Chronic Neuromusculoskeletal Issues in Athletes
Original Editor - Wanda van Niekerk
Top Contributors - Wanda van Niekerk, Stacy Lawrence and Kim Jackson
Introduction
Athletes with longstanding neuromusculoskeletal symptoms face unique challenges that impact both their physical performance and mental health. These symptoms often result from severe injuries, repetitive strain, or chronic conditions that are compounded by the high demands of athletic activities. Studies have shown that severe musculoskeletal injuries are strongly associated with increased symptoms of anxiety, depression, and distress, emphasizing the importance of integrated care approaches that address both physical and psychological health. [1]
Patients with difficult or longstanding musculoskeletal symptoms may present with:[2]
- Chronic low back pain or neck pain[2]
- Recurring or ongoing tendinopathies[2]
- Multiple areas of pain[2]
- Continual joint problems[2]
- Non-healing fractures[2]
- Persistent foot pain[2]
These persistent symptoms may be due to conditions masquerading as sports injuries, but chances are that they may be true musculoskeletal problems.[2] The question is then, how do clinicians approach these “difficult” and persisting presentations?
Prevalence of Neuromusculoskeletal Symptoms in Athletes
The prevalence of musculoskeletal pain varies across sports disciplines and levels of participation. For example, sports like rugby, soccer, and combat sports have higher rates of tendinopathy, joint injuries, and muscle strains, as identified in cross-sectional studies[3]. Amateur and professional athletes also experience different rates of pain and injury, which influence their approach to training and recovery[4].
Determining the diagnosis
Give yourself enough time to assess the patient with a long history of persistent problems. Also explain to the patient the necessity to revisit the entire history, previous examinations and other investigations used.[5][2]
Start at the very beginning
- Get the details of the patients' earliest symptoms in his or her own words, rather than from a referral letter.[2]
- Assess the presenting complaint, the time course and the response to previous therapy.[2]
- Remember to investigate the past medical history as well as family history.[5][2]
- Be specific with questioning - associated musculoskeletal symptoms may provide clues to an alternative diagnosis.[2]
- Assess the patients’ demands of his or her work as symptoms might arise from this, rather than from their sport.[2]
- Investigate the patients' history of non-musculoskeletal symptoms as well.[5][2]
Physical Examination
- Be thorough and meticulous with your assessment.[2]
- Always examine the spine (referred pain commonly goes undiagnosed)[2]
- Continue the examination even if an abnormality has been found, there may be a combination of contributing factors involved.[2]
- Routine physical examinations are not always sensitive enough to test for pain in the athletic population and therefore functional assessments need to be a part of the physical examination.[5][2]
Previous investigations
- Reassess the results of previous investigations, false negatives and incorrect interpretation of results may lead to a prolonged diagnosis.[2]
- Consider other suitable tests that have not yet been performed.[2]
- Collaboration between the clinician and radiologist is useful to optimise the outcome for the patient.[2]
Challenges in Diagnosis and Management
Athletes with spinal cord injuries report unique experiences of neuropathic pain that significantly affect their quality of life and athletic performance. Their challenges underline the importance of specialized pain management strategies, including personalised communication and rehabilitation plans [6]. The psychological burden of long-term pain and injury can also compromise recovery, making it crucial to integrate mental health support into musculoskeletal care strategies.
Rehabilitation and Recovery Approaches
Effective management of neuromusculoskeletal symptoms in athletes requires a multidisciplinary approach that includes evidence-based interventions such as physical therapy, strength training, and psychological counselling. Research highlights the need for programs tailored to the specific demands of an athlete's sport and injury type. For example, youth athletes who experience significant injuries benefit from comprehensive rehabilitation plans that address both physical recovery and overall well-being [7].
Management
In certain cases of patients with difficult or longstanding problems, the patient may not respond to treatment, although the diagnosis seems straightforward. In such cases it is worth to:[2]
- Establish that the diagnosis is in fact correct[5][2]
- Review the details of past treatment techniques[2]
- Aim to elicit the underlying cause of the problem[2]
- Contemplate various treatment options[2]
- Surgical intervention is the last resort and only when the indications for surgery are met[2]
Correct diagnosis?
- Some conditions can be easily misdiagnosed. Some patients present with a presumably straightforward condition when in fact they are suffering from a different condition.
