Musculoskeletal Injury: Sprain, Strain, or Break? (What To Do)
“Injury taught me I need to learn how to face challenges.”
-Shawn Johnson
I was racing toward the volleyball at full speed. My friend—nearly double my weight as the left guard of the football team—wasn't far behind. I got to the ball first thinking I had won the spontaneous sprint but he didn’t see it that way. He jovially bear-hugged me from behind, threw me over his shoulder, and I extended my arm to brace for the impact. My elbow bent the opposite way it should and, like that, I was down for the count.
This was back in high school when skyrocketing testosterone (and a not-yet fully developed frontal lobe) impacted any activity we did–including an errant ball got away from our volleyball game. The pain was immediately severe but it got better with time. A musculoskeletal injury was just part of play back then. I thought it was nothing more than a contusion, or maybe a sprain at worst. As long as I kept my elbow bent at a 90-degree angle I was able to live my life. It was the summertime so I wasn’t rowing at the time but I was able to log plenty of miles running without any significant concern. It was 11 days later when my mom took me to the doctor to diagnose a fracture.
My elbow recovery took way longer than it should have because I was slow to act on the recovery. I didn’t immobilize it and took no no active approach to heal it or precautions to keep it safe. As a result, I ended up with nagging soreness many months later during the fall rowing season and I still lack some range of motion to this day. For any musculoskeletal injury since then I did my due diligence in learning exactly what was happening in my body and caring for it appropriately. Lesson learned.
Musculoskeletal Injury Impact
“When you can’t control what’s happening, challenge yourself to control the way you respond to what’s happening. That’s where your power is.”
- Anonymous
While my residual deficits are minor at best, I see these types of injuries all of the time with more significant consequences. The patient who crushed his hand in the machine at work in his 20’s, never went to the hospital, and now needs help buttoning shirts. The guy who thought he could keep up with the young guys on the court and came away with shoulder pain. The ankle sprain from that missed step that prevents a patient from reaching to the ground without teetering to the side.
Musculoskeletal injuries are going to happen. That fall to the ground from a standing height was comical as a kid but it turns deadly in older age. A kid can crash his dirt bike 10 times without injury but dislocates his shoulder on the first rung of the monkey bar. We may never know when it will happen but what is important to know is what it truly is and what to do about it.
Here I break down 3 of the most common types of musculoskeletal injuries: a sprain, a strain, and a fracture. Knowing the difference means that you can get appropriate care which is the first step to truly healing from an injury without lifelong consequences.
Sprains
A sprain (a.k.a a torn ligament) is when a ligament is stretched and/or torn. Ligaments are tough bands of connective tissue that go from one bone to another bone. The role of the ligament is to stabilize the body’s joints.
Sprains typically occur due to acute trauma and you’ll probably feel a pop or tear in the joint when this happens. They are common with contact sports, landing awkwardly when jumping, and falling onto an outstretched hand (a “FOOSH” injury).
Common Sprain Locations
Your body has over 900 ligaments holding it together. As a result, sprains happen often and all over the body. Some of the most common areas and types include:
Shoulder: a.k.a. a separated shoulder at the acromioclavicular (AC) joint.
Wrist: radial sprain (thumb side) or ulnar sprain (pinky side)
Ankle: inversion sprain (rolling inward) or eversion sprain (rolling outward)
Knee: involves one of the 4 ligaments (ACL, MCL, LCL, PCL)
Symptoms
Pain
Bruising
Swelling
Inflammation
Diagnosis
Diagnosing a sprain is typically based on a physical examination and report by the patient. X-rays may be used to rule out a fracture or dislocation. X-rays can’t detect pure muscle injuries though. An MRI can be helpful in determining the location and severity of the injury.
Severity
Grade 1 (Mild): Microscopic structural damage only. There is some local tenderness. The joint is stable. Recovery time is usually 1-2 weeks.
Grade 2 (Moderate): The ligament is partially torn (ruptured), there is visible swelling, and the area is tender. The joint is typically stable. Recovery time is 3-6 weeks.
