Overuse Injuries - an Individualised Approach

Original Editor - Wanda van Niekerk based on the course by Merike Hopkins
Top Contributors - Wanda van Niekerk, Lucinda hampton, Kim Jackson, Tarina van der Stockt and Jess Bell  

Introduction

Overuse injuries are a common phenomenon and challenging to assess and manage. Various factors contribute to the development of these type of injuries. The diagnosis, treatment and understanding why the injury occurred are some of the challenges that clinicians may deal with in the management of athletes with overuse injuries.

Definition of Overuse Injuries

Overuse injuries are characterised by the absence of a single, identifiable or traumatic cause. There is a gradual onset and injury is caused by repeated micro-trauma. The term "overuse" is used as the onset of these type of injuries are usually precipitated by a period of inappropriate tissue loading such as:

• Excessive magnitude or volume of load
• Insufficient recovery between bouts of load

Why Does Overuse Lead to Injury?

An overuse injury is usually caused by repetitive activities over a period of time. This repetitive microtrauma overloads the capacity of the tissue to repair itself. During exercise, the various tissues such as muscles, tendons, bones and ligaments, are being loaded and experience excessive physiological stress. After the specific exercise activity, the tissues undergo adaptation in order to strengthen and to be able to withstand similar stress in the future. If the adaptive capability of a specific tissue type is exceeded and injury occurs, this is most often an overuse injury. Therefore, in overzealous athletes, that do not allow adequate time for adaptation to occur before the next workout or training session, the cumulative tissue damage eventually exceeds the threshold that the tissue can handle and this causes pain and dysfunction.

Structures Affected by Overuse Injuries

• 
  Bone
  • eg. bone stress injuries, stress fracture, osteitis, periostitis, apophysitis
• Tendons
  • eg. tendinopathy
• Ligaments
  • eg. medial ulnar collateral ligament injury in baseball pitchers
• Muscle
  • eg. myofascial pain, chronic compartment syndromes, exercise-induced muscle soreness
• Bursa
  • subacromial bursa, greater trochanteric bursa
• Nerve
  • eg. nerve entrapment syndromes
• Cartilage
• Skin
  • eg. blisters

Risk Factors of Overuse Injuries

Training loads, intense competition schedules and inadequate or insufficient recovery are some of the factors that place athletes at higher risk for developing an overuse injury. Risk factors can also be classified as intrinsic and extrinsic risk factors:

• Intrinsic Risk Factors
  • Malalignment issues, eg genu valgum or varum, patella alta, femoral neck anteversion
  • Leg length discrepancy
  • Muscle imbalance
  • Muscle weakness
  • Flexibility issues, such as generalised muscle tightness, restricted joint range of motion, focal areas of muscle thickening
  • Body composition
  • Biological sex
  • Genetic factors
  • Endocrine factors
  • Metabolic conditions

• Extrinsic Risk Factors
  • Training load errors, such as excessive volume, intensity, increase, inadequate recovery
  • Surfaces, for example hard, soft or cambered areas
  • Shoes
  • Equipment
  • Environmental conditions
  • Nutrition
  • Psychological factors

Signs and Symptoms of Common Overuse Injuries

The table below highlights some signs and symptoms that will guide your decision and diagnostic processes.

Table 1. Signs and Symptoms of Common Overuse Injuries

Overuse Injury	Signs and Symptoms
Bone stress injuries	localised pain over area tenderness over area/fracture site history of recent changes in training or starting with new activity often normal X-rays, sometimes a periosteal reaction is noticed abnormal appearance on MRI, bone scintigraphy or CT scan
Chronic compartment syndrome	pain starts during activity and stops with rest
Tendinopathy	pain after exercise pain the following morning after exercise may be pain-free at rest and become more painful with use pain disappears after warming-up, or athlete can train or run through the pain, pain returns after exercise when athlete cool down early stages of condition - athlete able to train fully, but this may influence the healing process localised tenderness on examination swelling and crepitus may be present

Physiotherapy and Overuse Injuries

Physiotherapists are advocates for physical activity and are closely involved and invested in restoring the appropriate level of function in clients. This level of function is different for every client or athlete, and it is crucial that a customised and individualised approach is used. Ways to help athletes back to their highest level of function and return to play is by having good knowledge about the athlete’s specific sport and understanding the physical and psychological requirements and demands of the sport.

Imagery explaining overuse injury management

Patient education is important in the management of overuse injuries. Furthermore, it is of great value to involve the multidisciplinary team and coaches. The treatment or intervention approach is based on managing the load and/or the forces that caused the injury so that the involved tissue has enough healing time, but also to build resilience against these forces. A helpful imagery to use in educating patients about their overuse injury is the image of two tugboats pulling against each other. The green tugboat (good) will drive the overuse injury into healing and return to function or sport, whereas the red tugboat will draw the overuse injury away from healing and into more serious pathology. The key is to find the balance and fuelling the green tugboat with all the necessary interventions to facilitate healing, but not in a way that fuels the red tugboat and aggravates the pathology. In developing a treatment plan it is key to educate the client and to have a multidisciplinary and holistic approach. A dynamic flexible timeline should be established and a multi-phased, evidence-based and functional progression should be part of the intervention plan.

