Raiyyan Tahsan

Raiyyan Tahsan
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TC(962).TC(05).Orthopedics Case No 40. Strain

Strain — Definition / সংজ্ঞা

Strain হলো muscle বা tendon-এর overstretching, partial tear বা complete tear। Tendon হলো muscle-কে bone-এর সাথে যুক্ত করা fibrous cord। Strain সাধারণত back, neck, hamstring, calf, shoulder-এ বেশি হয়। AAOS অনুযায়ী strain-এ pain, muscle spasm, weakness, swelling, inflammation, cramping দেখা যায়।

Sprain vs Strain

  • Sprain: ligament injury — joint-এর ligament ছিঁড়ে/টানে।
  • Strain: muscle বা tendon injury — muscle/tendon টানে বা ছিঁড়ে।

Causes / কারণ

  1. Sudden overstretching: দৌড়, লাফ, হঠাৎ মোচড়, ভারী জিনিস তোলা।
  2. Poor warm-up: exercise বা sports-এর আগে warm-up না করলে muscle tight থাকে।
  3. Muscle fatigue: অতিরিক্ত কাজ/জিম/খেলা করলে muscle control কমে যায়।
  4. Weak or imbalanced muscle: hamstring–quadriceps imbalance, weak core, poor posture।
  5. Previous strain: আগের injury ঠিকমতো heal না হলে reinjury হয়।
  6. Improper technique: ভুলভাবে weight lifting, running mechanics, sudden acceleration।
  7. Dehydration/electrolyte imbalance: cramp ও muscle fatigue বাড়ায়।
  8. Direct trauma: ধাক্কা/পড়ে যাওয়া থেকেও muscle-tendon tear হতে পারে।

Symptoms / লক্ষণ

Mild strain — Grade I

  • হালকা ব্যথা
  • muscle tightness
  • movement করলে ব্যথা বাড়ে
  • সামান্য swelling
  • strength প্রায় normal

Moderate strain — Grade II

  • তীব্র ব্যথা
  • swelling ও bruising
  • muscle spasm
  • হাঁটা/নড়াচড়া কষ্টকর
  • strength কমে যায়
  • injured area চাপ দিলে tenderness

Severe strain — Grade III

  • muscle/tendon complete tear
  • sudden “pop” sensation
  • বেশি swelling/bruising
  • muscle defect বা gap feel করা যায়
  • affected limb ব্যবহার করা যায় না
  • severe weakness বা loss of function

Clinical Diagnosis / clinically কীভাবে diagnose করা হয়

Diagnosis মূলত history + physical examination দিয়ে হয়। Mayo Clinic অনুযায়ী exam-এ swelling, tender spots, pain location/intensity দেখে severity বোঝা হয়; complete tear হলে defect দেখা/মনে হতে পারে, আর ultrasound soft tissue injury আলাদা করতে সাহায্য করে।

Specific clinical assessment

  • History: injury কীভাবে হয়েছে, pop sound ছিল কি না, হাঁটতে পারছে কি না, previous injury আছে কি না।
  • Inspection: swelling, bruising, deformity, muscle gap।
  • Palpation: local tenderness, warmth, defect।
  • Range of motion: active ও passive movement pain।
  • Strength test: resisted contraction করলে pain/weakness।
  • Functional test: walking, squatting, heel raise, straight leg raise—injury site অনুযায়ী।
  • Neurovascular exam: pulse, sensation, capillary refill—especially severe swelling হলে।

Investigations / পরীক্ষা-নিরীক্ষা

সাধারণ strain-এ usually investigation লাগে না

Mild–moderate strain অনেক সময় clinical diagnosis দিয়েই manage করা যায়।

X-ray

  • fracture সন্দেহ হলে
  • severe trauma
  • bony tenderness
  • deformity
  • weight bear করতে না পারলে
  • avulsion injury সন্দেহ হলে

Ultrasound

  • partial/complete muscle tear দেখতে
  • hematoma দেখতে
  • tendon injury differentiate করতে
  • dynamic examination দরকার হলে

MRI

  • elite athlete/sports injury
  • severe pain + functional loss
  • complete tear সন্দেহ
  • surgery planning
  • symptoms 2–3 সপ্তাহেও improve না হলে

Lab test

  • সাধারণ strain-এ CBC/ESR/CRP লাগে না।
  • fever, infection, inflammatory myopathy, DVT suspicion থাকলে relevant lab করা যায়।