Grade 3 (Severe): The ligament is completely torn (ruptured), there is significant swelling, and the joint isn’t stable. Surgery may be required. Recovery time is several months.
Recovery Phases
There are 4 phases of recovery for a muscle sprain. The length of each phase and approach in each phase will vary depending on the grade. It is important to note that sprains tend to heal relatively slowly because the ligaments involved which are avascular (without blood vessels).
Phase 1: Protection
Rest
Protect (brace, wrap, splint, crutches, tape)
Early weightbearing as tolerated
Phase 2: Progressive ROM and Early Strengthening
Restore range of motion (ROM)
Restore strength
Resume low-level aerobic training
Phase 3: Advanced Strengthening & Neuromuscular control
Restore proprioception
Restore coordination
Phase 4: Return to Activity
Functional progression (work- and sport-specific skills)
When To See A Doctor
Mild sprains can typically be treated at home, however, more severe sprains require medical intervention. Seek out a doctor if you have any of these symptoms:
You heard a pop or crack
Numbness or tingling to the injured area
It’s not getting better within 24 hours
The area is tender to touch
Inability to put pressure on it
The area has been injured before
Rapid swelling or bruising to the area
Significant pain or fever
You suspect a growth plate injury (see below)
When To See A Therapist
The goal of occupational therapy (OT) and physical therapy (PT) in treating musculoskeletal injuries such as a sprain is to control the pain and to improve your overall function. You may benefit from OT or PT if the symptoms of your sprain limit your mobility or your activities of daily living (ADL) such as getting dressed or taking a shower, or your instrumental activities of daily living (IADL) such as doing household tasks and returning to work.
OT’s and PT’s can address your underlying issues through a hands-on assessment and treatment (manual therapy) to improve your strength, coordination, and range of motion (ROM); decrease your pain, provide resources and education, and create an individualized exercise program based on your functional status and goals. Through reassessments and convrsations the therapist will make sure your body is responding to the treatment appropriately. They will modify any interventions based on your overall progress.
Strains
A strain (a.k.a a pulled muscle, a muscle tear) is an injury to the muscle, the area connecting the muscle and the tendon, or the tendon itself. Tendons are fibrous tissue that connect muscles to bones. There tends to be tearing of blood vessels as well causing bruising although this is not always visible. A strain is caused by excessive stress to the tendon or muscle with a grade 3 strain considered a complete rupture.
Muscle strains tend to be a result of overuse, poor body mechanics, and muscles that are stiff, tight, or not warmed up. For example, a “pulled back” is common after lifting something heavy with poor body mechanics or through overuse. A rotator cuff strain can be a result of reaching up to block that shot (or even to grab that coffee cup from the cabinet) without a “warm up.”
Common Strain Locations
Rotator cuff
Long head of the biceps
Low back (“I threw my back out.” “I pulled my back.”)
Hamstrings
Quadriceps
Groin
Achilles
Symptoms
Pain or tenderness at rest
Muscle spasm
Muscle weakness
Swelling
Inflammation
Redness or bruising
Limited ROM
Diagnosis
The diagnosis is typically based on a physical examination and report by the patient. X-rays may be used to rule out a fracture or dislocation. X-rays can’t detect pure muscle injuries though. An MRI can be helpful in determining the location and severity of the injury.
Severity
You may have all of these symptoms in all cases of a strain, regardless of the severity. The severity is based on the amount of strength and range of motion that is lost.
Grade 1 (Mild): No decrease in strength. No decreases in active or passive range of motion. Pain is minimal (and may not occur until the next day).
Grade 2 (Moderate): Noticeable decrease in strength. Noticeable decrease in range of motion. Pain and swelling are present. There is not a complete rupture and about half of the muscle fibers are torn. The typical return to activity or sports is 2-3 months.
