Preventing Chronic Overuse Sports Injuries
Q: What are the most common chronic overuse sports injuries?
Dr. Pinzon: The majority of the injuries are, at least in my practice, primarily running and endurance sports injuries. I tend to treat a number of endurance athletes, such as triathletes/duathletes/cyclists, but I also see a variety of other patients with chronic overuse conditions, ranging from elderly golfers to pediatric soccer players.
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 injuries that cause an acute and obvious loss of function. Therefore, their frequency of occurrence is almost always underestimated in surveys of athletic injuries.
Interestingly, many of my patients with spine-related conditions have overlapping chronic overuse sports injuries. A spine condition can cause a chronic overuse condition in the hip, knee, or ankle. Likewise, an overuse condition in various joints can cause chronic spine pain, as well as other joint pain, such as shoulder pain. Most often, these symptoms are all synergistically related, and it is up to the physician specialist to uncover the primary source of the medical problem. Thus, a proper assessment of postural biomechanics is essential to identify treatment options.
Being trained as a Physical Medicine and Rehabilitation (PM&R) physician specialist, with specialties in interventional pain medicine and musculoskeletal/sports medicine, I spend a lot of time interviewing and examining patients to make sure we know the correct source of their overuse conditions. 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, which makes it difficult to convince them of the importance of intensive treatment for correction.
Q: How can physicians identify the underlying dysfunction leading to overuse injuries in athletes?
Dr. Pinzon: As we are all trained as medical specialists, the history is the most important part of the overall examination and should be thoroughly conducted before proceeding with the physical exam to further elaborate on the correct diagnosis. It is important to ask patients about what they think caused their current overuse sports condition, when symptom onset began, and what incites or alleviates the current pain condition.
Overuse injuries are almost always a result of change in three general areas: the athlete, the environment, or the activities (Table 1). During the examination, I study patients’ gait and shoe wear patterns, as well as watch them perform movements specific to their sport, such as serving a tennis ball, running, swinging a golf club, or pedaling a bicycle.
I also evaluate other anatomical areas that may be affected by the overuse injury. For example, I may examine the neck in a patient with a lumbar spine or hip problem, because the anatomy is all tied together, which can result in a chain reaction.
Musculoskeletal ultrasound can be used to determine if a patient has pathology in a tendon, ligament, or muscular source, particularly if a patient presents with a joint or myofascial effusion. This allows for earlier intervention with aspiration or treatment with intra-articular anesthetics, steroid injections, or regenerative medicine techniques, such as platelet-rich plasma (PRP) injections or stem cell injections.
Video analysis is another useful tool that helps break down running, swimming, and bicycling styles to show an athlete’s subtle biomechanics at work and identify what may be causing the chronic overuse syndrome.
Q: How can training errors lead to chronic overuse injuries?
Dr. Pinzon: Training errors are extremely important because many times athletes develop a certain chronic repetitive training pattern that what works for them, and they mistakenly believe that this method should always work over time. However, as we start to age and our anatomy changes or we develop small musculoskeletal injuries, we then need to change the way we train and compete. Even a small injury can affect the entire anatomy and how the body functions.
For example, professional golfers may need to change their swing as a result of an injury or the aging process. In addition, many endurance athletes may develop a plantar fasciitis that will indirectly affect how they run and walk, resulting in a change in their gait pattern. Therefore, pointing out these specific training errors and educating patients on how to better train are extremely important.
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 his or her regimen. While overuse injuries may involve bones, 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.
In addition, overuse injuries may be related to technical problems that can be resolved by changing footwear or apparel. Evaluating those elements during the physical examination and history is essential to providing proper, expedient medical care.
Q: How can physicians better collaborate with coaches/trainers to identify and correct training errors and prevent injuries or injury recurrence?
Dr. Pinzon: Educating coaches, athletic trainers, and physical therapists is key to helping an athlete avoid injury or reinjury.
For instance, children playing sports like soccer or other running, endurance sports are at risk for calcaneal apophysitis (Sever’s disease), which is caused by repetitive stress on the heel’s growth plate. The condition is common and tends to occur by age 9 in girls and 11 in boys. All parties involved in training and caring for these children should understand how to avoid injuries like this by use of appropriate footwear and orthotics (custom-molded or over the counter) and strengthening muscle groups such as the quadriceps, hamstrings, gluteals, and the calf muscles.