Case scenario 

Joy, 30, presents to the pharmacy for advice after having rolled her right ankle the previous day while playing netball. She asks how she should treat the injury, as she wants to play netball on the weekend to prepare for a competition in 8 weeks’ time. You observe that Joy can bear weight on her right foot, but there is considerable swelling around her ankle. On questioning, she says she was able to sleep last night after taking some paracetamol.

Learning objectives 

After reading this article, pharmacists should be able to: 

  • Explain the pathophysiology of strains and sprains 
  • Describe the signs and symptoms of strains and sprains 
  • Discuss treatment options for strains and sprains. 

Competency (2016) standards addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Accreditation expiry: 30/11/2026

Accreditation number: CAP23120TCMB

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Introduction 

Acute strains and sprains are common soft tissue (musculoskeletal) injuries. Many individuals present to the pharmacy with a sprain or a strain and seek advice from their pharmacist about how to best manage their injury to promote healing and reduce associated pain. 

This article aims to cover how a pharmacist can provide appropriate and evidence-based care to people with acute strains and sprains.

About strains and sprains 

The terms ‘sprain’ and ‘strain’ are often used interchangeably; however, they are different injuries. 

A sprain is caused when ligaments, which connect bones together, are overstretched or torn. The most common type is an ankle sprain, when an ankle ligament is overextended (from excessive tension) often from being forced, twisted or rolled in the wrong direction.1,2 Knee, wrist and thumb sprains are also common.3 

In contrast, a strain is an acute injury caused when muscles or tendons (heavy fibrous tissue bands that connect muscles to bones) are overstretched or torn.4 The most common soft tissue affected by acute strains are the hamstrings.3 

While anyone is at risk of developing a sprain or strain, they are often thought of as sports injuries, occurring more commonly in athletes, military personnel and dancers when compared to the general population.5-9 They are also common work-related injuries.10

Inflammation and healing 

Following an acute sprain or strain injury, the inflammatory response is triggered. This serves to protect the site of injury from further damage, prevent bleeding via haemostasis, initiate healing by removing damaged cells, and stimulate growth factors that promote soft tissue regeneration.11

The inflammatory response lasts for 24–48 hours and is a necessary part of the healing process. After this initial inflammatory response, damaged soft tissue continues to heal over time. Some scar tissue may be produced where there has been a tearing of tissues.11

Signs and symptoms 

The symptoms of sprains and strains are similar, with both presenting with pain, swelling and bruising. A sprain will also present with loss of power or mobility when moving the affected joint. An acute strain may present with muscle spasms and trouble moving the muscle.12 

While most people will make a full recovery from strains or sprains, there can be ongoing complications. For example, an ankle sprain can lead to chronic ankle instability,13,14 post-traumatic ankle osteoarthritis,15 and increased fall risk in older populations.11

When to refer 

Some patients will need to be referred to their doctor or an emergency department for further investigation and potential radiographic imaging, including when there is 17-19:

  • evidence of a deformed joint (possible dislocation)
  • inability to move a limb
  • evidence of a bone fracture/break
  • intense pain, numbness or tingling
  • difficulty or inability to bear weight on an injured foot or ankle
  • skin discoloration
  • skin that is cold to the touch
  • no symptom improvement with self-management.

Treatments for acute strains and sprains 

The pharmacological and non-pharmacological treatments of strains and sprains are similar due to the common inflammatory response seen.4

Non-pharmacological management 

The mnemonic RICE (rest, ice, compression, elevation) was first introduced for the early treatment of acute soft tissue injuries in 1978.20

In the 1990s RICE evolved to PRICE (protection, rest, ice, compression, elevation). The mnemonic POLICE (protection, optimal loading, ice, compression and elevation) is also currently in use. It is very similar to the PRICE guide (see Table 1) and serves as a reminder that after the initial inflammatory phase, complete rest can delay healing.21 

While there is still contention in the literature about some of the steps of PRICE/POLICE, notably the use of ice, they are seen as common-sense approaches for the management of acute strains and sprains in the first 24–72 hours following injury.1,22

The pharmacist should advise the patient to follow these steps for the acute management of soft tissue injuries (see Table 1). 