Differential Diagnosis / যেগুলোর সাথে confuse হতে পারে

  • Sprain — ligament injury
  • Fracture / avulsion fracture
  • Tendon rupture — Achilles rupture, biceps rupture
  • Dislocation
  • Contusion / muscle bruise
  • DOMS — delayed onset muscle soreness, exercise-এর 24–72 ঘন্টা পরে
  • DVT — calf pain + swelling + warmth
  • Compartment syndrome — severe pain, numbness, tight compartment; emergency
  • Radiculopathy / sciatica — back থেকে leg pain, numbness
  • Myositis / infection — fever, redness, severe tenderness

Complications / জটিলতা

  1. Chronic pain: ঠিকমতো rest/rehab না করলে ব্যথা দীর্ঘস্থায়ী হয়।
  2. Recurrent strain: premature return to play/work করলে আবার tear হয়।
  3. Muscle weakness: tear heal হলেও strengthening না করলে weakness থাকে।
  4. Reduced flexibility: scar tissue ও stiffness তৈরি হয়।
  5. Hematoma: muscle-এর ভেতরে blood collection।
  6. Myositis ossificans: repeated trauma/large hematoma থেকে muscle-এর ভেতরে bone-like calcification।
  7. Complete tendon rupture: severe strain untreated থাকলে function loss হতে পারে।
  8. Compartment syndrome: rare but emergency—severe pain, numbness, cold limb, pulse problem।

Treatment / Management — Guideline-based

First 48–72 hours: PRICE / POLICE approach

AAOS এবং Mayo Clinic strain/sprain-এর immediate care হিসেবে rest/ice/compression/elevation বা PRICE recommend করে; Mayo Clinic protect, rest, ice, compression, elevation বলেছে।

করণীয়

  • Protect: injured part support করুন; severe leg strain হলে crutch।
  • Relative Rest: painful activity বন্ধ, কিন্তু সম্পূর্ণ bed rest নয়।
  • Ice: 15–20 মিনিট, দিনে 3–5 বার, প্রথম 48 ঘন্টা; direct skin-এ ice নয়।
  • Compression: crepe bandage, তবে বেশি tight নয়।
  • Elevation: injured limb heart level-এর উপরে।
  • Early gentle movement: pain কমলে gentle ROM শুরু।
  • Physiotherapy: stretching → strengthening → functional training → return to work/sports।

Cleveland Clinic উল্লেখ করেছে, RICE acute pain/swelling কমাতে সাহায্য করে, তবে দীর্ঘদিন complete rest করা উচিত নয়; কয়েকদিন পর pain-free gradual movement দরকার।

Pharmacological Treatment / Drug List

Adult dose দেওয়া হলো। শিশু, pregnancy, CKD, liver disease, peptic ulcer, anticoagulant use, asthma, heart disease থাকলে dose আলাদা হবে—doctor ছাড়া NSAID খাবেন না।

1) Paracetamol — first-line pain relief

  1. Generic name: Paracetamol / Acetaminophen
  2. Therapeutic category: Analgesic, Antipyretic
  3. Pharmacological class: Para-aminophenol derivative; central COX inhibition
  4. Bangladesh available brand name with mg: Napa 500 mg, Napa One 1000 mg, Napa Extend 665 mg, Ace 500 mg, Fast 500 mg, Feva 500 mg, Reset 500 mg, Xpa 500 mg — MedEx-এ Napa ও Ace sprain/bodyache/myalgia/back pain indication হিসেবে আছে।
  5. Dose: 500 mg every 6–8 hours PRN; max 3,000 mg/day safe practical limit; doctor-advised max 4,000 mg/day in selected adults.
  6. Duration: 3–5 days.
  7. কেন used হয়: mild–moderate pain কমাতে; gastric ulcer/kidney risk থাকলে NSAID-এর চেয়ে safer option।
  8. Side effects: nausea, rash; overdose হলে severe liver injury।
  9. Interaction: alcohol, warfarin, other paracetamol-containing cold medicine।
  10. Avoid/caution: liver disease, chronic alcohol use।

2) Ibuprofen — pain + inflammation

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic, Anti-inflammatory
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Bangladesh available brand name with mg: Serviprofen 400 mg, Siflam 400 mg, Trufen 400 mg, Uniflam 400 mg — MedEx brand list.
  5. Dose: 200–400 mg every 6–8 hours after meal; MedEx adult max OTC-style dose 1200 mg/day উল্লেখ করে।
  6. Duration: 3–5 days; usually max 7 days unless doctor reviews.
  7. কেন used হয়: swelling, inflammatory pain, sports strain pain কমাতে।
  8. Side effects: gastritis, dyspepsia, GI bleeding, renal impairment, BP rise, bronchospasm।
  9. Interaction: anticoagulant/warfarin, aspirin, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate।
  10. Avoid/caution: peptic ulcer, CKD, uncontrolled HTN, heart failure, ischemic heart disease, NSAID-induced asthma, pregnancy 3rd trimester।

