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17 Articles in Volume 20, Issue #3
20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities
A Clinician’s Guide to Treating Chronic Overuse Injuries
Adhesive Arachnoiditis: No Longer a Rare Disease
Analgesics of the Future: Cebranopadol as an Opioid Alternative
Ask the PharmD: What role do vitamin D supplements play in treating dysmenorrhea?
Behavioral Pain Medicine: Managing the Affective Components of Pain
Chronic Fatigue Syndrome: Naltrexone as an Alternative Treatment
Chronic Pain and Coronavirus
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
Editorial: Why Are ER Opioids Out of Favor?
Fibromyalgia as a Neuropathic Pain Disorder: The Link to Small Fiber Neuropathy
How the COVID-19 Pandemic Is Transforming Pain Care
Hydroxychloroquine Use and Risk in the Management of Systemic Lupus Erythematosus
Management of Trigeminal Neuralgia in Multiple Sclerosis
Optimizing Care Using a Trauma-Informed Approach
Pediatric Pain Management: A Review of Clinical Diagnosis and Management
The Use of Low Dose Naltrexone in the Management of Chronic Pain

A Clinician’s Guide to Treating Chronic Overuse Injuries

In this updated clinical primer, learn about the risks, differential diagnoses, treatments, and preventive strategies for managing common musculoskeletal and sports injuries.
The evaluation and management of chronic overuse musculoskeletal injuries is one of the most pervasive concerns in sports medicine and for primary care practitioners, physical therapists, and pain management physicians who also encounter these patients. Overuse sports injuries outnumber acute, instantaneous injuries in almost every athletic activity. Because overuse sports injuries are not instantly disabling, they may 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.1
 
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 may seem less serious to the athletes, which makes it difficult to convince them of the importance of intensive treatment for correction.
 
Clinicians’ attitudes toward athletes with chronic overuse sports injuries are often inadequate 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 desired sport, the athletic injury will resolve over time.” The athletic patient has often sought treatments not because of the presumed injury, but rather because they are unable to continue their favored athletic participation. Therefore, the ability to return the athlete to functional activity is as much a part of the treatment as the alleviation of the symptoms.
 
Injury occurs when cumulative forces exceed the tissue’s ability to withstand such forces—either due to isolated macrotraumatic events or repetitive microtraumatic events. Often, specific biomechanical or physiological factors predispose an athlete to injury. It remains in the medical/health professionals’ domain to properly identify and assist the athlete in correcting these conditions to treat, prevent, and possibly reverse the detrimental effects. Prevention is always the best treatment but, failing that, the next best thing is proper and successful rehabilitation.
 
Overuse musculoskeletal (MSK) injuries account for more than 50% of injuries seen in sports medicine practices. This updated primer for clinicians, therefore, aims to highlight some of the most common injuries seen in athletes with a focus on the overuse/repetitive strain injury. But first, let's take a look at today's athlete and common overuse injury causes.
 
 

Image: iStock (bartoshd)Often, specific biomechanical or physiological factors predispose an athlete to injury. It remains in the medical/health professionals’ domain to properly identify and assist the athlete in correcting these conditions to treat, prevent, and possibly reverse the detrimental effects.

Common Causes of Overuse Sports Injuries

Overuse sports injuries, for both competitive or leisure-based athletes, are almost always a result of change in three general areas: the athlete, the environment, or the activities themselves. Identifying these changes requires patience, precision in history-taking, and a great understanding of the demands of the specific sporting activity.
 
Below are some possible changes an athlete may undertake that are important to ask about during assessment.
  • Continued athletic participation despite the presence of symptoms associated with another injury (eg, the pitcher who continues to throw despite persistent elbow tendonitis)
  • Continued participation with an existing injury, as the result of inadequate rehabilitation
  • Normal physiological changes (eg, rapid growth spurts in which musculotendinous flexibility often decreases and indirectly causes tendonitis, or Osgood-Schlatter knee syndrome)
  • Changes in environment
  • Personal changes (eg, clothing, gear, equipment)
  • Global changes (eg, sports-related regimen: running hills in a training regimen previously limited to running flat surfaces)
  • Changes in workout time or intensity (eg, athlete attempts to perfect a single, isolated skill)
The prevention of recurrence of overuse injuries is the most important aspect of managing overuse injuries. Thus, the clinician’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 can indirectly lead 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.1-6
 
 

Societal Changes Call for New Clinical Tactics

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 healthcare providers involved in managing related injuries. It is essential for all sports medicine providers to realize that a team approach, incorporating the collective knowledge, talent, expertise, and collaboration of physicians, physical therapists, athletic trainers, coaches, and others, affords the athlete optimal conditions for successful return to sport.
 