Grade 3 (Severe): Complete rupture of the muscle or tendon. This can often be palpable (although the swelling may interfere with this). There is severe pain and swelling and use of the muscle is lost. Surgery may be required to reattach the muscle or tendon. Recovery takes about 3-6 months.
Recovery Stages
Phase 1: Inflammatory Stage (1-7 days)
Goal: allow the bleeding to stop and for the body to get rid of any damaged cells. Minimize atrophy and scar development.
Rest
Protect (brace, wrap, splint, crutches, tape)
Phase 2: Repair (Proliferative) Stage (6 days to 2-3 weeks)
Goal: replacing the damaged cells with new ones.
Start mobilization within limitations of pain
Restore range of motion (ROM)
Restore strength
Resume low-level aerobic training
Phase 3: Remodeling (2 weeks to 12 months)
Goal: strengthen and align new cells
Restore proprioception
Restore coordination
Return to full activity when pain is 0-3/10, 90%-100% strength, and full ROM. There is a high chance of reinjury if return to sport and activity is too quick.
When To See A Doctor
Mile strains can be treated at home. You should see your doctor if any of these symptoms occur:
You heard a pop or crack
Numbness or tingling to the injured area
It’s not getting better within 24 hours
The area is tender to touch
Inability to put pressure on it
The area has been injured before
Rapid swelling or bruising to the area
Significant pain or fever
When To See A Therapist
The goal of occupational therapy (OT) and physical therapy (PT) in treating musculoskeletal injuries such as a strain is to control the pain and to improve your overall function. You may benefit from OT or PT if the symptoms of your sprain limit your mobility or your activities of daily living (ADL) such as getting dressed or taking a shower, or your instrumental activities of daily living (IADL) such as doing household tasks and returning to work.
OT’s and PT’s can address your underlying issues through a hands on assessment and treatment (manual therapy) to improve your strength, coordination, and range of motion (ROM); decrease your pain, provide resources and education, and create an individualized exercise program based on your functional status and goals. Through reassessments and convrsations the therapist will make sure your body is responding to the treatment appropriately. They will modify any interventions based on your overall progress.
Fractures
A fracture is a break in a bone. It occurs when more force is applied to the bone then the bone can handle. Fractures can occur for many reasons including falls, car accidents, sports injuries, or even running.
Kids & Fractures
Children’s bones are different from adults. A child’s bone is more flexible which means that it can absorb shock well but that it may buckle before it breaks leading to unique fractures called “greenstick” or “bowing” fractures. Although their bones may bend when breaking they tend to straighten back out as they heal (a process called remodeling). A child’s bone also has a dense layer of vascular connective tissue around it (called the periosteum) which makes the bones strong and allows them to heal faster.
One of the major concerns for an injury to a child's bone is the possibility of damage to the growth plate. Growth plates are areas of growing tissue at the end of long bones and they are the weakest part of a child’s skeleton. These areas determine the ultimate length and shape of the child’s bone when they are fully mature. If a bone is fractured at the growth plate then the bone may permanently stop growing (called growth arrest). If only a part of the growth plate is impacted then the bone may grow unevenly.
Growth plate injury risk peaks in adolescents but all children are at risk of these injuries (with boys being twice as likely to have one as girls). They account for about a third of all childhood fractures. Even an innocent-looking fall that would be a sprain in an adult could fracture a child’s growth plate so immediate assessment is important. (source)
Apophysitis is another type of injury found around children’s growth plates. Apophysitis is inflammation of stress to the growth plate found in young athletes. It typically occurs as the result of overusing the joint such as with pitching (“Little League Elbow” or “Little League Shoulder”) and jumping (Osgood-Schlatter Disease or Sever’s Disease). A combination of rest and therapy are the best approach to get children back to their sport in about 4-8 weeks.
Common Fracture Locations
Clavicle (collar bone)
Ankle
Vertebrae
Hip
Forearm
Elbow
Wrist
Symptoms
Intense and sudden pain
Inability to bear weight or use the injured area
Obvious displacement (the area looks out of place)
Swelling
Numbness and tingling
Diagnosis
Fractures are diagnosed through imaging such as an X-ray, MRI, CT scan, or a bone scan.