3) Naproxen / Naproxen sodium — longer acting NSAID

  1. Generic name: Naproxen / Naproxen sodium
  2. Therapeutic category: Analgesic, Anti-inflammatory
  3. Pharmacological class: NSAID; propionic acid derivative
  4. Bangladesh available brand name with mg: Naprosyn 250/500 mg, Naprox 250/500 mg, Napryn 250/500 mg, Naxin 250/500 mg, Naspro 250/500 mg, Nuprafen 250/500 mg — MedEx list.
  5. Dose: 250–500 mg twice daily after meal.
  6. Duration: 3–5 days; severe inflammation হলে doctor review সহ 7 days।
  7. কেন used হয়: moderate inflammatory pain, hamstring/calf/back strain pain।
  8. Side effects: gastritis, ulcer/bleeding, renal injury, edema, BP rise।
  9. Interaction: anticoagulant, aspirin, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate।
  10. Avoid/caution: ulcer, CKD, heart failure, uncontrolled HTN, pregnancy 3rd trimester।

4) Diclofenac — commonly prescribed NSAID, but caution

  1. Generic name: Diclofenac sodium/potassium
  2. Therapeutic category: Analgesic, Anti-inflammatory
  3. Pharmacological class: NSAID; phenylacetic acid derivative
  4. Bangladesh available brand name with mg: Diclofen 50 mg tablet, Diclofen SR 100 mg, A-Fenac 50 mg, G-Diclofenac 50 mg, Genac 50 mg, Fastfit gel 1%, Fengel gel 1%, Diclofen gel 1% — MedEx lists tablet/gel/injection strengths.
  5. Dose: oral 50 mg 2–3 times daily after meal; SR 100 mg once daily. Use lowest effective dose.
  6. Duration: 3–5 days.
  7. কেন used হয়: acute inflammatory pain, swelling, traumatic muscle pain।
  8. Side effects: gastritis, GI bleeding, kidney injury, edema, BP rise; diclofenac-এর cardiovascular risk তুলনামূলক বেশি হতে পারে।
  9. Interaction: lithium, digoxin, anticoagulant, cyclosporine, methotrexate, diuretics, other NSAIDs/steroids—MedEx diclofenac interaction list এ এগুলো উল্লেখ আছে।
  10. Avoid/caution: ischemic heart disease, stroke risk, CKD, ulcer, uncontrolled HTN, anticoagulant use।

5) Aceclofenac — pain + inflammation

  1. Generic name: Aceclofenac
  2. Therapeutic category: Analgesic, Anti-inflammatory
  3. Pharmacological class: NSAID; COX inhibitor
  4. Bangladesh available brand name with mg: Flexi 100 mg, Movex 100 mg, Avenac 100 mg, Mervan 100 mg, Labenac 100 mg, Ceclofen 100 mg, Painkil 100 mg, Flexi SR 200 mg — MedEx list.
  5. Dose: 100 mg twice daily after meal.
  6. Duration: 3–5 days.
  7. কেন used হয়: trauma, lumbago, inflammatory musculoskeletal pain; MedEx aceclofenac pain/inflammation and trauma/lumbago indication উল্লেখ করে।
  8. Side effects: dyspepsia, gastritis, nausea, dizziness, edema, renal risk।
  9. Interaction: anticoagulant, steroid, other NSAID, ACEi/ARB, diuretic, lithium, methotrexate।
  10. Avoid/caution: same NSAID cautions।

6) Etoricoxib — COX-2 selective NSAID

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, Anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor
  4. Bangladesh available brand name with mg: Etorix 60/90/120 mg, Oricox 60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Etoshine 60/90 mg, Riox 60/90/120 mg — MedEx list.
  5. Dose: 60–90 mg once daily after meal; acute severe pain sometimes 120 mg once daily very short course under doctor.
  6. Duration: 3–5 days.
  7. কেন used হয়: NSAID দরকার কিন্তু GI irritation কমাতে COX-2 option; তবে cardiac risk বিবেচনা জরুরি।
  8. Side effects: BP rise, edema, dyspepsia, renal impairment, cardiovascular risk।
  9. Interaction: warfarin/anticoagulant, ACEi/ARB, diuretic, lithium, methotrexate।
  10. Avoid/caution: ischemic heart disease, stroke/TIA history, uncontrolled HTN, CKD, heart failure।

