Strain VS Sprain

Strain vs Sprain

STRAINS

s"T"rain = "T"endon

Overstretch injury to musculotendinous unit (tendon)

Concentric: Mxl contraction as the origin and insertion of the mxl comes closer together, Mxl fibres shorten
Eccentric:Origin and insertion move farther apart, the mxl fibres lengthen

Eccentric contraction can produce. greater force within the mxl than concentric contraction, predisposing the mxl to injury at this time

Hypovascular nature of tendons contributes to decreased tissue health, allowing the tendon itself to rupture

Fun fact!
The younger people where the epiphyseal plate in the bone has not yet ossified, the mxl and tendons are stronger than the bone!

Because tendons are moderately vascularized, they are prone to partial or complete rupture at the area of least blood supply either in the middle of the tendon or at the musculotendinous junction.

What is the cause of STRAINS?

Sudden overstitching of the mxl

Extreme contraction of the mxl against heavy resistance

3 grades of Severity

Grade 1: Mild

Minor stretch and/or tear

Minimal loss of strength

Grade 2: Moderate

Tearing of musculotendinous fibres

There may be snapping sensation or sound at time off injury

Unable to continue activity d/t mxl weakness and pain

Grade 3: Severe

Complete rupture of the musculotehdinous unit or an avulsion fracture as the body attachment of the tendon is torn off while the unite remains intact

Palpable/visible gap appears at the injury site

Often mxl shortens and bunches up

Unable to continue activity d/t signifiant pain and mxl weakness

SXS

Acute:

Grade1: Local edema, heat, bruising 

tenderness at site of injury

Little to no loss of strength or ROM

Capable of continuing the activity

Grade2: Tearing of several or many fibres of the musculotendinous unit

Snapping noise or sensation at the site

Gap may be palpable

Moderate tenderness

Moderate pain with activities that contrast or stretch the musculotendinous unit

Moderate loss of strength and ROM

Bruising: Red, black, blue

Hematoma on site

Grade3: Complete rupture
Snapping noise or sensation at the time or injury
Local edema
 Gap palpated in the tissue
Mxl will likely bunch up d/t spasmodic contractions
Severe pain
Immediate loss of strength and ROM
Unable to continue activity
Bruising: Red, black, blue
Hematoma on site
Ruptured mxl in lower limbs is usually surgically repaired and then immobilized in a cast for 4-8wks

Early subacute: 
Grade1: Little to no pain and reduced strength

Grade2: Pain and moderately reduced strength

Grade3: Pain and markedly reduced strength w/ARROM
Pain, edema and inflammation are still present
Adhesions are developing around the site of injury
b/o poor vasculature, healing is relatively slow
Mxl guarding spasm diminishes
TrP occurs in the affected mxl, its synergist and its antagonists
Reduced ROM

Late subacute: 

Bruising: Yellow, Green, Brown

Hematoma diminishes

Gap is still palpable

Protective mxl spasm is replaced by increased tone in the affected mxl, its synergists and its antagonists.
TrP occur in affected mxl and in compensatory mxl
Adhesions are maturing around the injury
Reduced ROM

Chronic: 
No more bruising
Hypertonicity and TrP are present
Adhesions have matured around the injury
Tissue may be cool d/t ischemia
Full ROM of the joint may be reduced with Grade 2 & 3
Repetitive injury from overuse is too stressful for the mxl
Pocket of chronic edema may remain local to the site
Reduced strength of the affected musculotendinous unit and possible disuse atrophy may present

Questions to ask

Health Hx

Rx

Hx of strain (Is this the first time to strain? You have had it before at the same site?)

Did you hear any popping sound when you injured?

Were you assessed by MD?

Do you see anybody else? Chiro, Physio, etc.

Any hematoma, nerve damage or avulsion at the tendon's attachment?

What are you currently feeling?

Palliative & provocative

Swelling on site or distal to the site of injury?

With strain of wt bearing limb, did the limb "Give way" at the time of injury? >>> Indication of Grade 3 strain

Observation

Acute: Gait analysis

Taping or bandages or splint

Edema

Some redness

Early and late subacute:

Bruising

Early subacute-Purple and black

Late subacute-Yellow and green

Chronic:Habituated gait and posture may be observed w/ strain

Visible gap at the lesion site might be present from grade 3 strain

Scar might be formed if musculotendinous unit is reduced surgically

Palpation

Acute

Heat and tenderness present

Firm edema

Palpable gap

Protective mxl spasm

Mxl guarding

Early and Late subacute

Temperature on the site is diminishing

Local tenderness may present

Palpable gap or alteration in the Mxl's contour and hypertonicity 

TrP in affected Mxl

Chronic

Cool to touch d/t ischemia

Tenderness to the lesion site

If it is on shoulder, they may not be able to sleep on affected side

Palpable gap may present w/ Grade 2 & 3

Hypertonicity and TrP may be present

Disuse atrophy in affected mxl

Testing

Acute: ARROM of affected mxl is reduced

Other testing is CONTRAINDICATED in acute stage if Grade2&3 are suspected

How can you tell?

