Back Pain Doctor
Sprains, Strains and Soft-Tissue Injuries
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Soft-tissue injuries fall into two groups that behave quite differently. Acute injuries follow sudden trauma (a fall, a twist, a blow) and include sprains (ligament), strains (muscle and tendon) and contusions (bruising of muscle). Overuse injuries build gradually when an activity is repeated so often that the tissue never fully recovers between sessions; tendinopathy and bursitis are the common examples. Getting the category right matters, because early protection helps an acute injury while load management and progressive strengthening are what change an overuse problem.
Assessment focuses on the mechanism of injury, what structure is likely damaged, and whether anything more serious needs excluding: fracture, joint instability, a complete tendon rupture, or in the case of a deep contusion, compartment syndrome. Most soft-tissue injuries are diagnosed clinically and need no imaging. Investigations are ordered when they will change management, such as ruling out a fracture or characterising a suspected muscle tear or haematoma.
First-line care for an acute injury is relative rest, ice, compression and elevation in the first days, followed by graded exercise to restore movement and strength; bracing is used for moderate sprains and surgery reserved for severe ligament or tendon disruption. For overuse problems the mainstay is progressive loading under physiotherapy guidance. Complete rest rarely helps. Repeated corticosteroid injection around a tendon is discouraged in current Australian guidance because medium-term outcomes are poorer. Where a tendon problem has not responded to a well-delivered loading program, adjuncts such as shockwave therapy may be considered, with the evidence discussed case by case.
Common symptoms
- Pain, swelling and bruising after a fall, twist or blow
- Joint looseness or a sense of giving way
- Muscle spasm, weakness or cramping
- Pain that builds gradually with repeated activity
Commonly seen in
Evidence for twelve treatment options in sprains, strains and soft-tissue injuries
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).
Pairing reviewed 2026-09-02.
Where it fits
For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Dry needling studied, not injection
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Searched 12 November 2026 (PubMed: trigger point, dry needling, wet needling or intramuscular stimulation with muscle strain, muscle injury, sprain or contusion, 68 records; trial and review pass, 12; a second search of dry needling or trigger point injection with hamstring, muscle strain, muscle tear or calf strain, 23 records). No study has injected a trigger point to treat a fresh sprain or muscle strain. The research is on dry needling, the same needle with nothing injected and not offered here. A systematic review of dry needling in athletes found it generally helped pain and stiffness more than performance and identified the hamstrings as under-studied (Kużdżał, Sports Med 2025). A meta-analysis found no effect of needling on muscle strength (Mansfield, J Orthop Sports Phys Ther 2019). In chronic ankle instability, adding dry needling to balance training gave no extra benefit in a 24-person trial (Abbasi, J Bodyw Mov Ther 2023).
Pairing reviewed 2026-11-12.
Where it fits
No role in a fresh injury, where protection and then graded loading are the treatment. Considered only for pain that persists weeks later where examination finds a tender muscle band, alongside the strengthening programme.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Case series in professional athletes
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Searched 8 November 2026 (PubMed: muscle strain and contusion, ligament sprain, and wrist and finger sprain searches with corticosteroid, steroid or anaesthetic injection, 23, 51 and 13 records; and a randomised-trial and systematic-review pass, which found no controlled trial of corticosteroid or anaesthetic injection for a fresh strain or sprain). The positive evidence is uncontrolled and comes from professional sport: one NFL team's 58 intramuscular corticosteroid and anaesthetic injections for severe hamstring injuries, with 16% of players missing a game and no complications (Levine, Am J Sports Med 2000), and another team's 37 injections for strains and sprains, with every player returning and no complications (Drakos, HSS J 2014). For pain persisting after a sprain, series exist at the knee (Jones, Knee 2008: 34 people, deep MCL, sustained relief at 20 months) and the ankle (Xu, Zhongguo Gu Shang 2024: 88 people, sinus tarsi, 65% recurrence within a year). Against: a placebo-controlled trial of PRP with local anaesthetic in acute ankle sprains found no benefit (Rowden, J Emerg Med 2015); local anaesthetic injected into muscle damages muscle fibres (Reurink, Sports Med 2014); and in Australian rugby league, ankle and wrist injections given to keep playing were judged less safe than others at long-term follow-up (Orchard, Am J Sports Med 2010).
Pairing reviewed 2026-11-08.
