Conditions · Carrollwood · Tampa Bay

Strains and Sprains

What strain, sprain, and the grade on your paperwork mean, what they do and do not tell you, and an examination that decides what happens next.

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Dr. Bobby Koser, DC, chiropractic physician, working on a patient’s neck and upper back at HealthSpine Chiropractic in Carrollwood, Tampa.

Discharge paperwork is written for other doctors, not for you. So when yours says cervical strain, lumbar sprain, grade 2 ligament injury, or musculotendinous injury, the words land without a translator, and the internet fills the silence badly. This page is the translator. Cervical strain and lumbar sprain name the spine, and Dr. Bobby Koser, DC, chiropractic physician, completed post-doctoral training in spinal MRI interpretation and clinical correlation. He examines the injured tissue along with the joints above and below it in the same visit, and reading your report with the person it belongs to is part of that examination. Bring yours.

Strains and Sprains Overview

What the words on your report mean

Strain and sprain name two different tissues. A strain is muscle and tendon. A sprain is ligament. They are examined and loaded differently, and they end up on the same paperwork constantly, because one event at one joint often reaches both.

Strain

A strain is an injury to a muscle or to the tendon that anchors it, the tendon being the cord that connects a muscle to bone. It happens when the fibers are pulled past what they could hold in that moment, most often while the muscle is lengthening and working at the same time: reaching, landing, catching yourself, taking a load you were not set up for. The places it turns up most are the hamstrings at the back of the thigh, the calf, the groin, and the long muscles running along the spine and between the shoulder blades.

Also written as: pulled muscle, torn muscle, muscle tear, musculotendinous injury. A strain of the muscles along the spine is usually written by region rather than by muscle, which is where cervical strain, thoracic strain, and lumbar strain come from.

Sprain

A sprain is an injury to a ligament. Ligaments are the short, dense bands that hold one bone to the next and keep a joint inside the range it is built to move through. A sprain is those fibers being stretched or torn when the joint is forced past that range. The ankle rolling inward is the version most people picture, and the same event happens at the knee, the thumb, the shoulder, and at the small paired joints of the neck and the back.

Also written as: ligament injury, ligamentous injury, capsular injury, sprain of ligaments of the cervical spine. When a report says musculoligamentous injury, it is naming both sides at once, the muscle and tendon side and the ligament side, because at most joints the two are injured together.

Grade 1, grade 2, grade 3

Clinical notes and reports often put a number on a strain or a sprain. The number describes how much of the tissue is involved and whether the structure is still continuous:

Grade 1: fibers are stretched, or some of them are torn, and the structure is still continuous.
Grade 2: a partial tear, with more of the fibers involved and the structure still connected end to end.
Grade 3: a tear through the full thickness of the structure.

The number describes tissue at one moment, written on whichever scale the examiner or the radiologist was using, and different scales exist for different tissues and different imaging methods, so a grade belongs to the scale it was written on. It is a real finding about real tissue, and it does not settle the question in either direction: a low number does not mean the injury was not real, and a high number does not, on its own, describe how the joint is working. How the joint tests, what you can load today, and what the days since the injury have actually looked like fill in the rest. That is what an examination is for.

The other words that travel with these two

Contusion: an injury from a direct blow to the muscle rather than from the muscle being over-lengthened.
Myofascial pain: pain coming from a muscle and the fascia, the covering tissue wrapped around it.
Trigger point: a tight, painful knot in a muscle, tender under a finger and often referring pain somewhere else.
Laxity or instability: the joint moving further than the examiner expects when the ligament is tested by hand.
Effusion: fluid inside the joint itself, which is different from swelling in the tissue around it.
Avulsion: the tendon or ligament pulling away from the bone, sometimes taking a fragment of bone with it.

Also written as: soft tissue injury, the umbrella term paperwork uses when it is naming a category rather than a structure.

A finding is not a diagnosis

Two published studies are worth knowing about before you read your own report again, and they say the same thing in two different places on the body.

In a review of MRI reports from 108 ankles, from 104 patients, that were not causing symptoms on the outer side, about 38% had healthy ligaments on the inner and outer sides of the ankle, the medial and lateral ligaments. In the rest, the radiologists recorded ligament discontinuity on a four-grade scale: grade I in 25 cases, grade II in 32, grade III in 5 and grade IV in 5.¹ In a second study, this one a look back at MRI scans of 253 people whose hamstrings were not causing symptoms, 35% had normal tendons on both sides, at a median age of 51, meaning half of that group were older and half younger, with ages running from 13 to 88. Of the same 253, 15% had a partial tear on both sides at a median age of 63, and 2% had a complete tear on both sides at a median age of 68.²

That cuts in both directions, and both matter. A word like tear or discontinuity on your own report does not by itself settle what is causing your pain, and your pain is not less real because the same words turn up on scans of people who were not hurting. Which of those two is true for you depends on where the finding is, whether it matches what you feel and what the joint does under a hand, and that is the work an examination does.

Neither review describes a joint that had just been injured, so nothing in those numbers describes an ankle or a hamstring after a crash, a fall, or a sports injury, and both reviews are narrower than they first sound. The ankle review covered consecutive ankles, and its authors noted that an ankle MRI is rarely done unless the ankle has been injured or is painful. The hamstring study was a look back at 253 consecutive patients at a referral center whose hamstrings were not causing symptoms, and in it the groups with tears were older than the group with normal tendons, medians of 63 and 68 against 51, so those percentages are not three slices of one identical population. The authors of the ankle review wrote that longer studies would be needed before anyone could say what causes these findings or where they lead. And each review looked at one region, the ligaments at the ankle and the hamstring tendons at the hip end of the thigh, so neither describes strains and sprains as a category.

1. Galli MM, et al. Examining the relation of osteochondral lesions of the talus to ligamentous and lateral ankle tendinous pathologic features: a comprehensive MRI review in an asymptomatic lateral ankle population. J Foot Ankle Surg. 2014;53(4):429-433. PubMed

2. Thompson SM, et al. The prevalence of proximal hamstring pathology on MRI in the asymptomatic population. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):108-111. PubMed

How long a strain or a sprain takes

The follow-up studies answer this from the far end, starting with the people who were still having trouble a year after the injury.

In a systematic review of 31 studies of adults whose ankle sprain was conventionally treated, meaning they got the usual care for a sprain, 5% to 33% still had pain a year later, and 3% to 34% had at least one re-sprain, recorded anywhere from two weeks to 96 months after the injury. In the higher-quality studies in that review, between none and a third of patients described the ankle as feeling unstable, and in the lower-quality studies the range ran from 7% to 53%. Across the whole review, pain reporting dropped rapidly over the first two weeks, and 36% to 85% reported a full recovery within a period of three years.³ Put the other way, in some of those studies most people had not reported a full recovery three years on. Every figure there is a range across studies rather than a rate for any one person, everyone counted in it was under conventional treatment for the injury, and the review covered sprains of the ligaments on the outer side of the ankle in adults, so it describes ankles and does not stretch to sprains as a category.

The second thing worth knowing is that the picture and the time out do not always line up the way people assume they will. In a four-year study of 23 European professional soccer teams, 516 hamstring injuries were recorded and 58% of them were scanned. 70% of the injuries that were scanned came back grade 0 or grade 1, which on that study’s scale means no fiber disruption was visible on the MRI, and those injuries accounted for 56% of the total time missed in that study, 2,141 days out of 3,830. In that study, time out of play averaged 8 days at grade 0 give or take 3, 17 days at grade 1 give or take 10, 22 days at grade 2 give or take 11, and 73 days at grade 3, the top of the four-grade scale, give or take 60.⁴ Those numbers come from professional players followed from 2007 to 2011, men treated by a full-time team medical staff whose job was returning them to the field, and what was measured was time lost from play, recorded by that staff, which is a different question from how a person feels.

These are group figures from the populations those studies defined, and they are not a schedule for the tissue you injured. What a monitored plan does instead is retest the same things at each visit, so the direction you are actually moving is measured rather than assumed.

3. van Rijn RM, et al. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121(4):324-331.e6. PubMed

4. Ekstrand J, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med. 2012;46(2):112-117. PubMed

When an X-ray is part of the decision

A decision rule tells you about bone, not about everything that hurts. Two of them are published, and both are worth understanding for what they leave out as much as for what they answer.

The Ottawa ankle rules are a bedside checklist used to decide whether an ankle or midfoot X-ray is needed. In a systematic review that pooled 27 studies and 15,581 patients, a negative result on those rules left under a 1.4% chance of a fracture, a figure the reviewers arrived at by assuming that 15 out of every 100 people in the group had a fracture to begin with. In that same review the rules also flagged many people who had no fracture, what the reviewers called a modest specificity, and they estimated that using the rules should reduce unnecessary X-rays by 30% to 40%. The checklist answers one question, whether a bone is broken, and it says nothing about the ligaments.⁵ In that review the pooled studies included a children’s subgroup, so those figures are not adult-only.

The knee has its own version. In a meta-analysis of eight studies and 7,385 adults assessed by emergency physicians after an acute knee injury, the Ottawa knee rule identified about 99 out of every 100 knee fractures, and the reviewers concluded that it can be used to rule out a knee fracture and avoid an unnecessary X-ray. Put the other way, the reviewers published a range of statistical uncertainty around that pooled figure, and across that range the number not identified runs from none up to about 3 in every 100. In those same studies the rule also flagged about half of the people who did not have a fracture, a specificity of 0.49.⁶ Everyone in that meta-analysis was an adult with an acute knee injury assessed by an emergency physician, and the conclusion about avoiding an X-ray is the reviewers’ own.

Both checklists stop at the same place. A checklist that has answered the fracture question has answered the fracture question. It has said nothing about the ligament, the tendon, or the muscle, which is where a strain or a sprain lives, and a person can walk out of an imaging decision with a real injury and no film of it. That is what an examination is for, and the examination is also what decides whether imaging is needed in the first place.

5. Bachmann LM, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417. PubMed

6. Sims JI, et al. Diagnostic accuracy of the Ottawa Knee Rule in adult acute knee injuries: a systematic review and meta-analysis. Eur Radiol. 2020;30(8):4438-4446. PubMed

Symptoms, and the warning signs we screen for

Most strains and sprains arrive with a story attached, and the story is worth bringing with you: what the body was doing at the moment it happened, what came on immediately, and what showed up the next morning instead. A strain is usually felt in the muscle itself, tender along its length, worse when that muscle is asked to contract or to stretch, and stiffest after sitting still. A sprain is usually felt at the joint line, with swelling that settles around the joint, and it announces itself on the specific movements that load the injured band.

In the spine the same two tissues get injured and the presentation is less tidy, because the muscles, the ligaments, and the small paired joints all sit within an inch of each other. Neck and upper back injuries often show up as a band of tightness between the shoulder blades and a range of motion that has quietly shrunk. Low back injuries often show up as pain that is provoked by the first bend or the first lift rather than by lying still. Timing matters too: swelling within minutes of the injury is a different signal from swelling that builds over a day, and both belong in the history.

Common, and examined here

Pain that started with one identifiable moment: a fall, a lift, a landing, a collision
Swelling or bruising around a joint, or tenderness along the length of a muscle
A joint that feels unreliable on stairs or on uneven ground
Tightness between the shoulder blades or along the neck since an injury
Pain that settles with rest and returns the moment the same load comes back
Paperwork with the word strain or sprain and a grade nobody has explained to you

Emergency, not an appointment

Not being able to put weight on the leg or the foot after an injury
A joint or limb that looks out of shape, or a bone that looks or feels out of place
New numbness, pins and needles, weakness, or a limb that has gone cold or pale
A pop at the moment of injury with swelling that comes on within minutes
After a back injury, new loss of bowel or bladder control, or numbness in the groin or inner thighs

A limb that cannot take weight, or that looks out of shape after an injury, needs imaging before anything else happens. A limb that has gone cold or pale, or that is losing feeling or strength, can mean the nerve or the blood supply is involved. New loss of bowel or bladder control with numbness in the groin or inner thighs can signal cauda equina syndrome, a surgical emergency. A pop at the moment of injury followed by swelling within minutes means the joint needs to be assessed before it is loaded again. Go to the emergency department now. Screening for these is part of the examination here.

How we approach a strain or a sprain

The examination comes first: your history in detail, the injured tissue tested directly by hand, the joint taken through its range and its ligaments assessed, strength and load tolerance measured, and the joints above and below examined in the same visit, because after an ankle injury how the knee and the hip are loading is part of what gets tested, and after a back injury so are the hip and the neck. Bring any X-ray, MRI, report, or discharge paperwork you have. Reading it with you is part of the visit. That visit is the Pain Source Exam.

When conservative care fits, it is built in phases, and the phase you are in is what decides what a visit does.

Protection. Early on the work is keeping the injured tissue inside what it can take right now: which movements to keep, which to leave alone for the moment, offloading or taping where the examination calls for it, and a clear answer on what you can do at work and at home in the meantime.
Loading. Then load comes back deliberately. The injured muscle or ligament is asked to do a measured amount more, prescribed at a dose you can actually complete, and reviewed at the next visit.
Return to activity. The last phase is the specific thing you are going back to: the stairs, the shift, the lift, the run, tested rather than assumed, alongside the balance and control work a joint needs when it is asked to react at speed.

Alongside that, and decided by the examination rather than chosen in advance: a chiropractic adjustment where the examination finds restricted motion in the joints around the injury, hands-on muscle work, and dry needling for trigger points, meaning tight, painful knots in a muscle, or myofascial pain, meaning pain from a muscle and its covering tissue. Care is monitored, and the plan changes if you are not improving.

Some injuries are examined here and then sent elsewhere, and that call is part of the visit.

An examination that suggests a fracture: imaging before anything else.
Any of the emergency signs above: the emergency department, not an appointment.
A joint that tests unstable or gives way under load: orthopedic opinion, with the ligaments assessed before the joint is loaded further.
An examination that suggests a tendon has pulled away from the bone: orthopedic opinion.
An injury that is not progressing under a monitored plan, or findings that belong in front of a surgeon.

When we refer you, your records go with you. If the injured joint is the knee or the shoulder, those pages go further into what gets tested and what the reports say: knee pain and shoulder pain. Hurt in a car accident? Florida law gives you 14 days from the crash to begin care and keep your no-fault medical benefits. If that window is open, start at our auto accident page or our whiplash page and we will get you examined.

Common questions about strains and sprains

What is the difference between a strain and a sprain?

Different tissue. A strain is an injury to a muscle or to the tendon that anchors that muscle to bone. A sprain is an injury to a ligament, one of the short bands that hold one bone to the next and keep a joint inside its range. The two are examined and loaded differently, which is why the distinction is on your paperwork at all, and one event at one joint often produces both, which is why reports sometimes say musculoligamentous injury and name both sides at once.

My paperwork says grade 2. What does the grade mean?

The number describes how much of the tissue is involved and whether the structure is still continuous. Grade 1 means fibers stretched or some of them torn with the structure continuous, grade 2 means a partial tear with more fibers involved and the structure still connected end to end, and grade 3 means a tear through the full thickness. Different scales exist for different tissues and different imaging methods, so a grade belongs to the scale it was written on. It describes tissue at one moment. A low number does not mean the injury was not real, and a high number does not, on its own, describe how the joint is working. What it means for you comes from how the joint tests, what you can load, and what the days since the injury have looked like, and working that out is what the examination does.

How long does a sprained ankle take?

In a systematic review of 31 studies of adults whose ankle sprain was conventionally treated, meaning they got the usual care for a sprain, 5% to 33% still had pain a year later and 3% to 34% had at least one re-sprain, recorded anywhere from two weeks to 96 months afterward, and in the higher-quality studies in that review between none and a third of patients described the ankle as feeling unstable, and in the lower-quality studies the range ran from 7% to 53%. Across the whole review, pain reporting dropped rapidly over the first two weeks and 36% to 85% reported a full recovery within a period of three years, which also means that in some of those studies most people had not reported a full recovery three years on. Those are ranges across studies rather than a rate for any one person, everyone in them was under conventional treatment, and the review covered sprains of the ligaments on the outer side of the ankle in adults.

