Overuse Injuries in the Athlete

FOCUS | CLINICAL

Overuse injuries in the athlete

Kieran Fallon THE AUSTRALIAN Oxford Dictionary mainly from retrospective studies, that defines an athlete as ‘a skilled performer the occurrence of overuse injury depends in physical exercises’.1 Other references on many factors including the number of Background Most general practices will have patients indicate that participation in competition repetitions, age, previous injuries, state who have more than a passing interest should be included in the definition. of training, individual biomechanical in fitness and exercise. These range from The boundaries of this definition are variation, genetics and rate of change of the elite athlete to the recreational unclear, but inclusive coverage stretches training load.4 enthusiast. These patients are highly from world champions through to the However, this has been questioned motivated, but treating them can be recreational athlete who is interested by a recent prospective study of 300 challenging. in improving or maintaining his or her runners, which indicated that flexibility, Objective physical performance. arch height, quadriceps angle, rearfoot The aims of this article are to increase To facilitate a successful medical motion, lower extremity strength, weekly awareness of the management of a interaction, the mindset of the athlete mileage, footwear and previous injury are number of overuse injuries frequently needs to be understood. High-performing not significant aetiological factors across seen in athletes, to assist in athletes, and often recreational athletes, all overuse running injuries.5 understanding the mindset of the athlete in relation to his or her injuries tend to have the following characteristics: There is very little published evidence and to indicate the importance of a high levels of motivation and confidence, related to presentations of overuse confident approach to these problems an inner drive to succeed, self-discipline, sporting injuries to general practitioners and a multidisciplinary management a strong sense of focus, high resilience (GPs). When available, it generally refers plan in facilitating a successful outcome. and perfectionism.2 Both high-level and to frequencies of injuries to general body Discussion recreational athletes derive different, regions without mention of specific Athletes generally have dynamic indeed greater, meaning from sport and diagnoses.6 personalities and high standards for exercise than non-participants. They are themselves and others. Complete rest respectful of expertise, dislike rest and can be anathema to them. Fortunately, want to return to sport as soon as possible. The lower limb in cases of tendinopathy, a structured The definition of an overuse injury Many overuse injuries to the lower limb exercise program is an important component of management. A is generally based on the concept of an of athletes affect tendons. Histological proactive approach, often with the injury occurring in the absence of a single evidence indicates that in established assistance of a physiotherapist, is identifiable traumatic cause.3 Overuse cases, which are those generally seen likely to improve outcomes. is a relative term applied to conditions in general practice, the predominant for which the mechanism of injury is a pathology is degenerative with some single or closely related action repeated cellular and biochemical evidence many times. It has been suggested, of chronic inflammation.7,8 This has

resulted in the change in terminology • Educate the patient about the stem cells in the management of from tendinitis to tendinopathy and condition, avoiding use of the term tendinopathy.17 explains the relative ineffectiveness of ‘degenerative’. Indicate that tendons • To prevent recurrence, assess anti-inflammatory treatments. adapt to increases in training load, biomechanical risk factors and but often, in those keen to excel, the training.18 desire to improve can exceed the • Consider carefully the need for Achilles tendinopathy capability of the tendon. The shared ultrasonography or other investigation. Achilles tendinopathy occurs mainly goal is to rebalance the stress with the Clinical diagnosis is often satisfactory. in patients involved in sports requiring capabilities of the tendon. This will • Be prepared to support the patient running or jumping. The most frequent take some time and application. though a relatively prolonged course, presentation is as mid-tendon pain of • Avoid complete rest but also avoid which may be four months or longer. gradual onset with little, or a fusiform, high loads on the tendon, such as • If the patient fails to respond swelling typically 2–6 cm from the jumping, in cases of patellar or progressively, reconsider the diagnosis, tendon’s insertion into the calcaneus. Achilles tendinopathy. Substitute further investigation or referral to Insertional tendinopathy is associated isometric exercises; when tendon pain a physician in sport and exercise with pain and, at times, swelling at the decreases, higher load can be added. medicine (SEM). calcaneal