Sprains and Strains

Also indexed as: Joint Injuries, Ligament Injuries, Muscle Injuries

Sprains and strains are types of minor injuries to the soft tissues and connective tissues of the musculoskeletal system. Sprains usually refer to injuries to ligaments, but sometimes to other connective tissues, such as tendons and the capsules surrounding joints. Strains usually refer to injuries to muscles or to the areas where muscles become tendons. Sprains and strains may occur together, and occasionally are quite severe, requiring immobilization of the body part in a rigid cast for weeks, long-term rehabilitation programs, and sometimes surgery.

Checklist for Sprains and Strains

Rating Nutritional Supplements Herbs
3Stars Enzymes (chymotrypsin, trypsin)  
2Stars Bromelain
L-carnitine (for preventing exercise-related muscle injury)
Vitamin A (for deficiency only)
Vitamin C
Zinc (if deficient)		 Horse chestnut (topical)
1Star Chondroitin sulfate
Copper
DMSO (topical)
Enzymes (papain)
Glucosamine sulfate
Manganese
Multiple vitamin-mineral
Silicon
Vitamin E (for exercise-related muscle strain)		 Arnica (topical)
Comfrey (topical)
See also:  Homeopathic Remedies for Sprains and Strains
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of sprains and strains? The most common type of sprain is the ankle sprain. Ankle sprains have differing degrees of severity. Mild or minimal sprains with no tear of the ligament usually produce mild tenderness and some swelling. Moderate sprains, in which the ligament has been partially ruptured, produce obvious swelling, bruising, significant tenderness, and difficulty walking. Severe sprains, as when the ligament is completely torn from the bone (called avulsion), make walking impossible and produce marked swelling, internal bleeding and joint instability.

Symptoms of strains include muscle soreness, muscle spasm, pain, and possibly swelling or warmth over the involved muscle.

How is it treated? Conventional treatment of minor sprains and strains includes resting the affected area, applying cold packs or ice, wrapping the area with a compression bandage (ACE®), and keeping the affected area elevated as much as possible. Mild to moderate ankle sprains usually require strapping with elastic bandages or tape, or immobilization with a brace. Doctors recommend “RICE” for sprains and strains, which stands for rest, ice, compression, and elevation. A sprained ankle should always be X-rayed to rule out a fracture. Over-the-counter pain medications, such as aspirin, acetaminophen, and ibuprofen, are routinely recommended to relieve minor pain and reduce inflammation. In more severe cases, prescription pain medications, such as acetaminophen with codeine (Tylenol® with codeine) or acetaminophen with hydrocodone (Vicodin®) may be used.

Dietary changes that may be helpful: Adequate amounts of calories and protein are required for the body to repair damaged connective tissue. While major injuries requiring hospitalization raise protein and calorie requirements significantly, minor sprains and strains do not require changes from a typical, healthful diet.1

Nutritional supplements that may be helpful: Proteolytic enzymes, including bromelain, papain, trypsin, and chymotrypsin, may be helpful in healing minor injuries such as sprains and strains because they have anti-inflammatory activity and appear to promote tissue healing.2 3 4

Several preliminary trials have reported reduced pain and swelling, and/or faster healing in people with a variety of conditions using either bromelain,5 papain from papaya, 6 7 or a combination of trypsin and chymotrypsin.8 Double-blind trials have reported faster recovery from athletic injuries, including sprains and strains, and earlier return to activity using eight tablets daily of trypsin/chymotrypsin,9 10 11 12 four to eight tablets daily of papain,13 eight tablets of bromelain (single-blind only),14 or a combination of these enzymes.15 However, one double-blind trial using eight tablets per day of trypsin/chymotrypsin to treat sprained ankles found no significant effect on swelling, bruising, or overall function.16

Bromelain is measured in MCUs (milk clotting units) or GDUs (gelatin dissolving units). One GDU equals 1.5 MCU. Strong products contain at least 2,000 MCU (1,333 GDU) per gram (1,000 mg). A supplement containing 500 mg labeled “2,000 MCU per gram” would have 1,000 MCU of activity, because 500 mg is half a gram. Some doctors recommend 3,000 MCU taken three times per day for several days, followed by 2,000 MCU three times per day. Some of the research, however, uses smaller amounts, such as 2,000 MCU taken in divided amounts in the course of a day (500 MCU taken four times per day). Other enzyme preparations, such as trypsin/chymotrypsin, have different measuring units. Recommended use is typically two tablets four times per day on an empty stomach, but as with bromelain, the strength of trypsin/chymotrypsin tablets can vary significantly from product to product.

