Pharmacists are often patients’ first port of call for strains or sports injuries. Sultan ‘Sid’ Dajani gives a refresher on what pharmacists need to know
Key learning points
A sprain or a twisted joint can happen in most limbs but most commonly in the ankle. One or more ligaments of the ankle experience excessive stress and become abnormally stretched when the foot is moved past its normal range of motion. The sudden excess stress puts a strain on the ligaments. Once the strain goes beyond the yield point, the ligament becomes damaged, or sprained.
Blood vessels leak fluid into the joint, starting from the site of the injury. Increased blood flow and inflammatory exudates including white blood cells, macrophages and leukocytes migrate to the area, causing both inflammation and swelling.
This results in pain, sensitivity and throbbing as the nerves are further sensitised. As further blood flow increases to the site, the area looks a lot redder, feels a lot warmer, becomes more sensitive and there is a decrease in mobility.
Sprains commonly usually result from sports and exercise-related sudden movements, especially side-to-side motion, turning, and rolling of the foot. However, sprained ankles can also result from normal daily activities such as falling, tripping, slipping and missing a step or a curb. Other risk factors include:
Some pre-existing medical conditions can also increase risk. These include weak muscles, ligaments and tendons. These can either be hereditary or because of overstretched ligaments resulting from repetitive ankle sprains.
This can be best achieved by performing either sport-specific stretching exercises that prepare the body for exercise or by holding the muscles to a point of tension and holding the stretch. Advise people to avoid avoiding running on uneven surfaces; wearing footwear with poor heels; or high-heeled shoes with a small base of support.
The healing process has three concurrent strands to it. The initial inflammatory response promotes the influx of inflammatory mediators that clean the injury site of unwanted debris such as bacteria, dead or damaged cells through phagocytosis and provides protection against infection. The presence of inflammation significantly reduces movement and therefore reduces further damage. The vascular element includes the formation of scar tissue, clots and the proliferation of local blood vessels.
This means that, while sprains tend to be self-limiting, early, effective and appropriate intervention can enhance recovery by limiting the inflammatory process at an appropriate phase of recovery. The amount of inflammation is related to the extent of vessel damage, thus reducing pain, promoting rapid healing and shortening rehabilitation.
The location, accessibility and availability of treatments means community pharmacies are usually called upon for a wide range of sport and physical activity related injuries. It’s important that pharmacists and counter assistants know the symptoms to determine the injury is not a bone fracture and identify common injuries.
They should understand the risk factors and be able to advise on prevention of sports-related injuries. Equally they should be able to provide specific advice to patients on effective management, including the role of over-the-counter (OTC) pharmacological treatments.
The pharmacy team need to determine the severity of the sprain and whether it can be managed with appropriate self-care and advice or if a referral is necessary. Taking a comprehensive history enables them to understand the cause of the injury, identify the possible mechanism and likely severity. You should establish:
When possible, you should examine the injury in a consultation room. Sometimes the patient has already removed their footwear to avoid additional pain and it’s possible that any swelling may mean they cannot put their shoes back on.
Pharmacists need to observe the following symptoms and the severity to which they are present as this may indicate any underlying damage and require a referral.
Pharmacists also need to be aware of any other injuries that may have occurred during the sprain, such as a fall resulting in a head wound, dizziness, vomiting or concussion. The presence of:
could be indicate a fracture or dislocation, in which case the only option is to refer the patient to A&E.
Two approaches exist for the treatment of acute injuries:
PRICE stands for Protection, Rest, Ice, Compression and Elevation. Start as soon as possible and continue for the first 48 to 72 hours from the time of injury. The patient should rest and use crutches or slings to avoid any weight bearing movement.
Ice is often used to reduce swelling in cycles of 15 to 20 minutes on and 20 to 30 minutes off. Continue this cycle as far as practically possible for the first day until bedtime, then again as often as possible for up to 72 hours. However, do not leave ice on for too long – this can cause cold injuries, indicated if the area turns white.
Compression bandages are used to provide both support and compression. Start wrapping at the ball of the foot and slowly continue up to the base of the calf muscle. This pushes the swelling up toward the centre of the body so that it does not gather in the foot. At the same time, elevation and rest limits the amount of swelling to the areas and facilitates venous and lymphatic drainage.
After 48 hours, MICE (Movement, Ice, Compression and Elevation) can be introduced, with gentle movement replacing rest. If pain is experienced on repetition of gentle movement, or if there is constant pain, then rest should continue for another 24 hours before the introduction of movement is tried again. If this is unsuccessful, consider referral to a GP.
Use non-steroidal anti-inflammatory drugs (NSAIDs) to treat pain, reduce any localised heat, decrease swelling and improve mobility. Oral pain relief normally starts soon after the first dose and the full analgesic effect occurs within a week.
Topical NSAIDs can be applied directly to the site of the injury. Topically applied NSAIDs penetrate the skin and result in therapeutically significant concentrations in underlying inflamed soft tissues, joints and synovial fluid, probably entering the synovial joint mainly via systemic circulation.
In tendinopathies (painful tendons), inflammation plays a lesser role and so NSAIDs have little influence on healing but they can help with short-term analgesia. If used in the first seven days inn sprains, strains or ligament tears NSAIDs can also be used to limit pain and swelling thus increasing the chances of the patient regaining function and returning to activity sooner.
Patients should be advised to take NSAIDs with food. Following that advice, short-term use of NSAIDs is safe but patients should be counselled that long-term use increases the risks of systemic side effects (such as gastrointestinal and cardiovascular effects). It is estimated that 20 to 30% of people taking NSAIDs regularly experience side effects. [1, 2]
Topical preparations lack such associated systemic side effects. However patients are more likely to experience local side effects, including skin reactions (eg dermatitis, pruritis or erythema) and photosensitivity reactions, which usually resolve on discontinuation of treatment.
Patients are unlikely to gain any additional benefits by simultaneously using topical NSAIDs and oral NSAID therapy. Topical NSAIDs as sole therapy may be useful if the patient cannot tolerate oral NSAIDs.
Paracetamol and opioids are also recommended for rapid treatment of pain and consequent muscle spasm. Opioid use is limited by the development of side effects, such as constipation, dizziness and drowsiness, which may arise even at OTC doses, especially with prolonged use.
Most people improve significantly in the first two weeks. However, up to 30% may still have problems with pain and instability after one year. Re-injury is also very common and so aftercare counselling is necessary.
Returning to activity prematurely and before the ligaments have fully healed may cause them to heal in a stretched position, resulting in less stability at the ankle joint. This can lead to a condition known as Chronic Ankle Instability (CAI) and an increased risk of joint weakness and further ankle sprains.
Other advice to help prevent re-injury includes the use of protective equipment (e.g. mouthguards, helmets or knee pads) and appropriate, activity-specific training regimens, which includes recovery between activity episodes.
Sultan Dajani is a community pharmacist and Royal Pharmaceutical Society English Pharmacy Board Member