Acute

Snapping sensation at the time of injury?

Difficulty continuing the activity or unable to continue ADL?

Palpa ble gap?

ARROM?

Early and Late Subacute

AROM?

ARROM?

AR isometric contraction?

Grade1: minor loss of strength, minor pain

Grade2: Moderate loss of strength, Pain

Grade3: Significant loss of strength, Pain

Chronic

AROM:May be limited

ARROM

Mxl strength testing: Decreased w/disuse atrophy or Grade 3 strains

Special test for Strain

Thompson's test

Yergason's test(if strain is in the shoulder)

Drop arm test (if strain is in the shoulder)

Aply's scratch test

Thomas and Ely's test

Mxl length test of injured site

Treatment plan

Acute: Mxl is treated with RICE

Positioning: elevate affected area with pillow
Hydrotherapy: Cold

Early & Late Subacute
Stroking and squeezing tech distal to the site of injury
Hydrotherapy: Cold/Warm contrast

TrP

Promote ROM

Lymphatic drainage

Chronic

Outcomes

Acute: Reduce inflammation & edema

Reduce pain

NO direct tx on site

Early & Late subacute: Reduce inflammation & edema

Mid range PROM

Reduce spasm

TrP

Reduce adhesion

Chronic: Reduce sympathetic nervous sys tem firing

Reduce any chronic edema

TrP

Decrease tone

Restore ROM

Promote blood circulation to the injured site

Treat scar if mxl was surgically repaired 

Self Care

Hydrotherapy

Self massage

Maintain strength of the affected mxl in the pain-free manner

Stretch shortened mxl 

Increase strength gradually

Encourage activity

Frequency

Acute: Shorter more frequent tx 

Chronic: Longer, weekly tx

Grade1:Possible to return to activity with a support after 2 days

Grade2:Possible to return to activity after several days to several weeks

Grade3:Immobilization could be removed after 4-8 weeks

Return to activity after 8 weeks but may delay for up to several weeks d/t atrophy of the mxl

SPRAINS

Overstretch injury to a ligament

Trauma related sudden twist or wrench of the joint beyond its normal ROM

Cause

Congenital ligamentous laxity (Hypermobility)

Hx of previous sprains to that joint

Connective tissue pathology such as RA

Grade1-Mild: Minor stretch and tear to the ligament
They can still continue some activities with some discomfort

Grade2-Moderate:Tearing of Lig. fibres occurs
Snapping sound at the time of injury and Jt. gives way
Hyermobile yet stable on passive relaxed testing
They may have difficulty continuing the activity

Grade3-Severe:Complete rupture of the Lig. itself or avulsion fracture as the body attachment of the Lig. is turnoff while the Lig. remains intact
Surgically repaired or treated by the medically conservative approach of immobilization of the Jt. in a cast or strapping

Common sprains
Lateral ankle Lig.


MC Lig. of sprain (Inversion sprain) are 
Ant. talofibular Lig.
Post. talofibular Lig. 
Calcaneofigular Lig. 

Knee Lig.

MC Lig. of sprain

MCL, LCL, ACL, PCL,

Wrist Lig.

MC Lig. to be injured is Scapholunate ligament

Hyperextension of the wrist is usually the cause of the wrist sprain

Shoulder Lig.

Grade1: Acromioclaviular sprain involves tearing of Jt capsule

Grade2:Tear of the Jt capsule and acromioclavidular Lig

Grade3:Tear of the Jt capsule:Acromioclavidular Lig and conoid and 

trapezoid Lig

Fx may also be present

SXS

Acute
Grade1:Minor stretch to Lig
Mild pain, minimal edema, stable Jt
May continue activity

Grade2:Tearing of some or many fibres of the Lig
Snapping noise and Jt gives way
Moderate pain, edema, heat and bruising are present
Slight Jt instability
May have difficulty continuing the activity d/t pain

Grade3:Complete rupture or Avulsion Fx of Lig attachment
Snapping noise, Intense pain, significant edema, heat, bruising
Hematoma, Jt effusion may be present
Jt instability
Unable to continue activity

