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Sprain or Strain? What’s the difference and does it matter?

John had been seeing a chiropractor for the better part of 7 months because of neck pain resulting from a (MVC) Motor Vehicle Crash.  He had been treating 3 times a week and was still complaining of pain.  The insurance carrier stopped paying and demanded an independent evaluation.  Based upon the IME report the insurance carrier quit paying.  
The chiropractor had diagnosed John with an acute traumatic moderate sprain / strain to the cervical spine.  How this diagnosis was formulated was almost entirely based upon examination findings of painful Range of Motion (ROM).  The chiropractor took plain film radiographs at the onset of care, which consisted of static views (AP and Lateral).  The films demonstrated absence of fractures and were otherwise unremarkable (fig. 1).
There is some debate on this but in my opinion the word “acute” really only relates to the first 6 weeks following an injury where inflammation is the primary finding.  Thereafter, an injury should be qualified as “sub-acute”.  The sub-acute phase is when the majority of strengthening and rehabilitation should be taking place.  Should a problem persist beyond 3 months one should absolutely be ordering more advanced imaging and co-managing the patient.  After 3 months, an unresolved injury should be classified as a “chronic sequelae” meaning the injury is now in the adaptive phase where scar tissue, altered motion mechanics and ligament laxity have increased probability of becoming permanent.  The chiropractor never modified or updated his “acute” diagnosis throughout the entire length of treatment. To the insurance carrier and IME this suggested that the treatment was not helpful.  
Another aspect to this case is in the diagnosis of “sprain/strain”. These are two entirely different injuries involving different tissues.  Strains are disruptions of muscle while sprains are disruptions of ligaments.  
Strains are painful under active range of motion (AROM) but not typically under passive range of motion (PROM).  Both AROM and PROM can elicit pain with a sprain.  This pain pattern could suggest a sprain however, there is no way to Grade or Quantify the extent of the sprain with ROM findings.  
When assessing a patient who has been in a MVC, dynamic radiographs (X-Rays) should be ordered.  Standard X-rays are taken with the patient usually standing in a neutral position and screen for fractures, dislocations and some pathology.  Dynamic X-rays are taken with the patient at the end range of flexion, extension and sometimes also rotation and lateral bending.  While one can not visualize a ligament on X-ray one can make certain inferences from the motion dynamics.  Ligaments maintain the fluid relationship between joints.  When the joint is moved the dynamic x-rays can capture any abnormal play or slippage of a vertebrae.  This can be measured and quantified.  The American Medical Association (AMA) and Workers Compensation Carriers have established guidelines to assign disability to ligament disruptions.  Video Fluoroscopy (VF) is another imaging tool that is not often used but can provide powerful visual evidence to the presence of laxity.   VF is in essence an X-ray movie that is capable of demonstrating joint laxity in real time.

“In Motion MRI” can dynamically assess the integrity of disc injuries just as VF does for ligament laxity.

The instability is often so obvious that even a layperson without any radiographic training or education will almost always be able to identify the abnormal motion segment.  In a court setting or deposition, VF can deliver quite a visual impact.
In this case, the absence of actually being able to document ligament damage leaves only the Strain aspect of the diagnosis.  A strain purely relates to muscle and as such, one would expect a rapid recovery depending upon the extent of the muscle tears.  An acute moderate to severe strain should not take longer than 3 months to attain a pre-injury status.  Protracted recovery likely means something was missed in the diagnosis.  Doctors are allowed to change their opinion as new evidence presents itself.  However, it is the responsibility of the treating doctor to manage the case appropriately.    If after 3 months of care the patient is still complaining of pain or limitation, it is up to the doctor to gather the pieces of the puzzle that would explain the discrepancy.  Of the 7 months of care rendered, I would argue that at least 4 months was excessive in the absence of more substantial clinical evidence.  Very unfortunate for the patient’s recovery and their case.
In summary, the insurance company was justified in denying care because;
1. The injury was staged as “acute” and was never modified.
2. No substantial evidence to warrant the diagnosis of the cervical sprain.
3. No advanced imaging or co-management with a Pain Specialist, Physical Therapist or Orthopedist.  
4. Failure to properly evaluate the patient at onset and later when symptoms persisted.
Dr. Martinez is certified by the Spine Institute of San Diego in crash biomechanics, crash reconstruction, kinematics and injury mechanisms.  
Dr.Welch is a ABIME Certified Independent     Chiropractic Examiner.
sprain 2
Extension and Flexion stress radiographs can clearly demonstrate a segmental instability when a Neutral Lateral appears normal.

Special Points of Interest

  • Strains vs. Sprains
  • Plain film radiology
  • Stress radiology / Video fluoroscopy
  • In motion MRI