Where it fits
Not a routine treatment for a fresh strain or sprain, which is protected movement and progressive loading. Considered for a specific problem identified on assessment, most often pain that has persisted from one structure, as an adjunct that lets the rehabilitation program progress. See the note on cortisone.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. One small trial, no sham
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
There is no shockwave trial in a fresh sprain or strain. In persistent ankle sprains, one randomised trial of 30 people added shockwave to joint mobilisation and compared it with mobilisation alone: the shockwave group gained more on the Karlsson ankle function score (about 20 points against 14), but there was no sham, no between-group test in the abstract, no follow-up after treatment and no named device type (Aslam, Insights J Health Rehabil 2025). The one study naming its device in a ligament injury used focused shockwave (Hoshika, JSES Int 2025). PubMed searches for shockwave with sprain, ligament injury or soft-tissue injury (34 records, all read) and a trial and systematic-review pass (17 records) found no radial trial in an acute sprain or strain.
Pairing reviewed 2026-10-23.
Where it fits
Not part of early care. Considered once pain persists well beyond the expected healing time, mainly for the tender muscle and fascia around the injury, alongside the rehabilitation program.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Small studies in persistent sprains
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
There is no shockwave trial in a fresh sprain or strain. In persistent ligament problems the evidence is small and unblinded. In 63 young baseball pitchers with an elbow ligament (ulnar collateral) injury still painful after two months of physiotherapy, those who chose to add focused shockwave returned to sport more often than those who did not (86% against 59%) and started throwing a week sooner; the groups were not randomised (Hoshika, JSES Int 2025). In persistent ankle sprains, one 30-person randomised trial of shockwave added to joint mobilisation reported larger gains in ankle function, without a sham, a between-group test in the abstract, or a named device type (Aslam, Insights J Health Rehabil 2025). PubMed searches for shockwave with sprain, ligament injury or soft-tissue injury (34 records, all read) and a trial and systematic-review pass (17 records) found no trial in an acute sprain or strain. Shockwave for muscle strains is covered on the hamstring and calf pages.
Pairing reviewed 2026-10-23.
Where it fits
Not part of early care for a fresh sprain or strain. Discussed for a ligament or tendon attachment that is still painful months later, as an add-on that helps the person get back to loading while the rehabilitation program does the main work.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Not offered for this
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
The answer depends on the tissue, and for most sprains and strains it is not established. Muscle strains: the hamstring is the one muscle with randomised trials of its own, and they disagree. Pooled, return to sport was about a week sooner across nine trials and 474 people on limited-quality evidence (Bensa, Sports Med Open 2026), while the largest double-blind trial found no benefit over a placebo injection in 80 athletes (Reurink, N Engl J Med 2014; Br J Sports Med 2015), and re-injury was no less common, 15% against 16% (Nakagawa, Br J Sports Med 2026). No clinical study has tested it in a calf strain or a muscle bruise. Ligament sprains: in a small double-blind trial in severe ankle sprains, PRP was no better than a saline injection for pain or function (Rowden, J Emerg Med 2015), and in 21 people with a moderate sprain an advantage at eight weeks had gone by 24 weeks (Blanco-Rivera, Foot Ankle Surg 2019). The exception is the high ankle sprain, where a randomised trial in 16 elite athletes found return to play at 41 days against 60 (Laver, Knee Surg Sports Traumatol Arthrosc 2015). A German-Austrian-Swiss consensus found no clear evidence that any injection into an injured muscle helps (Hotfiel, J Exp Orthop 2018).
Pairing reviewed 2026-10-10.
Where it fits
Not offered for an acute muscle tear. These are monitored and rehabilitated. A torn muscle has already bled into the injury, so an injection of concentrated platelets is unlikely to add to what is there. Protection, graded loading and a staged return to sport are what change the outcome. For ligament sprains the answer differs by ligament and is set out on the ankle sprain, high ankle sprain and knee ligament pages.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Ankle trials: balance, not pain
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Prolotherapy has been tested against saline in ligament sprains at one site only, the ankle, and only once a sprain has become long-standing. In 114 people with chronic ankle instability, four dextrose injections into the anterior talofibular ligament did not change the main instability score at one year, but improved a balance test and reduced repeat sprains (Sit, Arch Phys Med Rehabil 2025); in 27 people with a chronic ankle ligament sprain, dextrose plus home physiotherapy was no better than saline plus physiotherapy for pain at 12 weeks (Wu, Arch Phys Med Rehabil 2025). For sprains at the knee's medial collateral ligament, the wrist, the fingers and the high ankle, the same search found a single knee case report and nothing else. Across chronic soft-tissue injury more broadly, a network meta-analysis of 87 trials, mostly shoulder and elbow tendon problems, found no statistically significant pain advantage for prolotherapy over other therapies overall (Goh, PLoS One 2021). No trial in an acute sprain or a muscle strain was found. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain, ankle instability, collateral ligament or syndesmosis terms (21 records), and prolotherapy with ligament, ankle, wrist, finger, thumb or soft-tissue injury terms (121 records, all screened), each with randomised-trial and systematic-review passes.
