Chronic Overuse Sports Injuries
The evaluation and management of chronic overuse sports/athletic injuries is one of the most pervasive concerns in sports medicine today. Overuse sports injuries outnumber acute, instantaneous injuries in almost every athletic activity. Because overuse sports injuries are not instantly disabling they attract less medical attention than those that cause an acute and obvious loss of function. Therefore, their frequency of occurrence is almost always underestimated in surveys of athletic injuries. The treatment of overuse sports injuries is made difficult by various factors, including an insidious onset which means that the problem is usually ignored at the start. When athletes actually present for treatment, the injuries are well established and more difficult to manage successfully. Additionally, these injuries seem less serious to the athletes and makes it difficult to convince them of the importance of intensive treatment for correction.
Physicians’ attitudes toward athletes with chronic overuse sports injuries are often inappropriate and frequently result in the athlete seeking inappropriate treatment options. All too often the athlete-patient is told: “If you only abstain from performing your sport, the injury will resolve.” The athlete-patient has sought treatment not because of the injury, but rather because they are unable to continue the athletic participation. Therefore, the ability to return the athlete to functional activity is as much part of the treatment as alleviation of the symptoms.
Overuse injuries are almost always a result of change in three general areas: the athlete, the environment, or the activities. Identifying these changes requires patience, precision in history-taking, and a great understanding of the demands of the specific sporting activity. The most common cause of overuse athletic injuries is continued athletic participation despite the presence of symptoms associated with another injury (eg. pitcher who continues to throw despite persistent elbow tendonitis). Continued participation with an existing injury also occurs as the result of inadequate rehabilitation. Some overuse dysfunctions are the result of normal physiological changes such as rapid growth spurts in which musculotendinous flexibility often decreases and indirectly causes tendonitis (eg. Osgood-Schlatter knee syndrome). Environmental alterations occur in the athlete’s personal environment (eg. equipment and clothing) or the more global sports environment (eg. running hills in a training regiment previously limited to running flat surfaces). Advancing to a higher level of athletic proficiency involves both quality and quantity of workouts. Even increasing workout time in an abrupt manner can result in overuse athletic injuries, especially when an athlete attempts to perfect a single, isolated skill. It should be obvious that discovering the changes that cause overuse problems requires an emphasis on history taking, more so than the diagnosis and management of acute injuries.
The prevention of recurrences of overuse injuries is the most important aspect of managing overuse injuries thus, the physician’s role becomes one of reinforcing and reminding the athlete to identify the appropriate changes to be made in their regimen. While overuse injuries may involve bone, ligaments, or musculotendinous structures, the majority of overuse injuries involve the latter. Muscle fatigue may occur due to relative lack of either strength or endurance. As a result, the muscle unit tightens and may undergo physiological structural damage (ie- hemorrhage or localized edema) followed by muscle spasms and shortening. This indirectly leads to muscle weakness so that reinjury occurs with less provocation. The resulting “overuse-tightness-pain-disuse-weakness-easier overuse cycle” continues until broken by active treatment interventions.1-5
As society’s emphasis on continued physical activity and athletics throughout one’s lifespan has increased, so have the knowledge and skill required by the community of health care providers involved in managing the related injuries. It is essential for all sports medicine providers to realize that a team approach (physicians, physical therapists, athletic trainers, coaches, etc.)—and taking advantage of the collective knowledge, talent, and expertise of all these specialists in a collaborative effort—affords the athlete the optimal conditions for successful return to sport.
This article highlights a few of the most common injuries seen in athletics with a focus on the overuse/repetitive strain injury. It is important to note that, for most athletes, up to 60% of the “overuse” type injuries are related to training errors. Interaction with the coach/trainer is critical in solving this problem. Pain will get the athlete into the clinic, but the tricky part may be figuring out exactly what is causing the pain. The old acronym RICE (Rest, Ice, Compression, and Elevation) along with NSAIDs can do a very nice job of decreasing/eliminating the chemical pain associated with the inflammatory response. However, the real challenge is to identify the underlying dysfunction.
A thorough physical exam, biomechanical assessment, and functional movement analysis can provide great insight into how the body moves and reveal any joint dysfunction and/or muscle imbalances. The muscle imbalance leads to changes in the length-tension relationships of involved muscles. This change in force coupling decreases neuromuscular efficiency and leads to more rapid fatigue. As the muscles fatigue, there is often a biomechanical compensation which may overload tissues not used to the elevated level of stress. Eventually, breakdown must occur and the athlete enters the cumulative injury cycle of pain.
Clinical Assessment, Diagnostic Evaluation, and Treatment Options
With the heightened interest in personal fitness and athletic participation, the physician is expected to see a variety of sports-related injuries and must be able to recognize these conditions in order to institute prompt and proper management. A thorough history, physical examination, radiographic studies, laboratory studies and, occasionally, further imaging studies are essential to establish and confirm the appropriate diagnosis and institute correct and adequate treatment for the injured athlete. The mechanism of injury must be established in order to proceed on the correct path. Symptoms must be evaluated in detail and categorized as to initial stimulus, location, intensity, and characterization of the pain pattern (the major symptom in overuse injuries). The primary purpose of the physical examination is to precisely define the anatomical structures involved in the overuse injury. With musculoskeletal injuries, the easiest way to localize the maximally painful area is to have the athlete assume the position of maximal discomfort and point out the most painful location. This usually involves stretching the involved muscle. While radiographic and other diagnostic testing are occasionally used to evaluate and often exclude other sources of more serious pathology, they should never be used initially to make a diagnosis, but instead used as a supplement to the thorough history and physical examination.1-6