Heat (thermotherapy), alcohol, running and massage (HARM) should be avoided for the first 48 hours following injury.4,23,24

Evidence shows that a gradual return to exercise and rehabilitation is key to recovery.1 Pharmacists should consider referring the individual to a physiotherapist or exercise physiologist, who can individualise and guide evidence-based rehabilitation, including manual joint mobilisations, strengthening and sports-specific exercises.4,25

Pharmacological management

Analgesia: Oral and topical 

The first-line analgesic for muscle strains/sprains immediately post-injury is paracetamol.4,26 

Evidence shows that paracetamol and oral non-steroidal anti-inflammatory drugs (NSAIDs) are equally efficacious in reducing sprain- and strain-related pain.26 NSAIDs can be used in combination with paracetamol.4 

For soft tissue to heal, the inflammatory response to an injury is a necessary phase. As NSAIDs reduce inflammation, there is a theoretical risk they may delay muscle repair.27-29. However, a recent meta-analysis found that the immediate use of NSAIDs does not impair or suppress the healing process.27 

The Therapeutic Guidelines currently advise that NSAIDs should not be used for more than 48 hours for acute muscle injury.4 This recommendation was influenced by a study that found that although more research is needed, the long-term use of NSAIDs may impair cellular healing and have a negative influence on muscle stem cell population.4 The individual should be advised not to use NSAIDs unnecessarily, and to use the minimum effective dose for the shortest time possible.30

A recent Cochrane systematic review found good evidence that some formulations of topical diclofenac and ketoprofen provide effective pain relief for acute sprains and strains.31 Diclofenac gel was shown to be the most effective of those assessed.31 The same review found that topical NSAIDs have the same adverse event rates as a placebo.31

Opioids are associated with a significant risk of harm, and adverse effects, such as constipation and sedation, and are rarely indicated for treatment of sprains and strains.4,26

Counterirritants

Counterirritants (e.g. capsaicin, menthol and camphor) are ingredients applied topically to the skin which excite then desensitise sensory neurons of the pain pathway.32,33 They are applied to produce a superficial irritation in one part of the body (e.g. skin), aiming to relieve pain in another part of the body (e.g. soft tissue underneath the skin). The mechanism of action is thought to be explained by the gate control theory of pain sensitivity. Counterirritants can produce a sensation of heat or cold, or both.32

Rubefacients (e.g. salicylates) are counterirritants that cause cutaneous vasodilation (increased blood flow to the skin). They cause mild skin reddening and may produce a feeling of warmth.34 

Despite their widespread utilisation, a recent Cochrane systemic review found no good evidence that the most used counterirritants, salicylates, reduce acute musculoskeletal injury pain.34

Conclusion 

Individuals with sprains and strains commonly present to community pharmacy and seek advice from the pharmacist.35 The pharmacist can provide support and evidence-based recommendations to protect the injury, reduce pain and promote the healing process. When needed, the pharmacist should refer the individual to other healthcare professionals, such as a physiotherapist and/or medical doctor, for additional investigations, treatment and rehabilitation.

Case scenario continued 

You recommend that Joy protect her ankle with a moonboot and some crutches, apply ice for 10 minutes every 1–2 hours (for up to 48 hours) and elevate her ankle above her heart as frequently as she can for the next few days. You advise Joy that relative rest – so that she does not provoke the pain (while maintaining some activity) – is recommended for the first 48 hours. Given the severity of the injury, it would not be advisable to play netball on the weekend. You recommend that Joy continue to take paracetamol for her pain (according to appropriate dosing instructions) and that she see a physiotherapist to assist with her rehabilitation, her return to netball and to help prevent any ongoing complications.

 

Key points 

  • Acute strains and sprains are common presentations to community pharmacy.
  • Pharmacists can provide support and evidence-based recommendations to these patients.
  • Referral may be required for further investigation and/or management where appropriate.

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References

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  3. Andreoli CV, Chiaramonti BC, Biruel E, de Castro Pochini A, Ejnisman B, Cohen M. Epidemiology of sports injuries in basketball: integrative systematic review. BMJ open sport & exercise medicine. 2018 Dec 1;4(1):e000468
  4. Limb conditions. Therapeutic guidelines; [updated 2017 March]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Rheumatology&topicfile=limb-conditions&guidelinename=Rheumatology&sectionId=toc_d1e114#toc_d1e114
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  23. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train 2013;48(4):528-45. doi: 10.4085/1062-6050-48.4.02
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Our authors

Dr Mary Bushell (she/her) BPharm(Hons), PhD, MPS is a pharmacist and a Clinical Assistant Professor in Pharmacy at the University of Canberra

Dr Toni Green (she/her) BPhysio, PhD is physiotherapist and researcher.

Our reviewer

Julie Briggs (she/her) BPharm, AcSHP, MPS

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