A stretching or tearing of ligament occurs when joints are moved beyond their normal range of motion and the collagen fibers within the ligament are pulled apart. Joint "sprains" most frequently occur at the knee (medially), the ankle (laterally), and the acromioclavicular joint of the shoulder (shoulder separation).

Ligament injuries are graded by physicians as follows:

• Grade 1 (mild) The ligament is stretched but still intact. Bleeding is minimal, and there is mild pain and swelling with no instability. There may have been a feeling of "popping".
• Grade 2 (moderate) This involves a partial rupture of the ligament, moderate bleeding, more severe pain and swelling, and inability to walk on the limb.
• Grade 3 (severe) A complete tear of the ligament resulting in severe pain, extensive bleeding, and swelling. The athlete is usually unable to bear weight on the limb. There may be a feeling of complete dislocation, even though that may not have happened.

Signs and Symptoms

• Varying degrees of pain may be present, however, this may not reflect the seriousness of the injury. Athletes sustaining complete ligament tears often report little pain.
• Athletes will often report a "popping" or "snapping" sound at the time of the injury.
• Immediate discoloration and swelling is often indicative of a more severe ligament sprain.
• There can be varying degrees of joint instability depending upon the severity of the injury.

On-Site Management

Suspect a Fracture. If the athlete is unwilling to move the area even after a few minutes, a fracture should be suspected. In these more serious cases, the shoe (in the case of an ankle) or other equipment/clothing should not be removed as this may cause further injury.

P.R.I.C.E. PROTECT the area from further injury (i.e. wrap). REST the area to promote healing. ICE the area to reduce inflammation. After 72 hours use both hot and cold treatment to encourage bad blood away from the area. COMPRESSION helps move inflammation away from the area. ELEVATE the area to promote circulation towards the heart, especially if a knee or ankle ligament injury.

Medical Referral. Prompt attention by a physician is necessary if a severe sprain is suspected. All athletes should be referred to a therapist for a comprehensive rehabilitation program consisting of strength and flexibility exercises as well as sport-specific return to activity drills.

Rehabilitation. For a mild to moderate sprain it is important to do relative rest, avoiding all aggresive exercise (i.e.: jumping, cutting, or throwing exercises. Work on range of motion (ex: with an ankle sprain draw the alphabet using the movement of your foot) and strength. Gradually build up to cutting and then jumping activities.

Return to Activity. The best test for return to activity following an ankle sprain is being able to comfortably hop up and down on the injured ankle. The ankle, however, should always be protected, either by taping or bracing. This is important because the ligament will frequently become lax or loose after injury. Neither of these methods guarantees that the ankle will not be reinjured.

Prevention

• Maintaining balanced strength and flexibility about a joint is essential. Proprioceptive exercises have been shown to significantly decrease the rate of ligament injury.
• Wraps, taping and/or bracing are often used in an attempt to minimize severe ranges of motion for the ankle and knee.
• Proper maintenance of equipment (such as ski bindings) can also help prevent injury.

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