Introduction
In this section, we will profoundly discuss sprains and strains in context, define them, and provide insight about therapeutic treatment approaches. In continuum, we will define, discuss, and conversely expound on therapeutic treatment approaches. As such, this section is a summative expose on clinical comprehensibility of sprains and strains and on the same level, appropriate clinical definitions of therapeutic treatment for sprains and strains.
Background information of sprains and strains
According to clinicians, a sprain is an injury that causes impact that stretches a ligament causing pain and swelling. The stretch on the muscle causes severe pain. Clinically, the sprain is two way, a torn or stretched ligament. However, need to understand what a ligament is important; hence, we will define the term ‘ligament’ in context. According to Medline Plus, (a service of the US National Library of Medicine and the National Institute of Health) the ligament is a tissue that connects a bone to a joint (Medline Plus, 1). The causes of ligament stretch and tearing range from falls, hits by objects, and falls. There are two types of sprains, the ankle and wrist sprain. The sprain is pain and causes swelling on the sprained area. According to Medline Plus, the main symptoms of a typical sprain include sharp pain on the affected area, immobility of the joint (ankle or wrist), and swelling (Medline Plus, 1).
A strain, clinically, is a torn tendon or muscle (Medline Plus, 1). A strain is actually a stretched tendon. The tendon is biologically defined as a tissue that attaches the muscle lying along the bone to that particular bone. Causes of strains are erratic and sudden and could be twisting of muscles. The common types of tendon strains are back, and hamstring injuries (common with athletes and sportsmen) (Medline Plus, 1). Sports are the common cause of strains. Symptoms of strains include muscle spasms which can be very painful eventually, problem with muscle movement, pain, and swelling.
Both strains and sprains are therapeutically treated. Resting of the injured limb and banding it to reduce muscle or tendon movement to reduce aggravation is the commonplace approach clinically. Icing the injured area and wearing a device that prevents movement is another approach. Alternatively, combining these approaches and compressing the injured area with a device and use of medicine is recommended. Once the pain recedes, exercises are introduced alongside physical therapy (Medline Plus, 1).
Hundreds of thousands of people suffer from traumatic tendon injuries monthly in many countries. The debilitating effects of these injuries are blamed for functional inability often referred to as residual problems. The treatment used is solely blamed for residual problems. Various reviews have been written about clinical and therapeutic effectiveness of sprain and strain treatment. The different forms of interventions in these tendon and muscle injuries, empirically discussed, provide insight on the most appropriate approach. Physiotherapeutic interventions commonly used by physiotherapists are discussed in reviews and journals. This paper will review this literature to provide a viewpoint on appropriate practice, method, therapeutic intervention, and other forms of arresting and treating sprains. Paucity of research developing around the sprain and strain therapy forces many reviewers to angle or center their review on ankle sprains. However, quality of evidence on related studies and research can uncap the paucity and provide sufficient guideline regarding appropriate diagnosis and treatment of both sprains and sprains. Arguably, there is sufficing literature providing guideline to physical therapeutic sprain and strain treatment today.
Contrary to previous approaches, mainly casting and resting, better approaches aimed at reducing sprain/strain pain and increasing recovery time-frame, newer physical therapy measures have been identified. Longitudinal Studies and empirical research have helped provide clinicians and physical therapists with solutions to faster treatment of the sprains and strains. Other studies have sought comparativeness in longitudinal studies, pitting methods against each other. In this research, we will focus mainly on physiotherapeutic approaches by borrowing from existing literature. This will mainly be centered on research projections and treatment methods theoretically.
Later in the study, we will briefly discuss physiotherapeutic methods we have found as ideal and summative, concur about clinically proposing and legitimizing these methods as ideal treatment to sprains and strains in context. Following a specific study design, this paper proposes a comprehensive treatment procedure to minimize sprains and strains. However, the study design does not lobby neither suggest a conclusive physical therapy, rather provides an overview and a starting point to physical therapy when treating strains and sprains. Further, the study determines various levels of health across diagnostics as a variable in outcome and treatment measures.
