When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Musculoskeletal sprains and strains

Last reviewed: 6 Nov 2023
Last updated: 05 Mar 2021



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
More key diagnostic factors

Other diagnostic factors

  • previous injury
  • symptom duration more than a few days
  • limited range of motion (ROM)
  • weakness
Other diagnostic factors

Risk factors

  • type of sports (basketball, ice skating, soccer, contact sports)
  • anatomic variation
  • eccentric exercise
  • pennate muscle architecture and type II muscle fibers (fast twitch)
  • muscle-tendon units that span 2 joints
  • previous history of ankle sprain
More risk factors

Diagnostic investigations

1st investigations to order

  • x-rays
  • MRI
  • ultrasound for nonligament injuries
More 1st investigations to order

Investigations to consider

  • diagnostic arthroscopy
More 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



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

Staff Orthopaedic Surgeon

Department of Orthopaedics

VA Medical Center




SNS declares that he has no competing interests.

Varatharaj Mounasamy, MD, FRCS

Assistant Professor

Department of Orthopaedic Surgery

Virginia Commonwealth University




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

Sakthivel Rajaram Manoharan, MD, MS

Spinal Clinical Research Fellow

Queens Medical Centre




SRM declares that he has no competing interests.


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 topic. IT declares that he has no competing interests.

Peer reviewers

Quanjun Cui, MD

Assistant Professor

Department of Orthopaedics

University of Virginia




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



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

  • Differentials

    • Fracture
    • Cartilage injury
    More Differentials
  • Guidelines

    • ACR Appropriateness Criteria Acute Trauma to the Ankle
    • Nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults: a clinical guideline from the American College of Physicians and American Academy of Family Physicians
    More Guidelines
  • Patient leaflets

    Ankle sprain

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer