Changes

June 2025 — reviewed. A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

Update

Goals

• Make a diagnosis of sprains and/or strains. 
• Manage symptoms of pain and swelling and enable a person to return to pre-injury functioning as soon as possible.
• Arrange appropriate referral of people needing specialist assessment or treatment.
• Provide advice on measures to prevent or reduce the risk of further sprains and strains.

Outcome measures

Audit criteria

QOF indicators

QIPP - options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• A sprain is a stretch and/or tear of a ligament. They occur as a result of abnormal or excessive forces applied to a joint.
  • Sprains are classified by severity as:
    • 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 joint instability.
  • They typically affect the ankles, knees, wrists, and thumbs.
• A strain (or 'pull') is a stretch and/or tear of muscle fibres and/or tendon. They occur either because a muscle has been stretched beyond its limits or it has been forced to contract too strongly.
  • Strains are classified by severity as:
    • First-degree (mild) strain — only a few muscle fibres are stretched or torn. Although the injured muscle is tender and painful, it has normal strength, but power may be limited by pain.
    • Second-degree (moderate) strain — there are several injured muscle fibres and more severe muscle pain and tenderness. There is also mild swelling, noticeable loss of strength, and sometimes a visible bruise.
    • Third-degree (severe) strain — the 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. There is a total loss of muscle function, severe pain and swelling, a visible bruise, and difficulty weight-bearing.
  • They typically affect the foot, thigh muscles, and back.

[Kuske, 2016; Vuurberg, 2018; Chen, 2019; AAOS, 2020; Newman, 2022]

What are the risk factors?

The risk of sprains and strains is increased in people who frequently participate in sports.

• Factors that increase the risk of injury during sports include:
  • The type of sport:
    • Contact sports (such as football, hockey, and boxing) and sports that feature quick starts (such as hurdling, long jump, and sprinting) increase the risk of strains.
    • Tennis, gymnastics, rowing, golf, and other sports that require extensive gripping increase the risk of hand sprains.
    • Racquet games and throwing increase the risk of elbow sprains.
    • Basketball, football, volleyball, and climbing increase the risk of ankle sprains.
    • Football has a high incidence of hamstring injuries.
  • Reduced strength, flexibility, and coordination — a lack of regular exercise can weaken muscles and joints, making them less flexible and hence more prone to injury.
  • Poor exercise technique — this may cause excessive pressure on particular joints or muscles, increasing the risk of injury.
  • Wearing inappropriate footwear — this can increase the risk of ankle sprains and strains. 
  • Inadequate warm-up before exercising and cool-down after exercising, leading to muscle fatigue and less support for joints.
• Other risk factors for sprains and strains include:
  • Increasing age — a systematic review of 10 studies found increasing age was a strong predictive risk factor for future calf muscle injury.
  • Previous sprain or strain.
  • Sudden trauma, for example, a fall, twist, or blow to the body.
  • Anatomical variations of the foot, ankle, and knee — for example, generalized joint laxity or flatfoot, or joint misalignment.
  • Reduced balance and postural control, reduced joint proprioception, or neuropathy — may increase the risk of ankle sprains and falls.
  • Excessive alcohol intake and drugs causing drowsiness — may increase the risk of ankle sprains and falls.
  • Being overweight or obese — may put excessive pressure on particular joints and muscles, increasing the risk of injury.
  • Being underweight — this may increase the risk of ankle sprains.
  • Overtraining and insufficient recovery time are major contributors to injury risk.
  • Biomechanical imbalances and neuromuscular deficiencies are now recognized as key intrinsic risk factors for non-contact injuries.
  • Environmental conditions and inadequate equipment (for example, worn-out shoes or uneven playing surfaces) are increasingly cited as extrinsic risk factors.

    [Read, 2016; Vuurberg, 2018; Chen, 2019; Macdonald, 2019; AAOS, 2020; Mason, 2022; Hoveidaei, 2025]

How common are sprains and strains?

• Around 30–50% of musculoskeletal injuries are reported as sprains or strains.
  
  • Lateral ankle sprains remain the most prevalent musculoskeletal injury in physically active populations. 
    
    • Around 5% of all emergency department visits in the UK  are due to ankle sprains.
    • An Australian cross-sectional population-based random sample study found that up to 70% of the general population reported having an ankle injury during their lifetime.
    • Approximately half of all ankle sprains occur during athletic activities.
  • US clinical practice guidelines on knee ligament injury state that approximately 70% of all anterior cruciate ligament knee injuries are non-contact in nature and 30% are contact injuries. The incidence of posterior cruciate ligament injury is 0.65–44% of all ligamentous knee injuries. The most common causes for posterior cruciate ligament injury are road traffic collisions and athletics. Acute hamstring strains are the most common muscle strain.