Conditional prognosis, especially psychological status of a patient are part of diagnostic reports while injury level, either ruptured skin, fracture or other pre-injury conditions will be briefly discusses as part of the diagnosis and pre-injury functional level in regard to proper diagnosis methodological quality. These aspects of diagnosis methodology quality, subsequent pre-injury reports, diagnosis, ideal treatment (physical therapy) with emphasis on physiotherapeutic approaches as appropriate correctional measures are our focus of our discussion later in the paper. We will use about 20 previous studies on physical therapy and sprain and strain studies as the basis of our study and discussion. With strict adherence to only literary review these studies to propose specific methodological approach to physical therapy for strains and sprains, we will examine only diagnosis on areas commonly affected by sprains and strains (joint areas, muscles of arms, wrists and arms).
Literature Review
According to Olga Dreeben, strains are injuries to muscles and tendons. Dreeben explains that, strains are caused when muscles and tendons are subjected or exposed to direct trauma or direct over-stretching and conversely, excessive muscular contraction (Dreeben, 211). Graded, the conditional level equaled 3 levels of strains without specifying areas of condition. Dreeben proposes three-tier approach (3 level diagnoses) with mild injury denoting a simple case of strain. The second level or outcome of diagnosis is moderate injury that denotes a serious tendonal or muscle injury with less dire psychological advances to the cohort. The 3rd level is the ‘severe injury’ that denotes a clinical case with threatening muscular injuries or tendonal contraction, all, depending on area affected (Dreeben, 211).
Diagnosis of sprains and strains may vary with each orthopedics expert. Clinical orthopedics diagnoses ankle sprains as an inversion twist of the human foot during activity (sport) and subsequent pain and swelling of the ankle muscle (Foster, 1). A third degree sprain is characterized by an audible snap. Swelling and acute pain follows causing immobilization. Orthopedic examination of a sprain follows standard procedure with many clinicians’ only prescribing painkillers since sprains can heal on themselves unless classified as 3rd degree. However, Rubin and Sallis differ with this approach and suggest RICE as standard post diagnosis approach. For diagnosis, Rubin and Sallis suggests diagnosis be made using knowledge of the ankle anatomy. Two, they suggest a knowledge of the ankle joint function and appropriate physical examination capability (Rubin & Sallis, 788).
Foster suggests diagnosis confirm a sprain and make sure there is no fracture (Foster, 1). Rubin and Sallis suggest patient be questioned about injury mechanism and past injury history (Rubin & Sallis, 788). Foster emphasizes use of RICE procedure as a post-diagnosis procedure to restore motion and relive pain. Rubin and Sallis however argue that diagnosis should be comprehensive. It should evaluate ecchymosis swelling, laxity of the ankle in mobility, and tenderness of skins and muscle beneath with the ankle sprain being considered as a lateral in nature (Hultman, Fältström, and Oberg 65-73). This means the interior talofibular and posterior fibular ligaments are immobilized based on degree of injury (Rubin & Sallis, 788). Proper diagnosis, according to Foster can determine if the calcaneofibular has been affected (Foster, 1). Rubin and Sallis concluded that, accurate orthopedic diagnosis is vital for appropriate physical therapy and pre-therapy treatment and minimizing of the ankles functional disability (Rubin & Sallis, 788).
Foster slightly differs with Rubin and Sallis diagnosis approach citing physical examination should confirm sprain and differentiate a sprain from a fracture, citing an injured ankle as evidence of the talofibular ankle ligament rupture (Foster, 1). However, he agrees that the degree of swelling (ecchoymosis) is indicative of a fracture (Foster, 1). On procedure, there is paucity of comprehensive research though Foster provides insight about how diagnostic procedure should be. Foster suggests that the examiner uses two hands on the ankle while the patient is sitting to distract the foot weight distracting the ankle joint from its normal position. Motion degree should be assessed with the pressure on the ankle reduced by supporting it with one hand.