Early subacute
Grade1:Stable
Grade2:Hypermobile yet stable
Grade3:Hypermobile and unstable w/Liamentous stress testing

Bruising: Black and blue
Pain, edema inflammation are still present but reduced
Adhesions are developing around the injury
d/t hypo vascular characteristic, it heals relatively slow
When protective spasm diminishes, TrP occurs on the site of injury and compensatory mxl
Reduced ROM
Loss of Proprioception at the Jt

Late subacute
Bruising: Yellow, green brown
Pain, edema, inflammation are diminishing
Adhesions are maturing around the injury
Increased tone of mxl crossing the Jt
Affected Jt may still be supported
Reduced ROM
Loss of proprioception at the Jt

Proprioception (or kinesthesia) is the sense though which we perceive the position and movement of our body, including our sense of equilibrium and balance, senses that depend on the notion of force (Jones, 2000)

Chronic
Pain local to the area only if the Lig is stretched
Bruising is gone
Adhesions have matured around the injury
Hyper tonicity and TrP are present
Full ROM of the Jt is restricted
Pocket of Chronic edema may remain local to the Lig
Mxl weakness or disuse atrophy may be present
They may still need some taping to support the Jt

Questions to ask

Health Hx
Any pathology?
Did you hear any snapping sound at the time of injury?
Nerve damage?
Fracture?
Palliative/Provocative

Observation

Acute: Antalgic gait if sprain is in a Wt.bearing Jt
Edema present at the affected Jt
If its Grade3, there may be distal edema present

Early and late subacute
Antalgic gait still present if sprain is in a Wt.bearing Jt

Edema diminishes both on site and distally

Bruising: changes from Purple and black to brown, yellow and green then disappears

If surgically reduced, scars are present

Chronic
Habituated antalgic gait and posture may be observed w/sprain or Wt. bearing Jt
Check Postural assessment!
There may be some edema local to the Lig. usually repetitive sprains of the same Jt

If surgically reduced, scars are present

Palpation

Acute: Hot to touch
Tenderness to the lesion site
Edema is firm
Protective Mxl spasm

Early and late subacute: Heat diminishes as time goes
Tenderness to the lesion site
Edema is less firm and adhesions are resent as healing process from the early to late subacute
Mxl tone becomes tighter and high in late subacute
TrP are present in these Mxl

Chronic
Cool to touch d/t ischemia
Point tenderness occurs locally
Chronic edema:Boggy, jelly-like feeling
Adhesions local to the Lig
Crepitus may present
Hyper tonicity and TrP are local to the site of injury
Reduced ROM

Testing

Acute: ROM of proximal affected and distal jt
Special test: Ballottable patella, Minor effusion test

Early and late subacute:
ROM, RROM
Isometric testing: Mxl crossing the affected jt are strong and painless w/strictly ligamentous injury. If mxl or tendons are also involved, there is pain at the lesion site in the contractile tissue
Special test: Ligamentous stress test, Ant drawer test (Ankle), Valgus or Varus, apple's distraction test, Brush test (Knee), 

Chronic:ROM, RROM
Special test: Ligamentous stress test

Treatment Plan

Acute:RICE
Elevate the injured site
Cold hydrotherapy
Reduce pain and edema
Maintain local circulation proximal to the injury ONLY
Maintain ROM w/ mid range PROM

Early and late subacute
Reduce inflammation, Edema
Prevent from excess adhesion formation
Increase drainage and venous return w/ effleurage, petrissage (Palm kneading, c-scooping, fingertip kneading, ONI tech)
GTO is als used to that jt
Reduce TrP
Mid-range PROM to maintain ROM
Hydrotherapy: Hot/Cold

How do you reduce adhesions?
Short cross-fibre strokes and frictions to the ligament


Chronic
Hydrotherapy:contrast
PROM
Reduce adhesion: Cross fibre, Joint play(gentle)

Contraindications

Distal circulation techniques in acute and early subacute stage because this could increase congestion through the injury site
Friction tech if they are taking anti-inflammatory or blood thinner

Self care for all phase of healing

Hydrotherapy
Self massage
Isometric contraction to strengthen the mxl
ROM to maintain Jt integrity

Treatment frequency

Acute: Short duration & frequent tx
Chronic: Long duration & weekly tx

When can they return to their activity?Grade1: 4-5 days
Grade2:7-14 days
Grade3:6-8 weeks

However...
sprained Lig may take up to 6 months for full maturation of the collagen fibres

It is recommended to receive massage therapy for weekly or biweekly up to 6 months.