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10 Articles in Volume 16, Issue #4
Achilles Tendon Injuries
Brain Trauma in Sports
Genetic Testing: Adjunct in the Medical Management of Chronic Pain
Letters to the Editor: Sleep Apnea, SPG Blocks for Migraines, Pancreatic Pain, CDC Guidelines
Pain and Weather—A Cloudy Issue
Phulchand Prithvi Raj, MD, Pioneer in Pain Management, Dies at 84
Physical Medicine & Rehabilitation
Preventing Chronic Overuse Sports Injuries
Sports-Related Pain: Topical Treatments
The “Missing Link” in the Physiology of Pain: Glial Cells

Preventing Chronic Overuse Sports Injuries

New treatments and prevention strategies in sports medicine are advancing at a rapid pace. Practical Pain Management spoke with Elmer G. Pinzon, MD, MPH, to keep readers up to date on how to best assist child/adolescent and adult athletes to recover from and prevent 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.

Elmer G. Pinzon, MD, MPH, has participated in multiple endurance sporting events and is experienced in treating the resultant overuse sports injuries, both for himself and his patients.

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.

I have been involved in sports preseason pre-examination (PPE) for football players, soccer players, and other various adolescent/teenage sports. Preseason is often the best time to educate not only the athletes, but also the coaches, athletic trainers, and sports-specific physical therapists. Educating your referral base is always extremely important to preventing and treating overuse sports injuries.


Q: What advances have been made in the past 5 to 10 years in terms of identifying or treating chronic overuse sports injuries?

Dr. Pinzon: Regenerative medicine has made a huge treatment “wave” not only in pain medicine, but also in sports medicine. Injections of autologous PRP or mesenchymal stem cells can help heal ligaments, tendons, cartilage, and musculoskeletal regions that are damaged by overuse sports injuries.1-8

These treatments have been used by professional athletes such as Kobe Bryant, Tiger Woods, Peyton Manning, and elite tennis players, to name a few. Athletes often need to return to play quickly and are offered short-term relief with intra-articular steroid injections. However, we know that over time, steroid injections can potentially harm surrounding muscular tissue. Regenerative medicine techniques, by contrast, are allowing athletes to return to play without causing any significant damage or any medication-type side effects.

In addition, a number of topical analgesic agents (eg, diclofenac topical 1% gel [Voltaren], diclofenac epolamine 1.3% patch [Flector], and various compounding analgesic agents with multiple medications added) are now available and offer more treatment options than oral analgesics that may be linked to greater risk for gastrointestinal or renal/hepatic side effects.9

Furthermore, the American College of Sports Medicine (ACSM), American Academy of Podiatric Sports Medicine (AAPSM), and American Orthopedic Society of Sports Medicine (AOSSM) have been working to develop strategies for preventing repetitive, overuse sports injuries, and incorporating prevention as one of the key elements of care instead of focusing only on treating active injuries. One key issue being worked on is strategies for limiting or delaying tackling in football, and educating players on proper tackling techniques to avoid concussive injuries and “spear tackling” (by keeping the football athlete’s head facing forward).

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 standby RICE (rest, ice, compression, and elevation) along with nonsteroidal anti-inflammatory drugs (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.

Lastly, advances in apparel, assistive clothing, and taping modalities/techniques have been introduced that may help prevent injuries. For example, apparel now is available to help cool the body when exercising in high temperatures. In addition, compression clothing in the form of shorts, leggings, shirts, socks, and arm sleeves has been helpful in the field of endurance sports. Furthermore, taping is often used in physical therapy to prevent injury during certain running, endurance, or triathlon events.

Q: How long have you practiced in this field, and what path led you to sports medicine?

Dr. Pinzon: I got into the field of sports medicine through a sort of natural progression in my interests in musculoskeletal and interventional pain medicine. I was interested in sports medicine during my residency in PM&R and my fellowship in interventional spine and musculoskeletal pain medicine.

I find a lot of fascination and satisfaction in treating athletes. Being an endurance athlete myself—I’ve completed numerous triathlons, century rides, endurance running events, 15 Ironman triathlon events, and mountain-climbing events—I can easily relate when athletic patients, friends, and family discuss their sports-related and overuse injuries.

In addition, athletes tend to be very self-driven, motivated, focused, and type-A personalities, which are also common characteristics of people in medical/professional fields. It takes tremendous mental/physical fortitude to want to get up every day to train on a routine, repetitive basis. I admire that and understand how the psyche of an athlete works in his/her favor.

About the Expert: Elmer G. Pinzon, MD, MPH, is medical director/owner/president at University Spine & Sports Specialists, and Volunteer Comprehensive Health & Regenerative Medicine, PLLC, based in Knoxville, Tennessee.

Last updated on: December 22, 2016

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