Therapeutic approaches suggested by research are nominally simple though effective. A longitudinal study conducted by Struijs and Kerkhoffs on knee strains suggests physiotherapeutic and proprioceptive training as convectional condition correction methodology (Struijs & Kerkhoffs, 1). However, Struijs and Kerkhoffs explain recurrence as a physical therapy deficit, with effectiveness of therapy determining actual recurrence possibility. The commonplace approach by physiotherapists includes ultrasound, superficial heat, motion exercise (proprioceptive training), and resting as standard physiotherapy (Struijs & Kerkhoffs, 1).
Random search of related literature on physical therapy for strains and sprains dating between 1990 and 2010 suggests that there are more approaches that are appropriate, yet not all are effective as suggested. However, by reviewing longitudinal studies providing insight about effectiveness of therapy, exercise therapy and manual mobilization provides results when correcting acute ankle sprains and strains (Van der Wees, et al, p. 27). This is based on systematic review of data. The data is random controlled tests on cohorts.
According to Van der Wees et al, randomized controlled tests proved exercise therapy of the ankle and a clinical outcome measure as effective correctional measures. This was based on evidence that the physiotherapeutic approaches were effective especially in correcting the condition and effectively reducing re-occurrence risks of the sprains and acute ankle sprains (Van der Wees, et al, 27). However, Dreeben suggests a more assertive physiotherapeutic approach. Dreeben suggests physiotherapists use isotonic and isokinetic exercise for the proprioceptive training option.
Cote, Prentice, Hooker, and Shields study on effects of cold, heat, and contrast bathe treatment on second-degree sprained ankles as therapeutic correctional measures showed positive results (Owens 175-186). The study provides insight about clinical measures required to correct sprains or strains during the post-acute stages of rehabilitation. Cote et al hoped to compare the outcome of the effects of cold, heat and contrast bathe treatment (Cote, Prentice, Hooker, and Shields, 1077-1076).
The study used first and second-degree sprained ankles as specimens for the comparative study. Thirsty cohorts with post-acute sprained ankles were subjected to cold, heat or contrast bath treatment cluster to determine reaction and clinically recordable responses concerning their injuries. Using edema as basis of comparative study outcomes, the increase in edema would provide sufficing evidence on which methodology was therapeutically appropriate to use. As treatment methodology, each (cold, heat, and contrast baths) increased edema on each specimen, (being sprained human ankle availed voluntarily). Heat and contrast bath produced almost identical results with edema level being high. Cold produced minor edema hence was, clinically suggested as ideal therapy for sprains after three days of tests using each method (Cote, Prentice, Hooker, and Shields, 1072-1076).
Cote et al concluded that cold therapy was ideal therapeutic treatment before rehabilitative exercise (Cote, Prentice, Hooker, and Shields, 1072-1076). Struijs and Kerkhoff compared ‘star excursion balance’ training alongside standard physiotherapy with standard therapy alone to determine which had the best outcomes on a grade 2 ankle sprain. Standard physiotherapy included a combo of approaches; superficial heat, motion exercises, ultra sound, and strengthening and stretching exercises. The ‘star excursion balance’ that came alongside standard physiotherapy was modified to provide proprioceptive and balance training to the patient. This program showed very effective in comparison to physiotherapy alone. However, the results did not show reduction of sprain recurrence after a month though leg balance was noted as a significant gain. As such, proprioceptive exercises combined standard physiotherapy was the best treatment for sprained ankles (Struijs & Kerkhoffs, 1).