Today’s Patients with Sports Injuries
Sports provide many benefits including improvement in health status and physical fitness, relaxation, entertainment and, for a select few, some prestige and a good source of income. Indirectly, the burgeoning population of elite athletes and the “weekend warriors” will see an exponential increase in the number of sports overuse injuries.
 
The popularity of endurance sports has grown steadily over the past several decades as well. From running and rowing to Ironman and century cycling events, the options for endurance training and competitive events are many. With the months of intense training required to compete in these events comes an increased risk of overuse sports injuries and resultant MSK pain.
 
For most athletes, “overuse” injuries are related to training errors. Interaction with the coach/trainer is critical in solving this problem. Pain may get the athlete into the clinic, but the tricky part may be figuring out exactly what is causing the pain. Traditional treatment approaches include the standby known as RICE (rest, ice, compression, and elevation) along with NSAIDs, which 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.
 
While prevention is the best treatment, equally important is early diagnosis of acute and chronic pain conditions and referral to sports medicine/MSK pain specialists and rehabilitation specialists. Endurance athletes frequently first present to their primary care provider with acute/subacute and sometimes, chronic injuries, such as MSK tendonitis or lower back pain, making a greater awareness of treatment options for common MSK pain conditions essential to care in this setting.
 
In addition, it is important for primary care physicians to convince their patients of the importance of rehabilitation to correct musculoskeletal abnormalities and avoid improper training before acute/subacute conditions become chronic. In endurance athletes, MSK injury occurs when repetitive, cumulative forces exceed the tissue’s ability to withstand such forces either due to isolated macrotrauma—such as a rotational injury to a joint, blunt trauma, or sudden overload causing a tear—or repetitive microtrauma—such as tendonitis, nerve compression, or stress fractures. Often, specific biomechanical or physiological factors predispose an athlete to injury.
 

Assessment and Diagnostic Evaluation

The clinician should expect to see a variety of athletic-related, MSK/sports 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 initiate correct and adequate treatment for the injured athlete.
 
A thorough physical exam, biomechanical assessment, and functional movement analysis can provide great insight into how the body moves and can 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.2
 
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 MSK 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.1-6,8

 

General and Advanced Treatment Options 

Conservative treatments such as exercise therapy, stretching/strengthening, manual therapies, Kinesio taping, and injections should be exhausted before an athlete is referred for surgery. These nonsurgical approaches may allow for the same success rates with fewer complications compared to surgical approaches. Early intervention for these common MSK pain conditions may be essential to prevent progression to chronic pain, and primary care physicians can play a key role in both diagnosing these conditions and referring patients for rehabilitation.9-20
 

Medications

In addition to commonly used topical analgesics or over-the-counter agents, long-lasting lidocaine ointments, compounded topical analgesic medications (eg, baclofen, bupivacaine, capsaicin, diclofenac), gabapentin, ketamine, ketoprofen, and tramadol have become more frequently used for acute and chronic pain conditions as well. These medications may be customized to include targeted and synergistic treatments such as topical analgesics, anti-inflammatory agents, muscle relaxants, neuroleptic agents, and mild opiates.15,16
 
Regenerative medicine & Injections
Regenerative medicine techniques are now on the forefront of research for potential treatments for chronic overuse musculoskeletal/sports injuries. Such techniques should be considered on a case-by-case setting. Injections of autologous platelet-rich plasma or mesenchymal stem cells may help heal ligaments, tendons, cartilage, and MSK regions that are damaged by overuse sports injuries.17-20 Future, high-quality studies are needed to determine the most appropriate and effective use of these agents.9
 
In addition, diagnostic ultrasound guidance has markedly improved the accuracy of delivering these regenerative medicines as well as delivery of steroid, hyaluronic, and anesthetic injections.19 Diagnostic ultrasound is also being used more often in sports medicine and physical therapy offices to determine whether a patient has pathology in a tendon, ligament, or muscle, particularly if a patient presents with a joint or myofascial effusion. Earlier diagnosis may facilitate interventions, as opposed to waiting for magnetic resonance imaging results to identify injury or trauma.
 
Intra-articular injection with a steroid (short-term) may reduce inflammation to allow the patient to better engage in physical therapy. Hyaluronic acid and regenerative medicine techniques (eg, platelet-rich plasma and stem cell injections) may be effective. Injections are given at the pathology site, based upon clinical evaluation or diagnostic (MRI/ultrasound/computed tomography) confirmation at multiple sights (eg, anterior/posterior/lateral/superior) with ultrasound guidance.
 

The following sections of this primer discuss individual treatment options, as well as differential diagnoses, pain management, and preventing recurrence of the most common overuse/sports injuries today.

 
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*Published online only in tandem with the May/June 2020 issue.
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