How To Treat Overuse Injuries In Athletes

By Patrick DeHeer, DPM, and Debra Mardis, DPM

Approximately 50 percent of all sports injuries are secondary to overuse.1 Overuse injuries result from repetitive microtrauma that leads to local tissue damage in the form of cellular and extracellular degeneration. Injury is most likely to occur when an athlete changes the intensity or length of training. This has been described as the “principle of transition.”1 A discrepancy between work and recovery can lead to breakdown on a cellular, extracellular or systemic level. Other factors that can influence wear and tear include biomechanical abnormalities, poor training, improper equipment and changes in the duration or frequency of activity. Determining the preexisting causes and factors attributing to injury may be useful in establishing preventative care measures for athletes. This article will discuss the mechanism of injury for the more common overuse conditions and relate appropriate treatments for them.

Evaluation of the athlete should begin with observation of both static and dynamic stance. Whenever possible, one must evaluate, document and treat biomechanical abnormalities. Researchers have found that limited dorsiflexion motion in the ankle causes hallux valgus, turf toe, midfoot strain, plantar fasciitis, ankle sprains, Achilles tendinitis, calf strains and hyperpronation.2 Researchers correlated arch height with injury in runners and found that transfer of foot eversion movement to internal leg rotation corresponded to knee pain, and increased significantly with increased arch height.2

However, the Ontario Cohort Study found little correlation between pes planus/cavus and the risk for injury.3 Further study of the preexisting biomechanical factors associated with overuse injuries is necessary to establish causative factors that determine injury risk. Current data is extrapolated from data gathered from military personnel. Assuming that this population is representative of the general population may be a faulty assumption when considering differences in equipment, such as combat boots and heavy backpacks.

The physical response to an overuse injury involves an inadequate, incomplete and disorganized repair mechanism, which results in a substantially defective “repaired” tendon lacking in extracellular tissue organization with decreased resistive strength and more vulnerability to further injury. Tendinopathies involve a triphasic repair response of inflammation, proliferation and maturation. A fatigued tendon loses its basal reparative ability with intensive repetitive activity, often eccentric in nature. This leads to cumulative microtrauma that further weakens the collagen cross-linking and noncollagenous matrix, and disturbs the micro- and macrovascular of the tendon. Damage can lead to tendinitis, tendinosis, tenosynovitis, or partial and complete ruptures.

An understanding of the anatomical and pathophysiologic basis of tendinopathies is important for diagnosis and management. Tendon degeneration may be preceded by acute and subsequently chronic phases of inflammatory “tendinitis.”1 Achilles, posterior tibial, peroneal brevis and peroneal longus tendons are most often involved in these cases.

Tackling Achilles Tendon Injuries
Achilles tendon disorders, which have been inappropriately generalized as “Achilles tendinitis,” are one of the most common sports injuries, particularly among runners.4 Achilles tendon disorders are commonly divided into non-insertional and insertional categories. Paratendinitis is associated with thickening of the surrounding paratenon, pain at 2 cm to 6 cm above the insertion and crepitus with ankle flexion. One can examine the Achilles tendon for paratendinitis by looking for changes such as fluid accumulation or thickening on ultrasound or magnetic resonance imaging (MRI). Paratendonosis is another type of noninsertional disorder that differs from paratendinitis in that it results in degeneration of the tendon due to lack of repair of the inflamed paratenon. Achilles enthesopathy, pain at the insertion site that may be osseous or tendon in origin, is also present with jumping or sprinting.4

Etiological factors of Achilles tendon disorders remain largely unknown.1 Microtrauma due to stress from repetitive eccentric loading of the muscle and tendon, especially while the tendon is fatigued, is the most common mechanism of injury. Other factors related to this condition include repetitive loading of the tendon at heel contact due to an equinus deformity, shoe factors, excessive pronation and training errors.5 A patient generally complains of a gradual increase in pain 2 cm to 6 cm proximal to the insertion of the tendon after exercise within days of a change in activity levels or training techniques. While rest relieves the symptoms, the return to activity reactivates the pain. Initial treatment includes rest (with the patient resuming activity as long as symptoms are not induced), ice, antiinflammatory medication, heel lifts and physical therapy.