Many studies on physiotherapeutic approaches provide insight about approaches that can ease sprains. There is paucity of similar research providing resolves for strains. However, both strain and sprain therapy correlate both in practice and in context with many therapists opting using standard therapy to treat either. Though different, mainly because each is unique in nature and affects a specific type of tissue, sprains and strains are caused by the same forces, stretching, impact, and other forms of stressors. This similarity is what makes approaches to correction-treatment methodology to follow a single standard practice.
Deeben explains that sprains and strains are injuries due to active lifestyle (Deeben, 78, a). An intervention method is recommended depending on degree of injury on the ligament. In some cases, injuries might be so critical that the muscle is torn severely. About 90% of sprains reported all are ankle related. Specifically, the sprain and the main culprit within the ligament being the talobifular ligament affect lateral ligaments of the ankle. Surgery may be an intervention option if the sprain is severe, often classified as grade 3 severities. However, clinical procedures require patient be subjected to the RICE formula within 24-48 hours after injury. Subsequently, the patient should be subjected to ROM, after the RICE (Deeben, 78, a). Physical therapy for a sprain case differs mainly with severity often graded in three severity case grades.
RICE treatment formula aims at restoring activity of the ankle. ROM aims at strengthening and improving motion of the ankle and the ligaments (Noyes, Paulos, Mooar, and Signer 1596-1600). The last phase of sprain treatment involves rehabilitating the patient into active activities through functional exercises only if the second phase successfully provided treatment through proprioceptive exercises and used of orthotic devices to treat the ligament and restore motion on the ankle and the tendons. Deeben suggests that the main goal of physical therapy for strains and sprains is mainly to maintain the patient’s motion. He suggests that success in physiotherapy can be achieved if mixlalities such as deep transverse, friction massage, and ultrasound.
Diagnosis to determine degree of sprain and other injuries on the areas of the ankle that were injured is important for successful physical therapy to offset. Skin and veins might suffer from tear, stretch, and compression. This could result to pain and eventual slow-down of the physical therapy. Diagnosis of sprains should as such be clinically thorough. With focus shifting from diagnosis to treatment, rehabilitation has become a vital aspect of the studies. Dai, Zhao, and Nester argue that rehabilitation robotics has become a growing field in physical therapy. Human movement is core when physical therapy for strains and sprains. Motion, based on mechanism development mainly through analysis and synthesis is relatively new as argued by Dai, Zhao, and Nester. They propose motion mechanism development through modern parallel robotics mechanisms. Dai, Zhao, and Nester examined effectiveness of this method to rehabilitate the sprains, especially the ankle sprain (Dai, Zhao, & Nester, 207-208).
This approach uses the ankle as the model. The ankle movement presented as an orientation platform for rehabilitative model for sprained ankles using devices using parallel mechanism with a central strut as ideal approach. The central strut is the basis of ankle rehabilitation. An analysis of stiffness of the central part of the ankle through comparative approach (central strut in the platform-type mechanism drop allowing independence of the central strut to support ankle rehabilitation)(Dai, Zhao,& Nester, 207- 208).
Foster, in his review of appropriate diagnostics on ankle sprains, explains that, diagnosis is the determinant of appropriate physical therapy. Correctional measures rely on outcomes of the clinical preciseness of the diagnosis. If pain associated with other affected areas is reported clinically, the rehabilitative process through physical therapy may use varied approaches (Foster). To provide a viewpoint to start diagnosis and subsequent physical therapy for sprains, Foster initializes comprehension of sprains as central. Ankle sprains result from force around the ankle (Foster). However according to Deeben, sprains and strains are injuries due to active lifestyle (Deeben, 78, a). According to Van Der Wees et al, sprain is a traumatic injury of the ankle (Van der Wees, et al, 27). Concerning causes, Foster argue s that. Sprains are because of force around the knee. He argues that, this force exceeds the tensile limit of the knee ligament but less than that force, that can cause a fracture. The ankle, according to Foster is a central strut as argued by Dai, Zhao, & Nester that the central strut is the basis of ankle rehabilitation (Foster).
