Musculoskeletal sprains and strains

Last reviewed: March 2019

Last updated: April 2018

Summary

Muscle injuries occur from either direct or indirect trauma.

Predisposing factors include type of muscle architecture (i.e., pennate muscle, type II fast twitch muscle fibres, and muscle-tendon units that span 2 joints), previous injury, and inadequate warm-up before exercise.

Eccentric contraction (i.e., muscle contraction associated with forcible lengthening of the contracting muscle, such as when lowering a weight or pitching a ball) causes more frequent injury.

History and physical examination are key in diagnosis and grading of the injury as grade 1 (mild), 2 (moderate), or 3 (severe with complete rupture).

Conservative treatment is all that is required for most patients with grade 1 or 2 injuries.

Imaging studies are usually not necessary but can be obtained if grade 3 rupture is suspected, or to confirm or determine associated injuries.

Definition

Strain is an injury to the muscle or musculotendinous junction, whereas sprain is an injury to the ligament. Muscle contusion occurs when a muscle is subjected to a sudden, heavy compressive force, such as a direct blow to the muscle.

In strains, an excessive tensile force subjected onto the muscle leads to the overstraining of the myofibres and consequently to a rupture near the musculotendinous junction. Muscle strains typically concern the superficial muscles working across 2 joints, such as the rectus femoris, semitendinosus, and gastrocnemius muscles. Muscle strain usually occurs in eccentric exercise. In eccentric exercise the contracting muscle is forcibly lengthened; in concentric exercise it shortens. While concentric contractions initiate movements, eccentric contractions slow or stop them (e.g., when lowering a weight).

History and exam

Key diagnostic factors

acute onset of symptoms
mechanism of injury
severe pain
swelling
bruising
palpable gap in normal position for Achilles tendon (Achilles tendon rupture)
positive calf squeeze test (Achilles tendon rupture)
positive Matles test (Achilles tendon rupture)
positive biceps squeeze test (biceps tendon rupture)
positive Hook test (biceps tendon rupture)
pop sound
deformity

Full details

Other diagnostic factors

previous injury
symptom duration more than a few days
limited ROM
weakness

Full details

Risk factors

type of sports (basketball, ice skating, football, contact sports)
anatomical variation
eccentric exercise
pennate muscle architecture and type II muscle fibres (fast twitch)
muscle-tendon units that span 2 joints
previous history ankle sprain

Full details

Diagnostic investigations

1st investigations to order

x-rays
MRI
ultrasound for non-ligament injuries

Full details

Investigations to consider

diagnostic arthroscopy

Full details

Treatment algorithm

ACUTE

presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected

presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)

ONGOING

with worse pain and/or without functional improvement at 1-week review

Contributors

Authors VIEW ALL 

Senthil N. Sambandam, MBBS, MS, MRCS(Edn)

Staff Orthopaedic Surgeon

Department of Orthopaedics

VA Medical Center

Cheyenne

Disclosures

SNS declares that he has no competing interests.

Varatharaj Mounasamy, MD, FRCS

Assistant Professor

Department of Orthopaedic Surgery

Virginia Commonwealth University

Richmond

Disclosures

VM is an editorial board member, European Journal of Orthopaedic Surgery & Traumatology.

Sakthivel Rajaram Manoharan, MD, MS

Spinal Clinical Research Fellow

Queens Medical Centre

Nottingham

Disclosures

SRM declares that he has no competing interests.

Acknowledgements

Dr Senthil N. Sambandam, Dr Varatharaj Mounasamy, and Dr Sakthivel Rajaram Manoharan would like to gratefully acknowledge Dr Issada Thongtrangan, a previous contributor to this monograph. IT declares that he has no competing interests.

Peer reviewers VIEW ALL 

Quanjun Cui, MD

Assistant Professor

Department of Orthopaedics

University of Virginia

Charlottesville

Disclosures

QC declares that he has no competing interests.

Nicola Maffulli, MD, MS, PhD, FRCS(Orth)

Professor of Trauma and Orthopaedic Surgery

University Hospital of North Staffordshire

Keele University School of Medicine

Stoke on Trent

Disclosures

NM is an author of a study referenced in this monograph.

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Musculoskeletal sprains and strains

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

presenting within the first 24 to 48 hours: incomplete rupture (grade 1 or 2) suspected

presenting within the first 24 to 48 hours: confirmed complete rupture (grade 3)

with worse pain and/or without functional improvement at 1-week review

Contributors

Authors VIEW ALL 

Senthil N. Sambandam, MBBS, MS, MRCS(Edn)

Disclosures

Varatharaj Mounasamy, MD, FRCS

Disclosures

Sakthivel Rajaram Manoharan, MD, MS

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Quanjun Cui, MD

Disclosures

Nicola Maffulli, MD, MS, PhD, FRCS(Orth)

Disclosures

Differentials

Guidelines

Patient leaflets

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