One should implement treatment in the acute stage. Stretching and the use of a night splint while sleeping are crucial for long-term treatment. Orthoses and shoe gear alteration to treat biomechanical abnormalities are also important for long-term treatment. Resistant cases may require immobilization with a cast brace. Steroid injections are contraindicated in this area. Surgery may be required in cases where pain persists despite adequate conservative care. One may opt for newer modalities such as extracorporeal shockwave therapy (ESWT) or radiofrequency therapy. A more traditional approach of diseased tendon debridement with or without augmentation is another option.

Recognizing The Signs Of Posterior Tibial Tendon Dysfunction
Posterior tibial tendon dysfunction (PTTD) is a common cause of painful acquired adult flatfoot deformity. It is associated with substantial functional problems resulting in significant morbidity. Patients experience a loss of hindfoot inversion and an inability to negotiate uneven ground or climb and descend stairs. Symptoms progress and can include collapse of the medial longitudinal arch, hindfoot valgus and forefoot abduction abnormalities.

Clinicians would evaluate the “too many toes” sign from behind the patient as the condition presents when the foot is abducted and reveals four to five toes during static stance. One can use ultrasound and MRI in the diagnosis of PTTD. Ultrasonography can identify peritendinitis and tendinitis. Magnetic resonance imaging is more sensitive than ultrasound and one can use MRI to help identify the stage of the dysfunction.1

Stages of posterior tibial tendon dysfunction are useful in determining a treatment plan. Stage I includes peritendinitis and tendon degeneration with the tendon being normal in length. Stage II includes tendon elongation, insufficiency and possible deformity. Stage III includes an elongated tendon and a valgus deformity of the hindfoot. Stage IV involves valgus tilting of the talus in the ankle joint due to deltoid ligament insufficiency.

Treatment for acute conditions starts with rest, ice, compression, elevation (RICE) therapy and immobilization with either a cast brace or an ankle brace. Physical therapy is also important in the rehabilitation process. Long-term treatment includes equinus therapy with a night splint and stretching as equinus is often closely related to this condition. Conservative treatment with orthotic therapy and shoe gear alteration can control biomechanical abnormalities. Surgery may be required in cases where conservative therapy does not resolve symptoms and the procedure selection is typically based on the grade of the deformity.

Inside Insights On Peroneal Tendon Injuries
Peroneal tendon injuries are less common than Achilles tendon injuries and are perhaps underdiagnosed.6 Patients may present a chief complaint of lateral ankle pain and chronic ankle instability. Pain occurs behind and distal to the lateral malleolus, with swelling and tenderness along the tendon sheath. The swelling may be visible since the tendon is subcutaneous.

The anatomy of the peroneus longus appears to play a role in weakening the tendon as it courses through three fibro-osseous tunnels and changes directions in the hindfoot.7 Magnetic resonance imaging (MRI) may be indicated to differentiate from lateral ankle ligament injuries. Peroneal muscle weakness is a factor with inversion sprains of the ankle. Peroneal subluxation will also fall into this category of pathologies and is closely related to inversion injuries, resulting in damage to the superior peroneal retinaculum. Treatment includes stretching and strengthening, nonsteroidal antiinflammatory drugs (NSAIDs), taping of the ankle and use of an ankle brace during contact sports. These measures offer protection to the inverted ankle at foot strike. Immobilization of the foot with a cast brace may be indicated when there is a lack of improvement with the above treatments. Custom orthoses and shoe gear alteration may also be helpful for long-term treatment to control abnormal biomechanics. Again, surgery may be indicated when symptoms persist despite conservative care and the type of procedure is determined by the pathology.

What You Should Know About Tibialis Anterior Tendinitis Symptoms
Tibialis anterior tendinitis symptoms involve pain anteriorly at the ankle with possible swelling over the anterior ankle. Swelling may not be visible due to the location of the retinaculum over the tendon. However, crepitus may be palpable. Patients typically present with a chief complaint of pain on activity and this pain is relieved with rest. Chronic tendinitis occurs above the superior extensor retinaculum in the musculotendinous junction.6 This condition is closely related to abnormal biomechanics and excessive pronation. Treatment of anterior tendinitis is with RICE. Physical therapy with gentle stretching and active range of motion is also beneficial.
Limited weightbearing with a cast brace is indicated if symptoms are severe enough to alter the gait pattern. Bear in mind that NSAIDs are helpful for acute conditions. Orthoses are very important in long-term therapy as this condition is closely related to excessive pronation.