The ankle joint is the central strut where body gravity concentrates because it is the dynamic link between the ground and the force of gravity applying on the body (Foster). These factors make ankle sprain very common and most frequent orthopedic condition. Hultman, Falstrom, and Oberg argue that ankle sprains are most common injuries. Clinical practice usually suggests that these injuries heal by themselves without treatment apart from RICE (rest, ice, compression, and elevation) (Hultman, Falstrom, & Oberg, 65-73). In their evaluation of effects of early physiotherapy after a third degree sprain, Hultman, Falstrom, and Oberg discovered that early physical therapy had a very positive effect on patient ankle function after sustaining a 3rd degree ankle sprain (Hultman, Falstrom, & Oberg, 65-73).
Macintyre suggests a 4 steps physical therapeutic procedure with progress of the treatment being determined by clinical diagnosis. The diagnosis, according to Macintyre provides symptoms treatment guideline and treatment including early rehabilitation, late functional rehabilitation, and complete motion rehabilitation (Macintyre, 4). RICE (Rest, Ice, Compression and elevation), crutches, and minor motion on self, is Macintyre’s physical therapy (Macintyre, 4-8). Much of the research developing around physical therapy for sprains and strains suggest RICE as ideal approach. The aims of many treatments hypothesized across orthopedics are to minimize pain, straining the injury, and most importantly allow the ligaments to heal and restore mobility.
This means, physical therapy is a means of rehabilitating sprains and strains comprehensively to reduce immobility. While rehabilitating is defined as the second stage of sprain/strain treatment, the objective of this stage is to restore mobility of the ankle. More accurately, physical therapy aims at restoring normal functionality of the sprained area, mainly ankles. RICE procedure (Rest, ice, compression, and elevation) helps stop pain and tissue swelling. Success in the RICE procedure allows the patient to commence very gentle/minor exercises. The physical therapists should come up with a procedure that inhibits the sprained area from developing stiffness. Two, the procedure, alongside RICE, should improve the ankle motion to resuscitate mobility, flexibility, and strengthening of the ligament. This explains why research showed that many experts sought after restoring mobility and rather concentrated on strengthening the ankle purposely to alleviate possible re-injury (recurrence of sprain). This makes musculoskeletal intervention, a more advanced treatment, and rehabilitative form of sprain and strain correction, to be featured. Deeben suggests musculoskeletal (orthopedic) intervention as very idea. The orthopedic procedure is broad owing to the fact that it encompasses the treatment of almost every aspect of strains and sprains without omitting specific types of sprains. Deeben argues that, musculoskeletal intervention, as a physical therapy approach involves physiotherapy for rheumatologic conditions, orthopedic rehabilitation, sports injuries, manual therapy, aquatic exercises, and injury treatment (Deeben, 49, a).
According to Deeben, musculoskeletal intervention is a form of physical therapy that treats orthopedic disorders including sports injuries. Most of these injuries constitute the most common form of physical therapy clinical cases. Orthopedic physical therapy can be practiced in a variety of settings. The clinical set up aims at meeting the needs of different types of patients based on age and sex. Deeben insists that the clinical experience of the therapist significantly determine effectiveness of musculoskeletal interventions. Range of motion exercises (ROM) provides the patient with smooth recovery.
As such, physical therapy for sprains and strains is a systemic pain relief and aggravation reduction while gradual compression and elevation of injured muscle-ligament follows through range of motion exercises (ROM). Depending on physical therapists range of knowledge and experience in physical injury treatment and rehabilitation, physical therapy simply allows the gradual correction of tissue and muscle contraction subsequently strengthening these cohorts to avoid future extensive damage through ROM exercises as basis of strengthening these muscles.