insertion. Provocative clinical Eccentric exercise can be added when tests used to assist in diagnosis and/or pain is controlled.11 The assistance monitor progress include single leg heel of a physiotherapist experienced in Iliotibial band syndrome raises (low load) and hopping on the management of tendon pathology can Iliotibial band syndrome is the second affected leg (high load).9 be very useful during the exercise/ most common running injury and the most rehabilitation phase. common cause of lateral knee pain in • Consider alternative forms of runners.19 It is also associated with cycling, Patellar tendinopathy exercise, which can maintain training and less frequently with field sports, Patellar tendinopathy occurs primarily in adaptations such as increases in hockey, rowing, swimming, hiking and patients undertaking sports that involve plasma volume and muscle enzyme basketball. It is a syndrome related to jumping, such as volleyball, basketball and concentrations while not overly friction and is not a tendinopathy.19 netball. Pain that has a gradual onset and stressing the injured tendon. The iliotibial band is a long dense is aggravated by jumping and bounding • Monitor tendon load. If pain increases, fibrous structure that is a lateral thickening is felt in the region of the lower pole of for example by >2/10 after exercise, of the fascia lata in the thigh. It also the patella at the origin of the tendon. reduce the load for several days and receives most of the tendon of gluteus Tenderness is felt in the same region. return to exercise at a lower level. maximus. Distally it passes over the lateral Provocative clinical tests used to • Where patients are seeking relevant femoral epicondyle. If the leg is extended augment diagnosis and/or monitor information, advise them that: at the knee, the iliotibial band can be seen progress include performing a squat with –– stretching does not improve as the structure leading to flattening of the the feet on a declining surface (low load) outcomes and may be detrimental lateral aspect of the thigh. and a high single-leg jump or landing from –– nonsteroidal anti-inflammatory Pain at the lateral aspect of the knee a height (high load).9 drugs (NSAIDs) do not change the occurs as a result of pressure leading to outcome and are rarely required for friction of the band on the lateral femoral pain relief 11 condyle as the knee moves through General management principles –– corticosteroid injections, although 30 degrees of flexion. The pain begins for tendinopathy used frequently, are generally not after a reasonably consistent duration of The management of established appropriate in the early phase of running and worsens if running continues. tendinopathy for athletes can be difficult, treatment despite some evidence The athlete eventually cannot continue. and some aspects remain controversial. for short-term pain relief.12 Focal tenderness will be found over the Management is based primarily on • If patients inquire about newer condyle, and a useful clinical test involves a supervised exercise program, the ‘biological’ therapies, including placing pressure over the condyle and exact details of which require further platelet-rich plasma (PRP) and moving the knee through 30 degrees of investigation.10 mesenchymal stem cells, advise flexion, thereby reproducing the pain. The following general principles them that recent systematic reviews Management involves avoidance of apply to most cases of established suggest that there may be a role for aggravating activities for up to 4–6 weeks, tendinopathy. Any contradictory advice PRP injection in some tendinopathies, with substitution of alternative activities related to specific tendons is mentioned but this issue is not resolved in the to maintain current training adaptations. in sections of this article related to those literature.13–16 There is no good Ice and NSAIDs may help for acute pain. specific tendons. evidence for the use of mesenchymal The patient should institute iliotibial

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band stretches, such as crossing the stress fractures. Stress reactions will training, the incidence of swimmer’s legs while standing and leaning away generally not be seen on X-ray. shoulder is approximately 35% in elite from the affected side, which places the Management involves a reduction and senior level swimmers.27 iliotibial band under maximum stretch. in training load until pain resolves. In subacromial pain syndrome, pain is The stretch is held for 30 seconds and Alternative activities such as cycling, felt at the anterior or lateral aspects of the repeated five times each stretch session, swimming and running in deep water shoulder when overhead activities such three times per day. using a floatation device are useful for a swimming or throwing are undertaken. Biomechanical assessment of the maintenance of fitness. Once the pain When impingement is present, abduction lower limbs, including footwear, is has resolved, a gradual return to previous will be limited, painful or both. generally performed by an SEM physician training levels can