Questionnaire/history?

Mechanism and timing of the injury?

Symptoms?

- Severity?

- Duration?

Usual physical activity level?

Any other risk factors for injury or re-injury?

Any previous sprain, strain or joint instability, including treatments and outcome?

Past medical history?

Current medication?

Known drug allergies?

Examination:

Swelling?

Bruising?

Limb deformity?

Asymmetry/misalignment suggesting fractur or dislocation?

Palpation of the joint or muscle?

- Point tenderness?

- Joint line tenderness?

Range of joint movement?

Strength testing?

Signs of joint instability?

Coordination and balance?

Ability to weight-bear?

Gait?

Neurovascular examination?

- Peripheral nerve injury?

- Peripheral pulses?

Sprain (stretch and/or tear of a ligament)?

Location (eg ankle, knee, wrist, thumb)?

Grade I: mild stretching of the ligament complex without joint instability?

Grade II: partial rupture of the ligament complex without joint instability?

Grade III: complete rupture of the ligament complex with instability of the joint?

Sprain (stretch and/or tear of muscle fibres or tendons)?

Location (eg foot, hamstring, back)?

First-degree (mild) strain (with only a few muscle fibres are stretched or torn)?

- Pain and tenderness?

- Normal strength (but power may be limited by pain)?

Second-degree (moderate) strain (with several injured muscle fibres)?

- More severe muscle pain and tenderness?

- Noticeable loss of strength?

- Mild swelling?

- Visible bruise (sometimes)?

Third-degree (severe) strain (with muscle tears all the way through, sometimes producing a 'pop' sensation as the muscle rips into two separate pieces or shears away from its tendon)?

- Severe pain?

- Total loss of muscle function?”

- Visible bruise?

- Difficulty weight-bearing?

Management:

Refer to emergency department if:

- Fracture or dislocation?

- Damage to nerves or circulation?

- Wound penetrating the joint?

- Bleeding disorder/haemarthrosis?

- Septic arthritis?

- Tendon rupture?

- Complete tear or tear of more than half the muscle belly?

- Large intramuscular haematoma?

Advised:

PRICE self-management strategy for the first 48–72 hours after injury:

Protection: protect from further injury

Rest: avoid activity for the first 48–72 hoursIce: apply ice wrapped in a damp towel for 15–20 minutes every 2–3 hours during the day for the first 48–72 hours

Compression: with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury, removed before sleep

Elevation: keep the injured area elevated and supported on a pillow until the swelling is controlled

Topical NSAIDs: work better than oral NSAIDs

Alternative agents to consider:

Oral NSAIDs Paracetamol Opioids not recommended unless injury is severe

(Note: If taken > 7 days risk for long-term use with the associated risks of dependency/overdose etc)

Acupressure - reduces pain and improves physical function

TENS (transcutaneous electrical nerve stimulation)

Review/refer:

Review after 5–7 days if there is lack of expected improvement 

Routine referral to physiotherapy if ongoing symptoms that are not improving as expected despite self-management strategies

Referral to orthopaedics, the urgency depending on clinical judgement, if: 

- Recovery is slower than expected.

- Worsening or new symptoms.

- Symptoms are out of proportion to the mechanism of injury or degree of trauma

Resource(s):

American College of Physicians & American Academy of Family Physicians Pain Management 2020NICE CKS 2020