According to Integrated Rehabilitative Services, combination of early mobilization, manual therapy, and neuromuscular re-education is critical in restoring sprained ligaments and subsequently strengthening them properly to reduce risk of similar injuries (Integrated Rehabilitative Services, 1). Integrated Rehabilitative Services argue that early mobilization of post-acute sprains and introduction of range of motion exercises increases recovery rate, improves muscle tone and strength. Van Der Wees and Van Os support this projection. Both found out that, early mobilization post acute sprains using manual physical therapy helped cohorts return to activity and sporting activity faster. Van Der Wees, et al review showed that manual therapy and neuromuscular training improved such results significantly. Bleakely review shared similar results as those of Van Der Wees et al. Bleakely et al and Van Der Wees et al found that manual therapy as more appropriate in terms of effectiveness. Several other studies Aiken et al, Detorri, and Eisenhart show that neuromuscular re-education, thrust manipulation of the joint reduced pain, and helped patients retuned to normal motion. Increase in range of motion exercises along thrust manipulation was reported as critical in speeding recovery of patients with ankle sprains. A study by Van Rijn reported recurrence of muscle injury where inadequate ROM and effective treatment physiotherapeutic was provided
Discussion
It is clinically evident that most sprains heal if physical therapy is employed as correctional intervention. This denotes the value of physiotherapy as a treatment method for sprains and strains. Clinicians report that sprains heal faster if RICE and ROM are applied systematically. While this is a less aggressive approach to physical therapy and sprains, many orthopedic clinics suggest a critical diagnosis of the injury before subsequent clinical prescriptions are provided.
RICE is the common physical therapy procedure. RICE means rest, ice, compression, and elevation and is mainly used to stop pain, swelling and restore motion on an immobilized ankle. A sprain may take up to 4 weeks (1 month) to heal completely with well-treated sprains taking only 2 weeks or less to heal. However, length or duration of healing process is determined by the degree of injury.
According to Wolfe et al, lack of sufficient physical therapy can lead to ankle joint instability. As such, it is very important that diagnosis results recommend physical therapy as part of the treatment. As such, orthopedic clinicians are required to use a standard protocol to make treatment and management of a sprain/strain efficient and effective. Wolfe et al suggest early use of RICE (Rest, Ice, Compression and elevation), Rom (range of motion exercises). In continuum, early motion under supervision is critical in restoring ligament strength though the results are observed much later after the healing of the sprain.
The outcome of this review provides standard procedure, RICE and ROM as idea approaches for effective physical therapy. Many studies carried out show outcomes based on general improvement, ease of pain, stopping and reduction of swelling, restoration of mobility are main physiotherapeutic approaches though proved useful in clinical orthopedic practice. The review did touch on orthotic devices, ultrasound, and other technologically controlled physical therapy, however, the review quantifies the irrelevance of the popularity with common procedure as RICE and ROM as more supported and clinically popular (Cote, Prentice, Hooker, and Shields 1072-1076). However, considering the fact that many studies might dwell on one subject and that smaller studies might yield inaccurate results, we base our argument solely on popular area of study, and commonplace procedure as observed in the studies. The study of ultrasound as a clinical orthopedic practice in treatment of sprains hardly provides any strong influence since none of the material reviewed strongly suggests effectiveness of ultrasound sprain therapy.
In regard to orthotic equipment, none of the reviewed literature strongly suggests that orthotic equipment are commonplace, enough to be available to serve thousands of cases reported almost daily and treated across a lengthy period of time. As such, the use of equipment, especially orthotic and strut-centered approach is not popular across musculoskeletal approaches.
As such, this variation and centralized view on RICE and ROM in practice with regard to sprain/strain treatment (with focus on ankle sprains) suggests that there is no comprehensive or ideological sprain management practice for sprain management and acute ankle sprains as argued by Kerkhoff, Rowe, Assendelft. Kelly, Struijs, and Van Dijk (Kerkhoff et al, 462-467).
Conclusion
The review has provided insight and a musculoskeletal approach using commonplace practice RICE and ROM exercise as ideal physical therapy for sprain and strains.
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