7) Diclofenac gel / topical NSAID — local pain

  1. Generic name: Diclofenac topical gel
  2. Therapeutic category: Topical analgesic, anti-inflammatory
  3. Pharmacological class: Topical NSAID
  4. Bangladesh available brand name with mg: Diclofen gel 1%, Fastfit gel 1%, Fengel gel 1%, Relnac gel 1%, Jefenac gel 1% — MedEx diclofenac topical preparations list করে।
  5. Dose: affected area-তে thin layer দিনে 3–4 বার; হাত ধুয়ে ফেলবেন।
  6. Duration: 7–14 days.
  7. কেন used হয়: localized mild–moderate strain pain; oral NSAID contraindicated হলে safer।
  8. Side effects: skin irritation, rash, burning sensation।
  9. Interaction: oral NSAID-এর সাথে একসাথে বেশি ব্যবহার করলে systemic NSAID risk বাড়তে পারে।
  10. Avoid/caution: broken skin, eczema, NSAID allergy।

8) Tizanidine — muscle spasm থাকলে

  1. Generic name: Tizanidine hydrochloride
  2. Therapeutic category: Skeletal muscle relaxant
  3. Pharmacological class: Centrally acting α2-adrenergic agonist
  4. Bangladesh available brand name with mg: Relentus 2 mg, Sirdalud 2 mg, Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg — MedEx list.
  5. Dose: 2 mg at night or 2 mg 2–3 times daily; MedEx painful muscle spasm dose 2–4 mg three times daily উল্লেখ করে।
  6. Duration: 3–5 days only; sedation থাকলে night dose preferable।
  7. কেন used হয়: painful muscle spasm/cramp কমাতে; MedEx spine-related painful muscle spasm indication উল্লেখ করে।
  8. Side effects: drowsiness, dizziness, dry mouth, hypotension, weakness, liver enzyme rise।
  9. Interaction: ciprofloxacin/fluvoxamine avoid; alcohol, sedatives, benzodiazepine, antihypertensive-এর সাথে sedation/hypotension বাড়ে।
  10. Avoid/caution: liver disease, elderly, low BP, driving/operating machine।

9) Eperisone — muscle tightness/spasm থাকলে

  1. Generic name: Eperisone hydrochloride
  2. Therapeutic category: Skeletal muscle relaxant
  3. Pharmacological class: Centrally acting muscle relaxant
  4. Bangladesh available brand name with mg: Myonil 50 mg, Eprel 50 mg, Ezymas 50 mg — MedEx brand list.
  5. Dose: 50 mg three times daily after meal; MedEx adult dose দিনে ৩টি tablet three divided dose উল্লেখ করে।
  6. Duration: 3–7 days.
  7. কেন used হয়: muscle tightness/spasm কমাতে; MedEx এটিকে centrally acting skeletal muscle relaxant বলেছে।
  8. Side effects: dizziness, drowsiness, nausea, abdominal pain, rash, diarrhea, headache, constipation।
  9. Interaction: tolperisone HCl ও methocarbamol-এর সাথে avoid—MedEx interaction।
  10. Avoid/caution: driving, elderly, hypersensitivity।

10) Pantoprazole — NSAID-induced gastric protection, selected patients

  1. Generic name: Pantoprazole sodium
  2. Therapeutic category: Anti-ulcerant, acid suppressant
  3. Pharmacological class: Proton pump inhibitor
  4. Bangladesh available brand name with mg: Pantonix 20/40 mg, Pansec 20/40 mg, Pantex 20/40 mg, Pantolok 20/40 mg, Pantomak 20/40 mg, Pantogut 20/40 mg — MedEx list.
  5. Dose: 20–40 mg once daily before breakfast while taking NSAID in high-risk patient.
  6. Duration: NSAID course চলাকালীন 3–7 days; ulcer/GERD থাকলে doctor-directed longer course।
  7. কেন used হয়: NSAID-associated gastritis/ulcer risk কমাতে; Pantonix NSAID-induced ulcer indication-এ ব্যবহৃত।
  8. Side effects: headache, diarrhea/constipation, abdominal discomfort; long-term হলে B12/Mg deficiency, infection risk।
  9. Interaction: clopidogrel interaction less than omeprazole but still review; warfarin/digoxin/methotrexate caution।
  10. Avoid/caution: unnecessary long-term use নয়।

Bangladesh doctors commonly কী prescribe করেন — practical list

Mild strain

  • Paracetamol 500 mg PRN
  • Diclofenac gel 1% local application
  • PRICE + rest + physiotherapy advice

Moderate strain with swelling

  • Paracetamol + short course NSAID: Ibuprofen / Naproxen / Aceclofenac
  • Topical diclofenac gel
  • PPI if gastritis/ulcer risk থাকে

