| Patient group |
Treatment line
| Treatmentshow all |
|
presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected
| 1st |
- rest, ice, compression, and elevation followed by gentle mobilisation
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Rest: protection of area assisted with, for example, semi-rigid boot or taping in gastrocnemius complex strain or use of crutches in groin strain for 48 hours.
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Ice: helps to reduce swelling, improves outcome.
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Compression and elevation in addition will help to reduce swelling. Compression should be applied with care so as not to constrict blood flow. Caution is required when using compression in people with, or suspected to have, peripheral arterial disease (e.g., older people or people with diabetes). If tissues distal to the compression become blue or painful, the compression should be loosened and reapplied with less tension.
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The injured joint or area should be rested for 2 to 3 days.
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Mobilisation can be started after 48 to 72 hours in accordance with patient's pain.
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The patient should be reviewed in 1 week either by telephone or in clinic/surgery.
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- analgesia
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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 adverse effects is greater than with acetaminophen. 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 for an NSAID, as it has the lowest risk of adverse effects.
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Indometacin is useful for treatment of inflammation, but there is no evidence for its use in muscle strains.
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In ligament sprains, piroxicam has been demonstrated to be of benefit.
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A combination of paracetamol and NSAID can be used, but a combination of 2 NSAIDs is contra-indicated.
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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.
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Typically, 7 days of treatment should be satisfactory, although these medicines may be used on an "as required" basis thereafter.
Primary Options
paracetamol
:
500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Secondary Options
ibuprofen
:
400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day
Tertiary Options
naproxen
:
250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
piroxicam
:
20 mg orally once daily when required
OR
indometacin
:
25-50 mg orally three times daily when required
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- physiotherapy
-
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Physiotherapy may be started after 48 hours and should take the form of a graded programme extending over 4 to 6 weeks.
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In muscle strains, the programme consists of isometric, isotonic, then isokinetic exercises.
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There is little evidence that ultrasound has any significant benefit in terms of symptom relief and it is therefore no longer recommended.
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Short-wave diathermy is commonly used, but there is little evidence to promote its use to improve swelling, pain, and ROM.
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In ligament sprains, physiotherapy would start with restoring motion and strength followed by endurance training. Patients should use semi-rigid supports when necessary, as in ankle sprains and wrist sprains, between sessions of physiotherapy.
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presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)
| 1st |
- physiotherapy or surgical repair
-
-
Features suggestive of grade 3 rupture in strains and sprains include the following: severe bruising; lack of concordance between pain level and history of injury; severe functional limitation, e.g., inability to walk; severe local tenderness and x-ray showing no fracture; significant swelling and pain.
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Ninety percent of patients with grade 3 rupture present in this way.
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Traditionally, surgical repair followed by rehabilitation with physiotherapy was advocated, but a series of randomised controlled trials has shown that functional therapy is the preferred treatment except in high-demand sporting indviduals, where surgical repair can be considered on a case-by-case basis following discussion with the patient.
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Surgical repair, if required, is usually done within 1 week, although the authors do not recommend to operate within 24 hours of injury, due to the detrimental effect of swelling on repair.
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Physiotherapists should be involved in the rehabilitation process.
|
|
|
- analgesia
-
-
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 adverse effects is greater than with acetaminophen. 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 for an NSAID, as it has the lowest risk of adverse effects.
-
Indometacin is useful for treatment of inflammation, but there is no evidence for its use in muscle strains.
-
In ligament sprains, piroxicam has been demonstrated to be of benefit.
-
A combination of paracetamol and NSAID can be used, but a combination of 2 NSAIDs is contra-indicated.
-
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.
Primary Options
paracetamol
:
500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Secondary Options
ibuprofen
:
400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day
Tertiary Options
naproxen
:
250-500 mg orally twice daily when required, maximum 1250 mg/day
OR
piroxicam
:
20 mg orally once daily when required
OR
indometacin
:
25-50 mg orally three times daily when required
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