One controlled trial showed that people who supplement with 3 grams per day L-carnitine for three weeks before engaging in an exercise regimen are less likely to experience muscle soreness.17

Antioxidant supplements, including vitamin C and vitamin E, may help prevent exercise-related muscle injuries by neutralizing free radicals produced during strenuous activities.18 Controlled research, some of it double-blind, has shown that 400–3,000 mg per day of vitamin C may reduce pain and speed up muscle strength recovery after intense exercise.19 20 Reductions in blood indicators of muscle damage and free radical activity have also been reported for supplementation with 400–1,200 IU per day of vitamin E in most studies,21 22 23 but no measurable benefits in exercise recovery have been reported.24 A combination of 90 mg per day of coenzyme Q10 and a very small amount of vitamin E did not produce any protective effects in one double-blind trial.25

Vitamin C is needed to make collagen, the “glue” that strengthens connective tissue. Injury, at least when severe, appears to increase vitamin C requirements,26 and vitamin C deficiency causes delayed healing from injury.27 Preliminary human studies have suggested that vitamin C supplementation in non-deficient people can speed healing of various types of trauma, including musculoskeletal injuries,28 29 but double-blind research has not confirmed these effects for athletic injuries, which included sprains and strains.30

Zinc is a component of many enzymes, including some that are needed to repair wounds. Even a mild deficiency of zinc can interfere with optimal recovery from everyday tissue damage as well as from more serious trauma.31 Trace minerals, such as manganese, copper, and silicon are also known to be important in the biochemistry of tissue healing.32 33 34 35 However, there have been no controlled studies of people with sprains or strains to explore the effect of deficiency of these minerals, or of oral supplementation, on the rate of healing.

Many vitamins and minerals have essential roles in tissue repair, and deficiencies of one or more of these nutrients have been demonstrated in animal studies to impair the healing process.36 This could argue for the use of multiple vitamin-mineral supplements by people with minor injuries who might have deficiencies due to poor diets or other problems, but controlled human research is lacking to support this.

Glucosamine sulfate and chondroitin sulfate may both play a role in wound healing by providing the raw material needed by the body to manufacture molecules called glycosaminoglycans found in skin, tendons, ligaments, and joints.37 Test tube and animal studies have found that these substances, and others like them, can promote improved tissue healing.38 39 40 41 Injectable forms of chondroitin sulfate have been used in Europe for various types of sports-related injuries to tendons and joints,42 43 44 45 and one preliminary trial reported reduced pain and good healing in young athletes with chondromalacia patella (cartilage softening in the knee) who were given 750–1,500 mg per day of oral glucosamine sulfate.46 However, specific human trials of glucosamine and chondroitin sulfate for healing sprains and strains are lacking.

The use of DMSO, a colorless, oily liquid primarily used as an industrial solvent, for therapeutic applications is controversial. However, some evidence indicates that dilutions, when applied directly to the skin, have anti-inflammatory properties and inhibit the transmission of pain messages by nerves, and in this way might ease the pain of minor injuries such as sprains and strains.47 48 49 However no controlled research exists to confirm these effects in sprains and strains. DMSO comes in different strengths and different degrees of purity. In addition, certain precautions must be taken when applying DMSO. For those reasons, DMSO should be used only with the supervision of a doctor.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Horse chestnut contains a compound called aescin that acts as an anti-inflammatory and reduces edema (swelling with fluid) following trauma, particularly sports injuries, surgery, and head injury.50 A topical gel containing 2% of the compound aescin found in horse chestnut is widely used in Germany to treat minor sports injuries, including sprains and strains.51 The gel is typically applied to affected area every two hours until swelling begins to subside.

Arnica is considered by some practitioners to be among the most effective wound-healing herbs available.52 As a homeopathic remedy, arnica is often recommended as both an internal and topical mean to treat minor injuries. Some healthcare practitioners recommend mixing 1 tablespoon of arnica tincture in 500 ml water, then soaking thin cloth or gauze in the liquid and applying it to the injured area for at least 15 minutes four to five times per day.

Comfrey is also widely used in traditional medicine as a topical application to help heal wounds.53

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Spinal manipulation is used by chiropractors, licensed naturopathic doctors, and some osteopathic doctors to relieve pain and improve healing of sprains and strains. One preliminary trial tested a combination of chiropractic manipulation, muscle stretching, and special exercises known as “proprioceptive neurofacilitation” to people who had sprain/strain neck injuries that had not resolved with other treatment.54 Treatment was reported to help the majority of people, and over one-third reported that their symptoms were completely gone or only mildly bothersome. In a larger preliminary trial,55 people who were still suffering neck pain a year after whiplash-type accidents were treated with spinal manipulation for an average of four months. At the end of the treatments, 72% reported at least some benefit and nearly half reported significant benefit or complete recovery, but people with the most severe symptoms derived little benefit.