Do I need an X-ray for an ankle or a knee injury?

That is a question about bone, and there are published checklists for it. The Ottawa ankle rules are a bedside checklist for deciding whether an ankle or midfoot X-ray is needed, and in a systematic review pooling 27 studies and 15,581 patients, a negative result left under a 1.4% chance of a fracture, a figure the reviewers reached by assuming 15 out of every 100 people in the group had a fracture to begin with. In that same review the rules also flagged many people with no fracture, what the reviewers called a modest specificity. In that review the pooled studies included a children’s subgroup, so those figures are not adult-only. For the knee, a meta-analysis of eight studies and 7,385 adults assessed by emergency physicians after an acute knee injury found the Ottawa knee rule identified about 99 out of every 100 knee fractures. Put the other way, the reviewers published a range of statistical uncertainty around that pooled figure, and across that range the number not identified runs from none up to about 3 in every 100. In those same studies the rule flagged about half of the people who did not have a fracture, a specificity of 0.49. Both checklists answer whether a bone is broken and say nothing about ligaments, tendons or muscle, and here the examination is what decides whether imaging is needed.

My MRI says tear. Is that why I hurt?

Not automatically, and it matters in both directions. In a review of MRI reports from 108 ankles, from 104 patients, that were not causing symptoms on the outer side, about 38% had healthy ligaments on the inner and outer sides of the ankle, the medial and lateral ligaments, and in the rest the radiologists recorded ligament discontinuity on a four-grade scale: grade I in 25 cases, grade II in 32, grade III in 5 and grade IV in 5. In a separate look at MRI scans of 253 consecutive patients at a referral center whose hamstrings were not causing symptoms, 35% had normal tendons on both sides at a median age of 51, meaning half of that group were older and half younger, while 15% had a partial tear on both sides at a median age of 63 and 2% had a complete tear on both sides at a median age of 68. Neither review describes a joint that had just been injured. The authors of the ankle review wrote that longer studies would be needed before anyone could say what causes these findings or where they lead. So a word on a report does not by itself settle what is causing your pain, and your pain is not less real because the same word turns up on scans of people who were not hurting. Which one applies to you is what an examination works out.

Should I rest it or keep moving it?

Both, in an order, and which part of that order you are in is the thing to get right. Early on the work is protection: keeping the injured tissue inside what it can take right now, with a clear answer about what you can do at work and at home. After that, load comes back on purpose, prescribed at an amount you can complete and reviewed at the next visit. The last phase is the specific activity you are returning to, tested rather than assumed. An examination is what places you in that sequence, and the plan is checked as you move through it.

Do you use dry needling for a muscle strain?

Dry needling is used here for trigger points, meaning tight, painful knots in a muscle, and for myofascial pain, meaning pain from a muscle and the covering tissue around it. The muscles around an injured joint are part of what the examination checks. Whether needling belongs in your plan is decided at that visit, after you have been examined.

When is a strain or a sprain an emergency?

Not being able to put weight on the leg or foot after an injury, a joint or limb that looks out of shape or feels out of place, new numbness, pins and needles, weakness, or a limb that has gone cold or pale, and a pop at the moment of injury with swelling that comes on within minutes. After a back injury, new loss of bowel or bladder control or numbness in the groin or inner thighs can signal cauda equina syndrome, a surgical emergency. Those need a physician before anything else happens, and imaging is part of that. Go to the emergency department now.

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This page is general health information and is not medical advice for any individual. The studies summarized describe groups, not any one person’s outcome, and whether any finding on your imaging explains your symptoms can only be determined by examination. Talk to Dr. Bobby Koser, DC, about your own situation, and seek emergency care immediately for the warning signs listed above.

Bring the injury, and the paperwork that came with it.

A complete examination with Dr. Bobby Koser, DC, the injured tissue and the joints around it examined together, and your findings explained the same day.