Fracture Classification Basics
Complete: extends across the bone
Incomplete/Partial: Does not extend across the bone (more common in kids)
Open/Compound: the bone breaks through the skin
Closed/Simple: the fracture doesn’t break the skin
Types Of Fractures
Transverse: straight fracture line across the bone (common with car accidents)
Spiral: spirals around the bone (twisting injuries like with soccer)
Greenstick: a partial fracture where the bone bends and breaks but does not separate (common in kids)
Stress (a.k.a. Hairline fractures): Crack in the bone, difficult to diagnose (common with overuse injuries such as with runners)
Compression: the bone is crushed (common with workplace injuries and osteoporisis of the spine)
Oblique: a diagonal break across the bone (common with falls)
Impacted: the broken ends of the bone are pushed together
Segmental: the same bone is broken in two locations leaving a “floating” bone
Comminuted: the same bone is broken in three or more locations
Bowing: an incomplete fracture or microfractures (most often in kids who fall on theif forearms)
Avulsion: a bone fragment is pulled off by a tendon or ligament (common with kids)
Recovery Phases
Phase 1: Inflammatory Phase (duration: 1-2 weeks)
This phase is also known as fracture hematoma formation. It begins immediately after the break occurs and lasts 1-2 weeks. The area becomes inflamed (red, swollen, painful) to jumpstart the healing process and prevent us from using the area. Blood clots form a hematoma at the edges of the bone which attracts healing cells and sets the framework for bone regrowth. Your body releases an onslaught of cytokines, growth factors, and prostaglandins to help with this healing.
Phase 2: Bone Regrowth Phase (duration: varies between 2-12 weeks)
During the second phase, the pain has decreased (although still tender and weak) and the site is ready for new bone growth. New fibrous tissue and cartilage starts as a soft callous and remodels into hard callous on the ends of the bones which ultimately join together. This hard callous is still weaker than bone but it lays the groundwork for new bone formation.
Phase 3: Remodeling Phase (duration: several months)
This final phase of bone healing takes the longest. Blood circulation around the site improves and the callous tissue remodels into highly organized and smoothed bone.
A fully healed fracture depends on many factors including the location and type of fracture as well as your age and health. The healing process can last anywhere between 3 weeks for a finger to a few months for a femur.
Treatment
The goal of treating a fracture is to make sure the bone is in the correct position, allow healing, and get back to normal use. Depending on the type of fracture, this may include:
Casting or Splinting
Traction: this is used to stretch muscles and tendons around the broken bone(s) by pulling them to align the ends of the bones.
Surgery: this is a last resort required to put bones in the proper position. Internal or external fixation devices (metal rods or pins inside or outside of the body) can be used to hold bone fragments in place while they heal.
When To See A Doctor
See a doctor any time you think you may have broken a bone. Open fractures and vertebral (spinal) fractures are considered medical emergencies. Get medical care immediately if you think you have either of these.
When To See A Therapist
The goal of occupational therapy (OT) and physical therapy (PT) in treating musculoskeletal injuries such as a fracture is to control the pain and to improve your overall function. You may benefit from OT or PT if the symptoms of your sprain limit your mobility or your activities of daily living (ADL) such as getting dressed or taking a shower, or your instrumental activities of daily living (IADL) such as doing household tasks and returning to work.
OT’s and PT’s can address your underlying issues through a hands on assessment and treatment (manual therapy) to improve your strength, coordination, and range of motion (ROM); decrease your pain, provide resources and education, and create an individualized exercise program based on your functional status and goals. Through reassessments and conversations the therapist will make sure your body is responding to the treatment appropriately. They will modify any interventions based on your overall progress.
Not every musculoskeletal injury is clear-cut. Talk to your healthcare provider if you have a fracture or anything beyond a mild sprain or strain.
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