- Common misdiagnosed conditions:[2]
| Obvious diagnosis | True or alternate diagnosis |
|---|---|
| Tennis elbow | Cervical disc abnormality |
| Persistent hamstring strain | Neural mechanosensitivity |
| Achilles tendinopathy | Posterior impingement
Retrocalcaneal bursitis |
| Patellafemoral pain/ Knee OA | Referred pain from the hip |
| Bucket handle tear of the meniscus | Referred pain form ruptured L4-5 disc |
- Biomechanical problems are often the reasons for persisting longstanding symptoms. Assess all relevant biomechanical factors.[2]
- Suggested biomechanical issues related to persistent symptoms in athletes[2]
| Persistent Symptom | Biomechanical issue possibly present |
|---|---|
| Shoulder pain in swimmer | Poor scapulae stability
Limited trunk rotation |
| Elbow pain in throwing athlete | letting the elbow hang because of trunk and lower limb weakness
Decreased glenohumeral external rotation |
| Lumbar pain in tennis player | Poor control of lumbar hyperextension |
| Anterior knee pain in runner | Weakness of vastus medialis and poor gluteal control of pelvis |
- Investigate training regimes and possible training errors.
- Always gather full and specific details of treatment received.[2]
- Make use of the multidisciplinary team approach.[2]
- Refer to appropriate professionals and experts in their specific field of interest.[2]
Preventative Strategies
Injury prevention remains a cornerstone of managing neuromusculoskeletal conditions. Dynamic warm-ups, proper equipment, and sport-specific conditioning are essential in reducing the incidence of injuries. For elite athletes, personalized monitoring and early intervention can mitigate the risk of chronic conditions and optimize long-term performance.[8]
Conclusion
Dealing with difficult and long standing musculoskeletal problems can be frustrating for both the patient and the clinician.Taking time to assess and perform detailed examinations is worthwhile and may discover the missing piece of the puzzle in the diagnosis or treatment. Critical review of all previous investigations is important and functional and biomechanical assessments is especially necessary with athletes.[2]
References
- ↑ Kiliç Ö, Aoki H, Goedhart E, Hägglund M, Kerkhoffs GMMJ, Kuijer PPFM, et al. Severe musculoskeletal time-loss injuries and symptoms of common mental disorders in professional soccer: a longitudinal analysis of 12-month follow-up data. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jul 11;26(3):946–54.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 Brukner P. Khan K. Clinical Sports Medicine. 3rd edition. Sydney: McGraw-Hill 2006.
- ↑ Goes RA, Lopes LR, Cossich VRA, de Miranda VAR, Coelho ON, do Carmo Bastos R, et al. Musculoskeletal injuries in athletes from five modalities: a cross-sectional study. BMC Musculoskeletal Disorders. 2020 Feb 24;21(1).
- ↑ Malam H, Bika C, Wiliam Richard Guessogo, Wiliam Mbang Bian, Guyot J, None Ahmadou, et al. Musculoskeletal pains among amateur and professional athletes of five disciplines in Senegal: a preliminary study. BMC Musculoskeletal Disorders [Internet]. 2023 Mar 22 [cited 2023 May 2];24(1).
- ↑ 5.0 5.1 5.2 5.3 5.4 Iolascon G, Tarantino U, Moretti A. Challenges and Solutions for Musculoskeletal Disorders in Athletes. Medicina. 2022 Jan 5;58(1):80.
- ↑ Todd K, Kramer J, Olsen K, Kathleen Martin Ginis. “I don’t know the correct way to describe it”: neuropathic pain experiences among athletes with spinal cord injury. BMJ Open Sport & Exercise Medicine [Internet]. 2024 Aug 1 [cited 2024 Aug 28];10(3):e001828–8.
- ↑ Saud Aldanyowi, Lama AlOraini. Personalizing Injury Management and Recovery: A Cross-Sectional Investigation of Musculoskeletal Injuries and Quality of Life in Athletes. Orthopedic Research and Reviews. 2024 May 1;Volume 16:137–51.
- ↑ Iolascon G, Tarantino U, Moretti A. Challenges and Solutions for Musculoskeletal Disorders in Athletes. Medicina. 2022 Jan 5;58(1):80.