References:

1. Souba WW, Wilmore D. Diet and nutrition in the care of the patient with surgery, trauma, and sepsis. In: Shils ME, Olson JA, Shike M, et al. Modern Nutrition in Health and Disease, 9th ed. Baltimore, MD: Williams & Wilkins, 1999, 1589–618.

2. Seligman B. Bromelain: An anti-inflammatory agent. Angiology 1962;13:508–10.

3. Castell JV, Friedrich G, Kuhn CS, et al. Intestinal absorption of undegraded proteins in men: presence of bromelain in plasma after oral intake. Am J Physiol 1997;273:G139–46.

4. Miller JM. Absorption of orally introduced proteolytic enzymes. Clin Med 1968;75:35–42 [review].

5. Cirelli MG. Five years experience with bromelains in therapy of edema and inflammation in postoperative tissue reaction, skin infections and trauma. Clin Med 1967;74(6):55–9.

6. Trickett P. Proteolytic enzymes in treatment of athletic injuries. Appl Ther 1964;6:647–52.

7. Sweeny FJ. Treatment of athletic injuries with an oral proteolytic enzyme. Med Times 1963:91:765.

8. Boyne PS, Medhurst H. Oral anti-inflammatory enzyme therapy in injuries in professional footballers. Practitioner 1967;198:543–6.

9. Deitrick RE. Oral proteolytic enzymes in the treatment of athletic injuries: A double-blind study. Pennsylvania Med J 1965;Oct:35–7.

10. Rathgeber WF. The use of proteolytic enzymes (Chymoral) in sporting injuries. S Afr Med J 1971;45:181–3.

11. Buck JE, Phillips N. Trial of Chymoral in professional footballers. Br J Clin Pract 1970;24:375–7.

12. Tsomides J, Goldberg RI. Controlled evaluation of oral chymotrypsin-trypsin treatment of injuries to the head and face. Clin Med 1969;76(11):40.

13. Holt HT. Carica papaya as ancillary therapy for athletic injuries. Curr Ther Res 1969;11:621–4.

14. Blonstein JL. Oral enzyme tablets in the treatment of boxing injuries. Practitioner 1967;198:547.

15. Baumüller M. Therapy of ankle joint distortions with hydrolytic enzymes—results from a double blind clinical trial. In Hermans GPH, Mosterd WL, eds. Sports, Medicine and Health. Amsterdam: Excerpta Medica, 1990, 1137.

16. Craig RP. The quantitative evaluation of the use of oral proteolytic enzymes in the treatment of sprained ankles. Injury 1975;6:313–6.

17. Giamberardino MA, Dragani L, Valente R, et al. Effects of prolonged L-carnitine administration on delayed muscle pain and CK release after eccentric effort. Int J Sports Med 1996;17:320–4.

18. Kanter M. Free radicals, exercise and antioxidant supplementation. Proc Nutr Soc 1998;57:9–13 [review].

19. Jakeman P, Maxwell S. Effect of antioxidant vitamin supplementation on muscle function after eccentric exercise. Eur J Appl Physiol 1993;67:426–30.

20. Kaminski M, Boal R. An effect of ascorbic acid on delayed-onset muscle soreness. Pain 1992;50:317–21.

21. McBride JM, Kraemer WJ, Triplett-McBride T, et al. Effect of resistance exercise on free radical production. Med Sci Sports Exerc 1998;30:67–72.

22. Rokitzki L, Logemann E, Huber G, et al. alpha-Tocopherol supplementation in racing cyclists during extreme endurance training. Int J Sport Nutr 1994;4:253–64.

23. Meydani M, Evans WJ, Handelman, et al. Protective effect of vitamin E on exercise-induced oxidative damage in young and older adults. Am J Physiol 1993;264(5 pt 2):R992–8.

24. Tiidus PM, Houston ME. Vitamin E status and response to exercise training. Sports Med 1995;20:12–23 [review].

25. Kaikkonen J, Kosonen L, Nyyssonen K, et al. Effect of combined coenzyme Q10 and d-alpha-tocopheryl acetate supplementation on exercise-induced lipid peroxidation and muscular damage: a placebo-controlled double-blind study in marathon runners. Free Radic Res 1998;29:85–92.