Assessment of Overuse Injuries

Key factors to consider in the assessment of an overuse injury include:

• the structure involved
• the nature and severity of the injury
• the duration of injury from the onset of symptoms – this will aid in understanding the progression of pathology

Diagnosis of Overuse Injury

Clinical history

• This is an important and valuable tool in the diagnosis of an overuse injury
• Listen to what your client, the coach or other medical staff working with the athlete is telling you!
• Establish specific causative factors (intrinsic and extrinsic)
• Also consider the forces created on the structures when the athlete is not taking part in sport (such as housework, gardening) - it is key to understand the total amount of forces created on the structure involved
• Consider certain populations more at risk of overuse injuries such as:
  • Children – the changing nature of training and competition in youth sports, combined with an immature musculoskeletal system
  • Female athletes (Female Athlete Triad)
  • Older athletes – factors such as bone density loss or old degenerative issues that may predispose to overuse injuries

Diagnostic Imaging

• Plain Radiographs – to diagnose associated or incidental bony abnormalities
• Ultrasound – effective imaging method for tendinopathies, although it is operator dependent
• MRI
• CT

Diagnosis

Identify the structure(s) involved, the nature and severity, as well as the duration from the onset. This will provide insight into the progression of the pathology. Early diagnosis significantly reduces the barriers to an optimal healing process.

Management of Overuse Injuries

A phase-appropriate intervention is necessary for the management of overuse injuries. Athletes present at different points of progression in the pathology (i.e. some will present early on with an overuse reaction, whereas others might have been struggling with an injury for much longer and the pathology of the injury is far more progressed.) Treatment aims can include:

• Identify and address the cause of injury
• Reduce inflammation and pain
• Promote healing
• Prevent complications
• Restore normal use of the injured area
• Develop a return to play strategy, as dictated by symptoms

Optimise tissue healing by systematically, gradually and optimally loading the structures in order to provide restoration of function and capacity.

Treatment modalities may include:

• Relative or graded rest and avoidance of aggravating activities while maintaining fitness
• Recovery protocols
  • Cryotherapy and manual therapy techniques
• Manual therapy
• Strengthening and rehabilitation
  • Phase appropriate loading
  • Exercises for progressive loading and conditioning (and also limiting the effects of detraining)
• Referral to appropriate healthcare providers
  • Psychologists - psychological readiness for return to play
  • Dietitians - appropriate nutritional advice considering the energy demand of the sport
  • Sports physician or specialists
• Read more on specific overuse injuries and their management:
  • Bone stress injuries
  • Runners and bone stress injuries
  • Femoral stress fracture
  • Evidence-based practice in tendinopathy
  • Differential diagnosis of tendinopathy
  • Managing difficult tendinopathies
  • Greater trochanteric pain syndrome

Prevention of Overuse Injuries

Overuse injury prevention strategies can target modifiable intrinsic and extrinsic risk factors. "As the inciting event for overuse injuries is cumulative tissue overload that occurs over time, close monitoring of athletes' training and competition loads may be a particularly effective prevention strategy." Some strategies include:

• Stretching - recent systematic reviews shows that the evidence to support the efficacy of stretching to prevent injuries is lacking. However, in handball players, targeted stretching of glenohumeral joint internal rotation is part of an effective multimodal training programme that is effective in reducing the rate of overuse shoulder injuries.
• Structured training programmes - these programmes, such as the FIFA 11+ have been effective in the prevention of lower limb injuries in team sports.
• Technique modification - for example tennis players can prevent "tennis elbow" by rather using a double-handed backhand shot
• Nutritional strategies - insufficient levels of calcium and vitamin D are reported as risk factors for stress fractures. In athletes with dietary intake issues or limited exposure to sunlight nutritional strategies can help with the prevention of these injuries.

Overuse Injury Surveillance

Many of the injury surveillance research provide information predominantly on acute sports injuries and often do not account for overuse injuries in sport. The reason for this being that many traditional sports injury surveillance studies make use of "time loss" from sports as the most important criteria for defining the occurrence of an injury and the duration of the "time loss" is used as a measure of the severity of the injury. By using these methods, the impact of overuse injuries in athletes is underestimated, as many athletes continue to train and compete, despite having injury-associated symptoms and limitations. Clarsen et al (2013) developed a new model of injury surveillance, which also allows for the review of the prevalence of overuse injuries (i.e. the magnitude, symptoms and consequences of overuse injuries) - the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O). An updated version of the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O2) was recently published. The four domains that the OSTRC-O evaluates include:

• sports participation
• training volume
• sports performance
• pain

Clinicians and researchers can administer the questionnaire at regular intervals (e.g. weekly) and are able to monitor how the consequences of an overuse injury change over time.

A modified version of the OSTRC-O was also developed to monitor all types of health problems in athletes - the OSTRC Questionnaire on Health Problems (OSTRC-H) and also recently updated to the OSTRC-H2 version.