 2 or 3 hours, or three to four times a day.

It has been considered that the ideal method of cryotherapy is to apply real ice over a damp towel, or a thick elastic bandage, placed between the ice bag and the injury to protect the skin, since the use of frozen gel packs increases the risk of causing frostbite.

Notwithstanding the above, it is important to comment that the author of the RICE method, reported in 1978, rescinded his recommendation for the use of ice in 2015, arguing that it may delay healing of injuries instead of facilitating it by affecting the inflammatory response, which is essential in this process. (2,3)

CRYOTHERAPY WITH PHASE-CHANGE MATERIAL AT 15°C

CRYOTHERAPY WITH PHASE-CHANGE MATERIAL AT 15°C (figure 10) (3)

The use of ice has the disadvantage of being very short-lasting and carrying the risk of causing dermal injuries due to cold. For this reason, its use is restricted to a maximum of 30 continuous minutes, avoiding direct application to the skin.

On the other hand, in the treatment of muscle injuries caused by strenuous exercise in athletes, the use of cryotherapy with “phase-change material” at 15°C (PCM) has begun, because it maintains cooling for a long time at the same temperature, for three hours, without the need to keep the athlete inactive. PCM consists of a material made with coconut oil and soybean oil, mixed with sodium chloride and encapsulated in flexible plastic (Glacier Tek^MR), which changes from solid to liquid state, due to body heat, while maintaining a constant cold temperature of 15°C.

Because of these characteristics, its use has been advised in ligament injuries such as sprains and tendon injuries.

Subacute stage

In the subacute stage, from the third day:

The basis of sprain treatment is physical therapy, and it should be started as early as possible to avoid joint stiffness and recover strength, flexibility, and balance.

In first-degree sprains, the use of an elastic bandage is sufficient, although an orthopedic device may be needed; physical therapy is immediate, only to increase range of motion.

In second-degree sprains, partial immobilization with an orthopedic device is always necessary to protect weight bearing and restrict movements more consistently; physical therapy should begin when pain and edema decrease.

In third-degree sprains with instability, the need for surgery is evaluated; if conservative treatment is followed, rigid immobilization with splinting is continued for two weeks, with plaster, synthetic support, or an orthosis, to allow ligament healing, and only after this time are exercises started. In weight-bearing joints, crutches and orthopedic support may be needed to protect the ligament from stress during walking. NSAIDs and analgesics are used for two weeks. (figure 11)

USE OF KINESIOTAPING (5-8)

The use of kinesio taping (KT) has become a very popular way to treat all types of sports injuries, including sprains, which is why we will discuss the basis for its use and the results obtained based on evidence.

The KT tape was developed in the 1970s in Japan and was designed with the intention of providing therapeutic benefits and, at the same time, support and stability to muscles and joints without restricting their range of motion. KT tape differs from traditional white athletic tape because of the wave-pattern design on its adhesive surface, which gives it traction force on the skin that intends to lift it, as well as the fascia and soft tissue. It is hypoallergenic, water-resistant, breathable, and lightweight, closely resembling human skin in texture and stretch. The tape may remain on the skin from 3 to 7 days; however, it is estimated that after 72 hours it loses its properties and effect. (5)

According to its creator, KT provides:

• Correction of muscle function by strengthening weak muscles.
• Cutaneous stimulation that facilitates or limits movement.
• Reduction of edema by directing exudates toward the lymphatic ducts and lymph nodes.
• Correction of joints to relieve muscle spasms.
• Reduction of pain through neural pathways.

What is its theoretical function in edema?

When an injury occurs, the muscle becomes inflamed or contracts, reducing the subdermal space and altering the function of veins, arteries, lymphatic vessels, and nociceptors, forming exudates in the subdermal space.

Theoretically, to achieve its effect against edema, kinesio tape should be placed following the direction of the muscle, from its origin to its insertion, which facilitates muscle activation; both the tape and the muscle must be stretched. During active movement and when the muscle relaxes, its elastic strips form “wrinkles” that are capable of lifting the skin, increasing the subdermal space and relieving the pressure to which the elements within the space are subjected; in this way, both blood and lymphatic circulation increase in the region where it is applied, with decreased inflammation and also decreased pain, through release of compressed nociceptors. Therefore, its mode of action in cases of edema would be through its circulatory effect. (5)

It is mentioned that KT may also help in the treatment of sprain by improving muscle function and proprioception, increasing the joint’s range of motion by adjusting misalignment of muscle fibers, myofascial tissue, and joints.

