A Sprain Is a Tear: Understanding Injury Speak

Will Carroll@injuryexpertSports Injuries Lead WriterAugust 21, 2013

FOXBORO, MA - JULY 26: Tom Brady #12 directs traffic as Tim Tebow #5 looks on during the first day of New England Patriots Training Camp at Gillette Stadium on July 26, 2013 in Foxboro, Massachusetts. (Photo by Jim Rogash/Getty Images)
Jim Rogash/Getty Images

"It's just a sprain!"

I've seen this phrase uttered many times in the decade that I've been writing about injuries, and nothing seems to confuse people more. The fact is that the concept is very simple and yet continually misunderstood and misused—even by coaches and media that should know better.

Let's start with the simplest definition. A sprain is a tear. Period. Point blank. End of story.

A sprain is a tear.

The biggest issue is that most people use the term "tear" improperly, rather than "rupture." A rupture is a complete tear; a loss of structural integrity that is undoubtedly going to force a surgical fix.

The full definition of a sprain is a tearing or stretching of the fibers that make up a ligament. Anything from rolling your ankle to rupturing an ACL likely involves some level of sprain. Do either of those and you've torn ligaments.

Of course, it's a bit more complex than that since there are different levels of severity.

For that, sports medicine has gone to a system of gradations. Sprains come in three grades, usually designated with roman numerals and going up in severity.

A Grade I sprain is a minimal or mild level of tearing or stretching, and usually involves little in the way of swelling or lingering damage. This is the kind of sprain that will cost a player a couple days and some time with an ice pack.

If the ligament were a rope, there would be a bit of fraying, but it's still good enough to tow your boat.

A Grade II sprain is a moderate level of damage. There's a significant tearing of the fibers—enough that the defect is notable—and there is likely laxity and pain on manual testing.

In some cases, a Grade II could require surgery, but this is that tough part where the surgeon is making a judgement call about healing and function.

Using the rope analogy, there's a good chunk out of the rope. You could use it, but it's not the best idea. 

A Grade III sprain is a complete or near complete tearing of the ligament. If it is a complete tear, then the proper term is rupture.

Any Grade III sprain is going to require surgery, and in some ways, it's an easier surgical fix than a Grade II.

The rope analogy here is easy. A Grade III is when you have two smaller ropes having split somewhere in its length. You're going to need a new rope.

We could complicate these gradations with the occasionally seen plus or minuses, such as a Grade I+, which is a bad Grade I, but not enough to get to Grade II. Those are used inconsistently, if at all, so ignore them.

Now that we understand the gradations and the truth of the medical information, we have to get into translating what NFL coaches and injury reports actually say.

First, an X-ray shows us nothing in regard to soft tissue. An X-ray is very good at showing bones and is a decent tool for checking tendons, but there's very little specificity. If the X-ray is negative, that means the bones aren't broken. It doesn't mean the ligaments are intact.

The gold standard of checking a ligament is currently an MRI (magnetic resonance imaging). It's not perfect and can be tough to read in some cases—especially if there is significant swelling—but it's common. In almost all cases, it will be done, often simply because the confirmation is necessary before an insurance company will sign off on surgery.

The best testing might come right on the field. Athletic trainers and doctors can often be seen doing a series of manual tests. If you learn some of these tests, you can quickly see what the AT thinks is wrong or is at least ruling out. These tests can be very accurate—especially in the hands of an experienced practitioner.

There is also some movement to the use of handheld ultrasound devices. These are similar to what is commonly used to see a baby while inside the womb.

They are used by those in sports medicine to quickly look inside. It's not as clear a picture or as wide a view as an MRI, but it's more direct and immediate.

One other thing to watch out for is if you see the AT doing a test on the other (uninjured) leg. Sometimes, it's done to compare the injured leg to the uninjured leg. It's actually a positive sign if you see this, as a seriously compromised ligament is often so clear that no comparison is necessary. 

Finally, the term "structural integrity" is one that is grossly misused. The term "structure" is even debatable, though it usually indicates that the ligaments are not compromised. (Wouldn't it be so much easier to just say Grade II sprain?)

A coach saying that the "X-ray is negative and the knee is structurally sound" just told you nothing, but it looks good on the six o'clock news.

These aren't difficult concepts.

A sprain is merely a term, one with a specific underlying definition. Like any medical term, it describes a specific condition and can be modified to explain more specific information such as severity or duration.

If we can teach everyone these simple concepts, future generations of sports fans won't have to beat their head against the desk like I do each time I hear, "It's sprained, not torn."