occur. Clinical tests for subacromial or physiotherapist who can also advise Chronic exertional compartment pathologies have been assessed in four on other stretches and strengthening syndrome of the deep posterior relatively recent systematic reviews and exercises. Corticosteroid injection at the compartment can present with medial meta-analyses.28–31 Interpretation of these level of the lateral femoral epicondyle, tibial pain. The pain is often described as studies is complicated by the varying under the iliotibial band, can be used a tightness or pressure and tends to come definitions of rotator cuff disease used. By following failure of more conservative on at a reasonably consistent running including full-thickness rotator cuff tears, management. Recalcitrant cases can be distance. It worsens with continued these studies assess beyond the definition referred for surgical management. running and eventually leads to cessation of subacromial pain syndrome used above. of running. The pain resolves with rest and The authors of the 2013 Cochrane elevation of the limb, often within minutes. review indicated that ‘there is insufficient Medial tibial stress syndrome: As the deep posterior compartment is not evidence on which to base selection of Shin splints accessible to palpation, examination may physical tests for shoulder impingements, Medial tibial stress syndrome is defined be normal. The only definitive investigation and local lesions of bursa, tendon or as exercise-induced pain along the is compartment pressure testing. labrum that may accompany impingement, middle to distal postero-medial aspect of While a number of non-surgical in primary care’.28 In his 2012 the tibia.20 Earlier thought to be related therapeutic interventions have been meta-analysis, Hegedus concluded that, to tibial periostitis caused by traction, suggested, none have high-level evidence to in relation to subacromial impingement, more recent reports suggest that, while support them, with the exception of cessation the use of no single test could be the exact aetiology is unclear, the most of the inciting activity.24,25 If this is not unequivocally recommended but that common causes are likely to be tibial stress acceptable, fasciotomy can be considered. ‘the strongest summary sensitivity was reactions or stress fractures and chronic for the Hawkins–Kennedy test (80%)’.29 exertional compartment syndrome In 2012, Alqunaee et al reported on tests involving the deep posterior compartment The upper limb for subacromial impingement syndrome of the lower leg.21,22 Subacromial pain syndrome defined as ‘pain and pathology relating In cases of tibial stress reactions and Subacromial pain syndrome comprises all to the subacromial bursa and rotator cuff fractures, pain along the medial bone non-traumatic, usually unilateral, shoulder tendons within the subacromial space’. border may be particularly related to heel problems that cause pain, localised around The frequently used Hawkins–Kennedy, strike. Initially, in the bone stress phase, the acromion, often worsening during empty can and drop arm tests were found the pain typically occurs at the onset of or subsequent to lifting of the arm. The to have likelihood ratios of 1.79, 1.81 and activity and disappears as the athlete different clinical and/or radiological names – 2.62, respectively, suggesting that they warms up, only to reappear after cessation such as bursitis, supraspinatus tendinopathy, should be ‘interpreted with caution’.30 of exercise. With further overuse, pain partial tear of the rotator cuff, biceps Finally, Hermans et al, using a definition becomes more constant during running, tendinitis or tendon cuff degeneration – similar to Alqunaee et al, concluded eventually leading to cessation of exercise. are included in the syndrome.26 that among the pain provocation tests, a Pain at night and with any weight bearing Rotator cuff tendinopathy most positive painful arc test result was the only can occur with stress fractures. frequently affects the supraspinatus finding with a positive likelihood ratio On examination, pain is felt on hopping tendon. Impingement syndrome results greater than 2, at 3.7. The authors also or jumping. In cases of stress reaction, a from mechanical impingement of the suggested that a positive drop arm test linear area of tenderness will be found rotator cuff tendons and associated (defined in this study as a strength test), at the medial tibial border. If a stress structures beneath the anteroinferior with a likelihood ratio of 3.3, might help fracture is present, the tenderness will portion of the acromion, especially when identify patients with rotator cuff disease.31 be more focal. Diagnosis can be made on the shoulder is placed in the forward- These reviews highlight the relative clinical features.23 Should investigations flexed and internally rotated position. inadequacy of individual tests and be ordered, X-ray, bone scan and When defined as shoulder pain that the difficulty in identifying specific magnetic resonance imaging will reveal interferes with training or progress in pathologies by examination alone.

