What are the management guidelines for someone prone to muscle sprains and tendon/ligament sprains?

Management Guidelines for Recurrent Muscle and Ligament/Tendon Sprains

For individuals prone to recurrent muscle strains and ligament/tendon sprains, implement a comprehensive prevention program centered on supervised neuromuscular training with proprioception exercises combined with functional bracing during high-risk activities, as this approach has Level 1 evidence for reducing recurrent injuries by 38-62%. 1

Prevention Strategy: The Core Approach

Primary prevention requires ongoing supervised exercise therapy integrated into regular training activities, not just rehabilitation after injury. 1 This is the single most effective intervention for preventing recurrent sprains, with a relative risk reduction of 0.62 (95% CI 0.51-0.76) for ankle sprains, and even greater protection (RR 0.38) in athletes. 1

Exercise-Based Prevention Program

Your prevention program must include four components performed 3-4 times weekly:

• Proprioception training: Balance exercises on unstable surfaces, single-leg stance progressions, and perturbation training to restore neuromuscular control 1, 2
• Strengthening exercises: Focus on eccentric strengthening for muscles crossing two joints (hamstrings, gastrocnemius, rectus femoris) as these are most susceptible to strain 3, 4, 5
• Coordination exercises: Sport-specific movement patterns with emphasis on controlled deceleration 2
• Flexibility work: Stretching of posterior shoulder, hamstring, and calf muscle groups to address muscle imbalances 1, 3

Critical point: Home-based exercises alone are insufficient—supervised training by a physical therapist is superior and necessary for optimal outcomes. 2

Functional Support During Activity

Continue wearing lace-up or semi-rigid ankle braces during all high-risk activities indefinitely, even after full recovery. 1, 2 Functional support prevents recurrent ankle sprains with a relative risk of 0.30 (95% CI 0.21-0.43) compared to no support. 1 This applies to both ankle and other joint injuries prone to recurrence.

• Lace-up or semi-rigid braces are superior to tape or elastic bandages 2, 3
• Bracing does not limit performance but provides mechanical stability during vulnerable positions 1
• For muscle strains, continue support devices during return to activity if there is history of recurrent strains 3

Identifying and Addressing Risk Factors

Assess and modify these specific predisposing factors at each evaluation:

• Muscle strength imbalances: Preseason weakness in specific muscle groups (external rotators, hamstrings, supraspinatus) predicts in-season injuries requiring surgery 1
• Previous injury history: A prior sprain is the strongest predictor of recurrent injury due to residual ligament laxity and proprioceptive deficits 1
• Sport participation: Certain sports (basketball, volleyball, soccer) carry 7 per 1000 exposures risk for ankle sprains 1
• Inadequate rehabilitation: Incomplete recovery from previous injuries leads to chronic instability, pain, and decreased range of motion 2

When Acute Injury Occurs Despite Prevention

If a new sprain occurs, immediately implement functional treatment rather than immobilization:

First 48-72 Hours

• Apply PRICE protocol strategically (not RICE alone, which lacks evidence): Protection with brace, relative rest from painful activities only, ice 20-30 minutes 3-4 times daily, compression wrap, elevation 2, 3, 6
• Start weight-bearing immediately as tolerated—avoid complete rest beyond initial pain control 2
• Apply lace-up or semi-rigid brace within 48 hours and continue for 4-6 weeks 2

48-72 Hours Post-Injury

Begin supervised exercise therapy immediately—this has Level 1 evidence and is the most critical intervention for preventing chronic problems. 1, 2 Delaying exercise therapy worsens outcomes and increases recurrence risk.

Pain Management

• NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib) for <14 days to reduce pain and swelling, accelerating return to activity 2
• Avoid opioids—they cause more side effects without superior pain relief 2
• Caution with NSAIDs: They may suppress natural healing processes, so limit duration 1

Critical Pitfalls to Avoid

Never immobilize beyond 3-5 days—prolonged immobilization causes decreased range of motion, chronic pain, joint instability, and muscle deconditioning without any demonstrated benefits. 1, 2 Immobilization shows a relative risk of 1.17 for recurrent sprains compared to functional treatment. 1

Do not rely on passive modalities alone (ultrasound, laser therapy, electrotherapy)—these show no effect on pain, function, or return to play. 1 Manual mobilization only works when combined with exercise therapy. 1

Avoid serial casting for dystonia or fixed positions—this worsens symptoms and can cause complex regional pain syndrome. 1

Off-Season and Preseason Requirements

Maintain strength training year-round, particularly in the off-season. 1 Preseason weakness directly correlates with in-season injuries requiring surgical intervention. Continue your neuromuscular training program 3-4 times weekly even when not actively competing. 1

Long-Term Monitoring

• Re-examine 4-5 days after any new injury when swelling has decreased for accurate assessment of ligament damage 2
• Incorporate prevention exercises into regular training permanently—this has high cost-benefit ratios due to reduced recurrence rates 2
• Consider surgical consultation only if comprehensive 3-6 month exercise-based physiotherapy program fails to resolve chronic instability 1

The evidence is unequivocal: supervised exercise therapy combined with functional bracing prevents 38-62% of recurrent sprains, while immobilization and passive treatments fail. 1 Your management must prioritize active rehabilitation over rest.