[Waterman, 2010; Hiller, 2012; Chu, 2016; Logerstedt, 2017; Herzog, 2019; Leong, 2019; Bestwick-Stevenson, 2021]

What are the complications?

• Complications of a sprain or strain are more common with more severe injuries, and include:
  • Chronic instability, loss of function, chronic pain, and swelling — particularly following severe sprains. The International Ankle Consortium consensus statement states that [Gribble, 2016]:
    • Lateral ankle sprains can lead to persistent functional limitations; reduced quality of life; and are strongly associated with recurrent sprains, chronic ankle instability (CAI), and post-traumatic osteoarthritis.
    • CAI can occur in up to 70% of individuals with a history of lateral ankle sprain, especially if not properly rehabilitated.
    • Individuals with a history of lateral ankle sprain represent a significant proportion of surgical cases for end-stage post-traumatic ankle osteoarthritis. See the CKS topic on Osteoarthritis for more information.
  • Muscle atrophy, fibrosis, and compartment syndrome — particularly following severe or untreated muscle strains. Chronic muscle changes may result from prolonged immobilization or inadequate rehabilitation. 
  • Haemarthrosis (which presents with a very painful and tender joint swelling immediately after injury) or septic arthritis (which may present with fever, malaise, joint swelling, heat, and tenderness developing after injury), especially in cases involving joint capsule trauma or immunocompromised individuals.
  • Charcot arthropathy — particularly following a severe ankle sprain in a person with diabetes mellitus, due to impaired proprioception and delayed recognition of joint damage.
  • Complex regional pain syndrome  — a rare but serious complication that may follow even minor sprains or strains, characterized by disproportionate pain, sensory disturbances, and autonomic dysfunction.
  • Heterotopic ossification  — a rare but recognized complication, particularly following severe soft tissue trauma or surgery. This involves the abnormal formation of mature bone in non-skeletal tissues such as muscles or connective tissue. It may lead to pain, stiffness, and restricted joint mobility. 

[Edwards, 2014; Delco, 2016; Ratti, 2016]  [Strudwick, 2018; Vuurberg, 2018; Herzog, 2019; Mansur, 2022; Hong, 2023; Sonnery-Cottet, 2024]

What is the prognosis?

• The prognosis of a sprain or strain largely depends on the severity of the injury.
  • A mild injury will usually heal within a few weeks with conservative treatment, with minimal risk of long-term complications. 
  • A moderate injury should heal within a few weeks, but there is a high risk of re-injury in the first 4–6 weeks.
  • A severe injury may take months to heal fully, require surgical treatment, and result in complications.
• Early use of rest, ice, compression, and elevation (RICE), followed by a graded return to activity, is associated with faster recovery and reduced risk of recurrence.
• Recovery may be delayed in people with:
  • A history of previous injury to the same area.
  • Poor adherence to rehabilitation exercises.
  • High physical demands or early return to sport or work.
  • Comorbidities such as obesity or diabetes.
• Most people can expect to regain full function and return to pre-injury activity levels, although some may experience residual stiffness or weakness for a period after healing.

[Fulton, 2014; Bielska, 2019; Choi, 2020; Gaddi, 2022; Vaidya, 2022; Wulff, 2024; de Amorim, 2025]

How should I assess a suspected sprain or strain?

If a person presents with a suspected sprain or strain, with acute joint or muscle pain, and/or swelling, and/or bruising:

• Ask about:
  • The mechanism and timing of injury.
    • Sudden inversion and internal rotation of the ankle may indicate a lateral ankle sprain.
    • Acute hamstring strains often occur during sprinting or sudden acceleration.
    • Consider non-accidental injury or domestic abuse where appropriate.
  • The symptoms, including severity and duration.
    • Sprain — localized joint pain, tenderness, swelling, bruising, pain on weight-bearing, and reduced function.
    • Strain — muscle pain, cramping, spasm, weakness, inflammation, and/or bruising.
    • A ‘pop’ at the time of injury may suggest anterior cruciate ligament (ACL) injury or hamstring tear.
    • Chronic joint instability — consider if there is persistent pain, swelling, joint ‘giving way’, recurrent injury, or reduced function.
    • Duration and severity — symptoms lasting more than a few days may indicate a more severe injury.
  • Activity level and risk factors — assess baseline physical activity, previous injuries, use of bracing or taping, and any risk factors for re-injury.
• Examine the person for typical signs and possible complications.
  • Observe for signs of swelling, bruising, limb deformity, or asymmetry/misalignment that may suggest fracture or dislocation.
    • Note: bruising may take up to 24 hours to appear.
    • Note: examination of an acutely injured or painful joint can be difficult owing to pain, swelling, and guarding.
  • Palpate the joint or muscle, including for point tenderness and joint line tenderness.
    • Replication of the person’s ‘known pain’ on palpation and/or stressing of a ligament may indicate ligament injury.
  • Assess active and passive range of motion, strength, joint stability, coordination, balance, gait, and weight-bearing ability. Perform specific tests (for example, anterior drawer test for ankle instability) if appropriate. 
    
    • In ankle injuries with bruising and pain on palpation around the distal fibula, and/or a positive anterior drawer test, a rupture of the lateral ankle ligaments is likely.
    • In hamstring injuries, examination of the hip and lumbar spine should also be performed to identify any other potential causes of posterior thigh pain.
  • Perform a neurovascular examination to assess for peripheral nerve injury and check peripheral pulses are intact and symmetrical.
• Consider arranging referral to an Emergency Department for an X-ray, depending on clinical judgement, if:
  • Needed to assess the extent of an injury and/or for associated injuries.
  • A fracture or other complication is suspected. See the section on X-ray clinical decision rules for more information.
  • An alternative diagnosis is suspected.

What is the differential diagnosis?

Alternative conditions that may present similarly to sprains and strains include:

• Tendinitis — an inflammation or irritation of a tendon or sheath (the covering of a tendon) caused by a series of small stresses that repeatedly aggravate the tendon. Symptoms typically include swelling and pain that worsen with activity.
• Bursitis — inflammation of a bursa (a small, jelly-like sac that acts as a cushion to help reduce friction between bones and soft tissues). A series of small stresses and overuse can cause the bursa in the shoulder, elbow, hip, knee, or ankle to swell. See the CKS topics on Greater trochanteric pain syndrome (trochanteric bursitis), Olecranon bursitis, and Pre-patellar bursitis for more information.
• Tendon rupture or injury — indicated by an inability to move the area served by that tendon's muscle and/or a palpable gap in the tendon.
• Meniscus injury — often affects the knee and involves a twisting injury with a tearing sensation, followed by severe pain. There may be mild to moderate swelling within 24 hours and possible locking of the joint. 
• Achilles tendinopathy — a predominantly degenerative condition that causes pain, swelling, weakness, and stiffness of the Achilles tendon. See the CKS topic on Achilles tendinopathy for more information.
• Stress fractures — may present with posterior thigh pain similar to hamstring strain.
• Joint hypermobility syndrome or Ehlers-Danlos syndrome — heritable connective tissue disease that can cause joint hypermobility and hyperextensibility, frequent dislocations and/or subluxations, joint pain, and early-onset osteoarthritis.
• Referred posterior thigh pain from the lumbar spine, hip joint, or sacroiliac joint. See the CKS topics on Sciatica (lumbar radiculopathy) and Back pain - low (without radiculopathy) for more information.
• Other non-traumatic causes of knee pain — may be caused by several conditions, including Osgood-Schlatter's disease, osteoarthritis, deep vein thrombosis, tumours, and Baker's cyst. See the CKS topic on Knee pain - assessment for more information.

Scenario: Management

From age 5 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of sprains and strains.

Search dates

February 2020 - March 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 21st Februrary 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

#1    MeSH descriptor: [Sprains and Strains] explode all trees            
#2    MeSH descriptor: [Ankle Injuries] explode all trees            
#3    MeSH descriptor: [Knee Injuries] explode all trees            
#4    MeSH descriptor: [Wrist Injuries] explode all trees            
#5    (sprain or sprains or sprained):ti,ab,kw            
#6    ((musc* or (soft next tissue) or hamstring*) near/2 strain*):ti,ab,kw            
#7    ((knee or ankle or wrist) near/2 injur*):ti,ab,kw            
#8    (ottawa near/3 rule*):ti,ab,kw            
#9    #1 or #2 or #3 or #4 or #5 or #6 or #7    or #8    

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
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• Non-personal financial gain or benefit

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Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.