Management of rotator cuff Faculty of Medicine, College of Health and Medicine, and meta-analysis with bias assessment. Australian National University, ACT; Visiting Medical Am J Sports Med 2018;46(8):2020–32. tendinopathy follows the general Officer, Department of Rheumatology, The Canberra doi: 10.1177/0363546517743746. plan for tendinopathy as previously Hospital, ACT. [email protected] 15. Fitzpatrick J, Bulsara M, Zheng MH. described in this article. However, for Competing interests: None. The effectiveness of platelet-rich plasma Funding: None. in the treatment of tendinopathy. A meta- analgesia in the short term, NSAIDs are analysis of randomized controlled clinical Provenance and peer review: Commissioned, effective.32 Recent evidence indicates trials. Am J Sports Med 2018;45(1):226–33. externally peer reviewed. doi: 10.1177/0363546516643716. that subacromial corticosteroid injection 16. Lamplot JD, Rodeo SA, Brophy RH. is superior to no treatment33 and local References A practical guide for the current use of anaesthetic injection34 at up to eight 1. Moore B. Australian Oxford Dictionary. Melbourne: biologic therapies in sports medicine. Am Oxford University Press, 1999. J Sports Med 2019:363546519836090. weeks following the injection. Should a doi: 10.1177/0363546519836090. 2. MacNamara Á, Button A, Collins D. The role of significant, inflamed bursa be present, a psychological characteristics in facilitating the 17. Pas HIMFL, Moen MH, Haisma HJ, Winters M. pathway to elite performance Part 1: Identifying No evidence for the use of stem cell therapy corticosteroid injection into the bursa is for tendon disorders: A systematic review. Br J mental skills and behaviours. Sport Psychol Sports Med 2017;51(13):996–1002. doi: 10.1136/ appropriate. A trial of physical therapy, 2010;24(1):52–73. doi: 10.1123/tsp.24.1.52. bjsports-2016-096794. rather than manual therapy, is supported 3. Aicale R, Tarantino D, Maffulli N. Overuse injuries 18. Johnston CA, Taunton JE, Lloyd-Smith DR, in sport: A comprehensive overview. J Orthop Surg by systematic reviews that concluded that McKenzie DC. Preventing running injuries. Res 2018;13(1):309. doi: 10.1186/s13018-018-1017-5. exercise has both short- and long-term Practical approach for family doctors. Can Fam 4. Ristolainen L, Kettunen JA, Waller B, Heinonen A, Physician 2003;49:1101–09. benefits with respect to pain and function Kujala UM. Training-related risk factors in the 19. Pegrum J, Self A, Hall N. Iliotibial band syndrome. in rotator cuff disease.35 etiology of overuse injuries in endurance sports. BMJ 2019;364:l980. doi: 10.1136/bmj.l980. J Sports Med Phys Fitness 2014;54(1):78–87. In relation to surgical management, a 20. Burrus MT, Werner BC, Starman JS, 5. Messier SP, Martin DF, Mihalko SL, et al. A 2-year et al. Chronic leg pain in athletes. Am recent Cochrane review did not support prospective cohort study of overuse running J Sports Med 2014;43(6):1538–47. the use of subacromial decompression injuries: The runners and injury longitudinal study doi: 10.1177/0363546514545859. (TRAILS). Am J Sports Med 2018;46(9):2211–21. 21. Winters M. The diagnosis and management of surgery in the treatment of rotator cuff doi: 10.1177/0363546518773755. medial tibial stress syndrome. An evidence update. disease manifesting as painful shoulder 6. Baarvelda F, Vissera CA, Kollena BJ, Backx FJ. Unfallchirurg 2019. doi: 10.1007/s00113-019- impingement.36 Sports-related injuries in primary health care. 0667-z. Fam Pract 2011;28(1):29–33. doi: 10.1093/fampra/ 22. Blackman P. Shin pain in athletes: Assessment cmq075. and managment. Aust Fam Physician 7. Dakin SG, Newton J, Martinez FO, et al. Chronic 2010;39(1–2):24–29. Conclusion inflammation is a feature of Achilles tendinopathy 23. Winters M, Bakker EWP, Moen MH, Barten CC, and rupture. Br J Sports Med 2018;52(6):359–67. Knowledge of common injuries and Teeuwen R, Weir A. Medial tibial stress doi: 10.1136/bjsports-2017-098161. syndrome can be diagnosed reliably using a clear understanding of an athlete’s 8. Dean BJ, Gelthings P, Dakin SG, Carr AJ. history and physical examination. Br J Sports goals are the bases for successful injury Are inflammatory cells increased in painful Med 2018;52(19):1267–72. doi: 10.1136/ human tendinopathy? A systematic review. Br bjsports-2016-097037. management. Combining these with a J Sports Med 2016;50(4):216–20. doi: 10.1136/ 24. Rajasekaran S, Hall MM. Nonoperative positive outlook; informed history-taking; bjsports-2015-09754. management of chronic exertional compartment competent examination and a structured, 9. Cook JL, Purdam CR. The challenge of managing syndrome: A systematic review. Curr Sports tendinopathy in competing athletes. Br J Med Rep 2016;15(3):191–98. doi: 10.1249/ well-monitored, often multidisciplinary Sports Med 2014;48(7):506–09. doi: 10.1136/ JSR.0000000000000261. treatment plan facilitates optimal bjsports-2012-092078. 25. Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional outcomes for the athlete and GP. 10. Cook JL, Stasinopoulos D, Brismée JM. Insertional and mid-substance Achilles tendinopathies: compartment syndrome: A review of current Eccentric training is not for everyone – Updated literature. Phys Sportsmed 2017;45(4):391–98. evidence of non-surgical management. doi: 10.1080/00913847.2017.1384289. Key points J Man Manip Ther 2018;26(3):119–22. 26. Diercks R, Bron C, Dorrestijn O, et al. Guideline doi: 10.1080/10669817.2018.1470302. for diagnosis and treatment of subacromial pain syndrome: A multidisciplinary review • Athletes often dislike complete rest but 11. Cook JL. Ten treatments to avoid in by the Dutch Orthopaedic Association. patients with lower limb tendon pain. Br J generally will comply with an active Acta Orthop 2014;85(3):314–22. Sports Med 2018;52(14):882. doi: 10.1136/ doi: 10.3109/17453674.2014.920991. rehabilitation program. bjsports-2018-099045. 27. Matzkin E, Suslavich K, Wes D. Swimmer’s Tendinopathies can be difficult to 12. Dean BJ, Lostis E, Oakley T, Rombach I, • shoulder: Painful shoulder in the competitive treat. Their management focuses on a Morrey ME, Carr AJ. The risks and benefits swimmer. J Am Acad Orthop Surg of glucocorticoid treatment for tendinopathy: progressive exercise program. 2016;24(8):527–36. doi: 10.5435/JAAOS-D-15- A systematic review of the effects of local 00313. Collaboration with a physiotherapist glucocorticoid on tendon. Sem Arthritis • 28. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Rheum 2014;43(4):570–76. doi: 10.1016/j. and assessment of biomechanical Physical tests for shoulder impingements semarthrit.2013.08.006. predisposing factors can be highly and local lesions of bursa, tendon or labrum 13. Andriolo L, Altamura SA, Reale D, Candrian C, that may accompany impingement. Cochrane beneficial in the management of Zaffagnini F, Filardo G. Nonsurgical treatments Database Syst Rev 2013;(4):CD007427. overuse injuries. of patellar tendinopathy: Multiple injections doi: 10.1002/14651858.CD007427.pub2. of platelet-rich plasma are a suitable option. 29. Hegedus EJ, Goode AP, Cook CE, et al. Which A systematic review and meta-analysis. physical examination tests provide clinicians Am J Sports Med 2019;47(4):1001–18. with the most value when examining the Author doi: 10.1177/0363546518759674. shoulder? Update of a systematic review Kieran Fallon MBBS (Hons), MD (ANU), MSpExSc, 14. Chen X, Jones IA, Park C, Vangsness CT Jr. with meta-analysis of individual tests. Br J MHEd, FRACGP, FACSEP, SFHEA, Professor of The efficacy of platelet-rich plasma on tendon Sports Med 2012;46(14):964–78. doi: 10.1136/ Musculoskeletal, Sport and Exercise Medicine, and ligament healing. A systematic review bjsports-2012-091066.

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30. Alqunaee M, Galvin R, Fahey T. Diagnostic 34. Cook T, Minns Lowe C, Maybury M, Lewis JS. accuracy of clinical tests for subacromial Are corticosteroid injections more beneficial than impingement syndrome: A systematic anaesthetic injections alone in the management review and meta-analysis. Arch Phys Med of rotator cuff-related shoulder pain? A systematic Rehabil 2012;93(2):229–36. doi: 10.1016/j. review. Br J Sports Med 2018;52(8):497–504. apmr.2011.08.035. doi: 10.1136/bjsports-2016-097444. 31. Hermans J, Liume JJ, Meuffels DE, Reijman M, 35. Whittle S, Buchbinder R. In the clinic. Rotator Simel DL, Bierma-Zeinstra SM. Does this patient cuff disease. Ann Intern Med 2015;162(1):ITC1–15. with shoulder pain have rotator cuff disease? doi: 10.7326/AITC201501060. The Rational Clinical Examination systematic 36. Karjalainen TV, Jain NB, Page CM, et al. review. JAMA 2013;310(8):837–47. doi: 10.1001/ Subacromial decompression surgery for rotator jama.2013.276187. cuff disease. Cochrane Database Syst Rev 32. Boudreault J, Desmeules F, Roy JS, Dionne C, 2019;1:CD005619. doi: 10.1002/14651858. Frémont P, Macdermid JC. The efficacy of oral CD005619.pub3. non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: A systematic review and meta- analysis. J Rehabil Med 2014;46(4):294–306. doi: 10.2340/16501977-1800. 33. Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: A systematic review and meta-analysis of RCTs. Br J Sports Med 2017;51(18):1340–47. doi: 10.1136/ bjsports-2016-096515. correspondence [email protected]