26. Levine M. New concepts in the biology and biochemistry of ascorbic acid. N Engl J Med 1986;314:892–902 [review].

27. Mazzotta MY. Nutrition and wound healing. J Am Podiatr Med Assoc 1994;84:456–62 [review].

28. Mazzotta MY. Nutrition and wound healing. J Am Podiatr Med Assoc 1994;84:456–62 [review].

29. Ringsdorf WM Jr, Cheraskin E. Vitamin C and human wound healing. Oral Surg Oral Med Oral Pathol 1982;53:231–6 [review].

30. Gey GO, Cooper KH, Bottenberg RA. Effect of ascorbic acid on endurance performance and athletic injury. JAMA 1970;211:105.

31. Sandstead HH. Understanding zinc: Recent observations and interpretations. J Lab Clin Med 1994;124:322–7.

32. Tenaud I, Sainte-Marie I, Jumbou O, et al. In vitro modulation of keratinocyte wound healing integrins by zinc, copper and manganese. Br J Dermatol 1999;140:26–34.

33. Pereira CE, Felcman J. Correlation between five minerals and the healing effect of Brazilian medicinal plants. Biol Trace Elem Res 1998;65:251–9.

34. Carlisle EM. Silicon as an essential trace element in animal nutrition. Ciba Found Symp 1986;121:123–39.

35. Leach RM. Role of manganese in mucopolysaccharide metabolism. Fed Proc 1971;30:991.

36. Bucci, L. Nutrition Applied to Injury Rehabilitation and Sports Medicine. Boca Raton, FL: CRC Press, 1995, 61–166.

37. Morrison LM, Murata K. Absorption, distribution, metabolism and excretion of acid mucopolysaccharides administered to animals and patients. In: Morrison LM, Schjeide OA, Meyer K. Coronary heart disease and the mucopolysaccharides (glycosaminoglycans). Springfield: Charles C. Thomas, 1974, 109–27.

38. Denuziere A, Ferrier D, Damour O, et al. Chitosan-chondroitin sulfate and chitosan-hyaluronate polyelectrolyte complexes: biological properties. Biomaterials 1998;19:1275–85.

39. McCarty MF. Glucosamine for wound healing. Med Hypotheses 1996;47:273–5 [review].

40. Glade MJ. Polysulfated glycosaminoglycan accelerates net synthesis of collagen and glycosaminoglycans by arthritic equine cartilage tissues and chondrocytes. Am J Vet Res 1990;51:779–85.

41. Prudden JF, Wolarsky ER, Balassa L. The acceleration of healing. Surg Gynecol Obstet 1969;128:1321–6 [review].

42. Bucci L. Nutrition applied to injury rehabilitation and sports medicine. Boca Raton, FL: CRC Press, 1995, 193.

43. Sprengel H, Franke J, Sprengel A. Personal experiences in the conservative therapy of patellar chondropathy. Beitr Orthop Traumatol 1990;37:259–66 [in German].

44. Lysholm J. The relation between pain and torque in an isokinetic strength test of knee extension. Arthroscopy 1987;3:182–4.

45. Ziegler R, Rau R. Conservative or operative treatment for chondropathia patellae? Beitr Orthop Traumatol 1980;27:201–11 [in German].

46. Böhmer D, Ambrus P, Szögy A, et al. Treatment of chondropathia patellae in young athletes with glucosamine sulfate. In: Bachl N, Prokop L, Suckert R, eds. Current topics in sports medicine. Vienna: Urban & Schwarzenberg, 1984, 799.

47. Swanson BN. Medical use of dimethyl sulfoxide (DMSO). Rev Clin Basic Pharmacol 1985;5:1–33 [review].

48. American Medical Association. Dimethyl sulfoxide. Controversy and Current Status–1981. JAMA 1982;248:1369–71 [review].

49. Jacob SW, Wood DC. Dimethyl sulfoxide (DMSO). Toxicology, pharmacology, and clinical experience. Am J Surg 1967;114:414–26 [review].

50. Guillaume M, Padioleau F. Veinotonic effect, vascular protection, anti-inflammatory and free radical scavenging properties of horse chestnut extract. Arzneimittelforschung 1994;44:25–35.

51. Pabst H. Kleine MW. Prevention and therapy of sports injuries. Experiences with an escin-containing gel. Fortschr Med 1986;104:44–6.

52. Weiss R. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd, 1988, 342.

53. Weiss R. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd, 1988, 342.

54. Woodward MN, Cook JC, Gargan MF, Bannister GC. Chiropractic treatment of chronic “whiplash” injuries. Injury 1996;27:643–5.

55. Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. J Orthop Med 1999;21:22–5.