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Contusions, Strains, and Sprains A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising). A hematoma develops from bleeding at the site of impact, leaving a characteristic “black and blue” appearance. Contusions can be minor or severe, isolated or in conjunction with additional injuries (e.g., fracture). Local symptoms include pain, swelling, and discoloration. Contusions can limit joint range of motion (ROM) near the injury, and the injured muscle may feel weak and stiff (American Academy of Orthopedic Surgeons [AAOS], 2019a). Most contusions resolve in 1 to 2 weeks; severe contusions may take longer to heal. A strain is an injury to a muscle or tendon from overuse, overstretching, or excessive stress; it is commonly known as a muscle pull (Babarinde, Ismail, & Schellack, 2018). Tendons are fibrous cords that attach muscle to a bone; strains often occur in tendons of the foot, leg (e.g., hamstring), and back. Strains can be categorized as acute or chronic and are graded along a continuum based on postinjury symptoms and loss of function. Acute strains can result from a single injurious incident; whereas, chronic strains result from repetitive injuries. Chronic strains can result from improper management of acute strains. Depending on the severity of muscle fiber damage, three degrees of strains can be classified (Babarinde et al., 2018): A first-degree strain is mild stretching of the muscle or tendon with no loss of ROM. Signs and symptoms may include the gradual onset of palpation-induced tenderness and mild muscle spasm. A second-degree strain involves moderate stretching and/or partial tearing of the muscle or tendon. Signs and symptoms include acute pain during the precipitating event, followed by tenderness at the site with increased pain with passive ROM (PROM), edema, significant muscle spasm, and ecchymosis. A third-degree strain is severe muscle or tendon stretching with rupturing and complete tearing of the involved tissue. Signs and symptoms include immediate pain described as tearing, snapping, or burning, muscle spasm, ecchymosis, edema, and loss of function. An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. X-rays do not reveal injuries to soft tissue or muscles, tendons, or ligaments, but magnetic resonance imaging (MRI) and ultrasound can identify tendon injury. A sprain is an injury to the ligaments and tendons that surround a joint. It is caused by a twisting motion or hyperextension (forcible) of a joint (Babarinde et al., 2018). While tendons connect muscle to bone, ligaments connect bone to bone. The function of a ligament is to stabilize and support the body’s joints while permitting mobility. An injured ligament causes joint instability, with the most vulnerable areas of the body being the ankles, knees, and wrists. The severity of a sprain is graded according to how badly the ligament has been damaged and whether or not the joint has been made unstable (Maughan, 2019): A Grade I sprain is stretching or slight tearing in some fibers of the ligament and mild, localized hematoma formation. Manifestations include mild pain, edema, and local tenderness. A Grade II sprain is more severe and involves partial tearing of the ligament. Manifestations include increased pain with motion, edema, tenderness, joint instability, ecchymosis, and partial loss of normal joint function. A Grade III sprain is a complete tear or rupture of the ligament. A Grade III sprain may also cause an avulsion of the bone. Symptoms include severe pain, edema, tenderness, ecchymosis, and abnormal joint motion. Management The treatment for contusions, strains, and sprains is guided by the severity of injury and the goal of protecting from further injury. Protection from further injury is accomplished through support of the affected area (e.g., sling, brace) and/or splinting, taping, or compression bandages. To control pain, bleeding, and inflammation, most contusions, strains, and sprains are managed with the RICE method, an acronym that refers to rest, ice, compression, and elevation (AAOS, 2019a). Rest prevents additional injury and promotes healing. Intermittent application of cold or ice packs during the first 24 to 72 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. Cold packs should not be in place for longer than 20 minutes at a time, and care must be taken to avoid skin and tissue damage from excessive cold (AAOS, 2019a). An elastic compression bandage controls bleeding, reduces edema, and provides support for the injured tissues. Elevation at or just above the level of the heart controls the swelling (AAOS, 2019a). If the sprain or strain is the most severe grade or degree, immobilization by a splint, brace, or cast may be necessary so that the joint will not lose its stability (see later discussions). Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for pain management (AAOS, 2019a). The neurovascular status, a type of focused assessment of the neurologic (motor and sensory) and vascular function of the injured extremity, is monitored at frequent intervals (e.g., every 15 minutes for the first 1 to 2 hours after injury) and then at lesser intervals (e.g., every 30 minutes) until stable. Decreases in sensation or motion and increases in pain level should be documented and reported to the patient’s primary provider immediately so that acute compartment syndrome can be prevented (see later discussion).