Nevertheless, in studies on acute ankle sprain, it has been observed that the application of KT tape has shown no benefit in reducing swelling after the sprain. Its action has been compared with other treatment modalities such as the use of sham taping or the use of acupuncture, alone or combining both techniques, with similar results and without showing any advantage. Apparently, the growing use of KT is due to massive marketing campaigns and not to high-quality scientific evidence from studies with clinically relevant results. (figures 12 and 13) (5,6,7)

For all of the above, it can be concluded that kinesiotape is an alternative that is not scientifically relevant, since, given the irregular results reported in various studies, it is not of great help against pain and inflammation produced by a muscle, tendon, or ligament injury.

However, as occurs in the treatment of other pathologies, despite the lack of studies with scientific evidence demonstrating its usefulness, KT is widely used, especially in athletes. It has been recommended not to use it as the main treatment, but as a complement to improve results. (8)

It is thought that the good result is due to its psychological action in the person who uses it, and that the mere fact of wearing it over the muscle provides relief, increasing confidence and security.

KT variants for treating lateral ankle sprains.

KT in knee ligament injury

Phases of physical therapy in sprain treatment

Phases of physical therapy in sprain treatment (figure 15) (1)

For properly conducted physical therapy, the patient should go to a specialized center; however, the general guidelines may be the following:

First phase. It begins after the RICE method and only protected mobility without resistance is recommended, to improve range of motion. It is indicated in first- and second-degree sprains. In knee or ankle sprain, walking begins with full or partial weight bearing, with or without protective support, depending on pain intensity.

Second phase. In this phase, proprioception exercises are added to recover balance and muscle strengthening. It is recommended to start when pain and edema decrease, so in first-degree injuries they may begin at the same time as those of the first phase; in second-degree injuries, it is necessary to wait a few days, and in third-degree injuries, after two weeks, once immobilization is removed.

Third phase. Exercises continue, but more consistently and with progressive intensity. Once range of motion is recovered, gradual return to sports activities is allowed, initially taking care with movements that affect the injured area. In lower-limb injuries, there should no longer be limping when walking.

The total time of the three phases ranges from two weeks in mild cases to three months in severe cases.

BIBLIOGRAPHY

1. Kruckenberg BM, Beahrs T, Haddad SL. Sprained ankle. Last Reviewed April 2022. AAOS OrthoInfo: Sprained Ankle
2. Mirkin G. Why Ice Delays Recovery. 2015. Available online at Why Ice Delays Recovery
3. Kwiecien SY, McHugh MP, Goodall S, Hicks KM, Hunter AM, Howatson G. Exploring the Efficacy of a Safe Cryotherapy Alternative: Physiological Temperature Changes From Cold-Water Immersion Versus Prolonged Cooling of Phase-Change Material. Int J Sports Physiol Perform. 2019 Sep 2:1288-1296. doi: 10.1123/ijspp.2018-0763. Epub ahead of print. PMID: 30958051.
4. Arenas J. Crioterapia y termoterapia en las lesiones del aparato locomotor. OFFARM, Elsevier. Feb 2002. 21(2): 106-11
5. Shin JC, Kim JH, Nam D, Park GC, Lee JS. Add-on effect of kinesiotape in patients with acute lateral ankle sprain: a randomized controlled trial. Trials. 2020 Feb 12;21(1):176. doi: 10.1186/s13063-020-4111-z. PMID: 32051009; PMCID: PMC7017523.
6. Nunes GS, Vargas VZ, Wageck B, Hauphental DP, da Luz CM, de Noronha M. Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial. J Physiother. 2015 Jan;61(1):28-33. doi: 10.1016/j.jphys.2014.11.002. Epub 2014 Dec 9. PMID: 25499648.
7. SilvaParreira PC, MenezesCosta LC, et al. Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review. Journal of Physiotherapy. 2014; 60: 31-39. 10.1016/j.jphys.2013.12.008.
8. Artioli DP, Bertolini GRF. Kinesio taping: application and results on pain: systematic review. Fisioter. Pesqui. Jan-Mar 2014; 21 (01). 10.1590/1809-2950/553210114

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