Strain with painful muscle spasm

  • Paracetamol or NSAID
  • Muscle relaxant: Tizanidine 2 mg at night or Eperisone 50 mg TDS
  • Physiotherapy after acute pain decreases

Severe strain / suspected tear

  • Analgesic
  • Immobilization/support
  • Ultrasound/MRI
  • Orthopedic referral
  • Surgery only if complete tendon/muscle tear or functional rupture

Normally strain-এ দরকার হয় না

  • Antibiotic
  • Steroid
  • Long-term painkiller
  • Opioid/tramadol
  • Repeated NSAID injection

Emergency referral / কখন দ্রুত ডাক্তার দেখাবেন

  • হাঁটতে/weight bear করতে পারছেন না
  • severe swelling/bruising
  • pop sound + sudden weakness
  • numbness/tingling/cold limb
  • pain progressively বাড়ছে
  • deformity বা muscle gap
  • fever/redness/warmth
  • back strain-এর সাথে urine/stool control problem, leg weakness, saddle anesthesia

Prevention / প্রতিরোধ

  1. Exercise-এর আগে 5–10 মিনিট warm-up।
  2. Heavy lifting-এর সময় correct posture।
  3. Sudden intensity increase করবেন না—10% rule follow।
  4. Regular stretching + strengthening।
  5. Previous strain হলে full rehab ছাড়া খেলাধুলায় return নয়।
  6. Proper footwear।
  7. Hydration maintain।
  8. Workstation posture ঠিক রাখা।
  9. Gym-এ ego lifting না করা।
  10. Pain থাকলে “push through” না করে rest + assessment।

Overview / Summary

Strain হলো muscle বা tendon-এর stretch/tear injury। Mild strain rest, ice, compression, elevation, paracetamol/topical gel এবং gradual rehab-এ ভালো হয়। Moderate pain/swelling হলে short-course NSAID ব্যবহার করা যায়, তবে ulcer, kidney disease, heart disease, uncontrolled BP, anticoagulant use থাকলে NSAID ঝুঁকিপূর্ণ। Severe strain বা complete tear সন্দেহ হলে ultrasound/MRI ও orthopedic referral দরকার।

Actionable Plan / Steps

  1. প্রথম 48 ঘন্টা PRICE: protect, relative rest, ice, compression, elevation।
  2. Pain mild হলে Paracetamol ± Diclofenac gel।
  3. Swelling/inflammation বেশি হলে doctor review করে short-course NSAID।
  4. Spasm থাকলে 3–5 দিনের জন্য muscle relaxant বিবেচনা।
  5. 3–7 দিনের মধ্যে pain কমলে gentle stretching শুরু।
  6. 1–2 সপ্তাহে strength training শুরু; pain-free না হলে sports/gym নয়।
  7. Severe weakness, pop sound, walking inability, numbness থাকলে urgent orthopedic consult।

Reference List

Textbook

  1. Harrison’s Principles of Internal Medicine, 21st ed. McGraw-Hill. Section: Disorders of joints and adjacent tissues / approach to musculoskeletal pain.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Elsevier. Chapter: Musculoskeletal disorders.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Elsevier. Chapter: Tissue repair, regeneration, fibrosis.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Elsevier. Chapter: Skeletal muscle contraction and neuromuscular function.

Guideline / Clinical source

  1. American Academy of Orthopaedic Surgeons. Sprains, Strains and Other Soft-Tissue Injuries — strain definition, symptoms, RICE, rehab.
  2. Mayo Clinic. Muscle strains: Diagnosis and treatment — exam, ultrasound, PRICE, analgesics, rehab.
  3. Cleveland Clinic. RICE Method for Injury — immediate soft tissue injury care and gradual movement.
  4. MedEx Bangladesh — Bangladesh brand availability and generic medicine data for paracetamol, NSAIDs, muscle relaxants, PPI.

Peer-reviewed journals with DOI

  1. Baoge L, Van Den Steen E, Rimbaut S, et al. Treatment of Skeletal Muscle Injury: A Review. ISRN Orthopedics. 2012;2012:689012. DOI: 10.5402/2012/689012.
  2. Jones P, Dalziel SR, Lamdin R, et al. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2020;8:CD007789. DOI: 10.1002/14651858.CD007789.pub3.
  3. van den Bekerom MPJ, Struijs PAA, Blankevoort L, et al. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47(4):435–443. DOI: 10.4085/1062-6050-47.4.14.

Md.Rafiqul Islam Lipu,Date:-06-06-2026 saturday ,Time:-12-27-49 Pm

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