Pairing reviewed 2026-10-14.
Where it fits
Not for a fresh sprain or strain, which is managed with graded rehabilitation. Can be discussed for a ligament that stays painful or unstable months after a completed rehabilitation program, with the evidence for that site stated. The rehabilitation program remains the treatment.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used here
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Tested once, in one joint. In 158 competitive athletes with a mild to moderate ankle sprain, hyaluronic acid injected around the ligaments within 48 hours and again on day four, on top of rest, ice, compression and elevation, gave less pain at day eight than a placebo injection and a return to sport at 11 days against 17 (Petrella, Clin J Sport Med 2007), with fewer repeat sprains over two years, 7 against 16 (Petrella, Phys Sportsmed 2009). That is a single research group, the injection went around the joint rather than into it, and a meta-analysis of 19 randomised trials in soft-tissue problems found no second sprain trial to set beside it (Khan, Sports Health 2022). Searches at the wrist, finger, knee ligament and syndesmosis, and in muscle strains and contusions, found no trial at all.
Pairing reviewed 2026-10-05.
Where it fits
Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a sprain or strain is not one.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
This treatment has not been tested in a fresh sprain or strain. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against sprain, strain, muscle injury, contusion and the common injury sites returns 23 records, and the only one that treats an injury with this technique is in the long-standing ankle sprain: 25 people with chronic ankle instability, two sessions of neurofascial 12.5% dextrose a month apart, large improvements in instability and pain scores at six months, no comparison group (Kazempour Mofrad, Anesth Pain Med 2022). A randomised-trial search over any dextrose injection for a sprain, strain or muscle injury finds one trial, also in the chronic ankle sprain, where 15% dextrose was no better than saline for pain or ankle function over 12 weeks (Wu, Arch Phys Med Rehabil 2025). No study was found for a muscle strain, a bruised muscle, or a wrist, finger or syndesmosis sprain. Two harm reports are worth knowing: complex regional pain syndrome after a small skin nerve was injured during prolotherapy for a lateral ankle sprain (Kim, Medicine 2021), and a fibrous nodule needing surgery after repeated prolotherapy in a finger (Oh, J Surg Case Rep 2023).
Pairing reviewed 2026-10-06.
Where it fits
Not part of treating a new sprain or strain. Occasionally worth discussing much later, where tender, hypersensitive skin or nerve-type pain persists over the injured area after the tissue has healed and a proper rehabilitation programme has had a fair trial.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Small series, persistent pain only
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with sprain, ligament injury, syndesmosis, contusion or the ligaments of the knee, wrist and hand, 5 records; with quadriceps and thigh terms, 24 records; with tendon rupture terms, 23 records; a randomised-trial and systematic-review pass returned none), together with this programme's 3 and 6 November searches of hamstring, calf and ankle injuries. No trial exists, and no study treated a fresh strain or sprain. The largest study is a series of seven people with pain persisting at least eight weeks after a hamstring injury and thickened tissue around a skin nerve on ultrasound: after an ultrasound-guided injection of 6 mL saline with 0.17% lignocaine, pain fell from 10 to under 1 out of 10, with no adverse events over a mean of 6.6 months, but there was no comparison group and three people needed two to four sessions (Shiwaku, J Funct Morphol Kinesiol 2025). Single case reports describe a nerve caught after an ankle sprain and freed this way (Zhu, Clin Case Rep 2026; Wu, Diagnostics 2024) and the sural nerve after recurrent calf strains (Fader, Orthopedics 2015).
Pairing reviewed 2026-11-10.
Where it fits
Not a treatment for a fresh strain or sprain, which is protected movement and progressive loading. Where pain persists months later and ultrasound shows a nerve caught in the healing tissue, hydrodissection may be discussed as a way to let the rehabilitation program progress.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
What is the difference between a sprain and a strain?
How are sprains graded?
Does shockwave therapy help these injuries?
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