How Sesamoiditis May Affect The Athlete
The sesamoids are small bones embedded in the flexor hallucis brevis (FHB) tendons, which articulate with the plantar aspect of the first metatarsal head. The athlete may present with pain in the plantar forefoot under the first metatarsal head. Tenderness is present with palpation of the sesamoid and if the metatarsophalangeal joint is dorsiflexed, the tenderness will move distally with the movement of the sesamoid.

While there will be no X-ray changes initially, later findings may include enlargement and/or fragmentation of the sesamoid. One may need to obtain a bone scan or MRI to identify stress fractures or osteonecrosis. Bone scans can show increased uptake by the affected sesamoid within approximately three weeks and are useful in excluding fracture of the sesamoid. Plain radiographs or CT scans can identify osteoarthritis. Bipartite sesamoids are common but corticated margins on radiographs help to distinguish this from the sharply defined edges of an acute sesamoid fracture.8

Treatment for an athlete with sesamoiditis should begin with rest from weightbearing exercises. Training can continue with a non-weightbearing exercise such as swimming while the symptoms resolve. Strapping U-shaped padding to the region will reduce the stresses on the sesamoids. Anti-inflammatory medication and flexibility exercises for the foot will also assist in recovery. Generally, the symptoms will remain for at least three weeks. Persistent symptoms, continuing over several months, may require surgical excision. Physical therapy can begin as soon as symptoms resolve. McBride indicates that permanent orthoses, including a first metatarsal extension and a midsole load shift, will also assist recovery and prevent recurrence of the injury.9

What You Should Know About Stress Fractures
Stress fractures are defined as partial or complete bone fractures that result from repeated application of a stress lower than the stress required to fracture the bone in a single loading.10 A stress fracture is the final result of an imbalance in focal mechanical stress and bone remodeling. Stress fractures occur as a result of training errors (i.e. too rapid an increase in training intensity or mileage, etc.).4 Patients with stress fractures report recent changes in their workout routine. Repetitive loading of bone causes bony stress reactions. Bone remodeling is impaired when loading increases too rapidly. Patients with stress fractures will present with pain after the initiation of activity or with a specific movement. Symptoms appear gradually over several weeks. Tenderness may be present but not necessarily swelling.

Commonly used imaging studies include radiographs, bone scans and MRI. Radiographs are often normal. In approximately two-thirds of symptomatic patients, radiographs are initially negative and only half ever develop positive radiograph findings.11 Radionuclide bone scans are sensitive to stress fractures and can be positive only a few days after the injury.8 The patient may present with a history of an insidious onset of activity-related pain that becomes progressively worse over time. The most obvious physical examination feature is localized bony tenderness.

The treatment of stress fractures includes a short period of immobilization in a walking boot (three to six weeks) combined with RICE therapy. These patients generally return to full sport activity within six to eight weeks. One should appropriately address any abnormal biomechanics that may have initially led to this condition.

Key Pointers On Treating Cuboid Subluxation
Cuboid subluxation may occur with ankle sprains.8 A common but relatively unrecognized sequela to lateral ankle sprains is injury to the joints and ligaments around the tarsal cuboid, resulting in cuboid subluxation. It is usually defined as a minor disruption or subluxation of the structural integrity of the calcaneocuboid portion of the midtarsal joint.12

Patients present with a complaint of lateral midfoot pain and an inability to roll through the foot for push-off. During the physical exam, the practitioner can elicit pain upon palpation of the plantar aspect of the foot by pressing into the cuboid. Mobility of the transverse tarsal joints is diminished compared with the opposite foot. A step-off at the base of the fourth metatarsal may be palpable as the cuboid typically subluxes toward the plantar aspect of the foot. Diagnostic tests such as radiographs, CT scans or MRI are relatively ineffective because of the normal variations that exist between the cuboid and its surrounding structures. However, diagnostic testing may help differentiate between cuboid subluxation, tarsal sinus syndrome, fractures, tarsal coalition and arthritis.

Treatment for cuboid subluxation requires a manual reduction maneuver or passive padding in conjunction with a low Dye strapping. Manual reduction consists of upward pressure on the plantar aspect of the cuboid while the foot is in plantarflexion. Padding consists of a 1/4-inch felt pad cut into a strip approximately 1.5 inches by 2 to 3 inches (4 cm to 5 or 7.5 cm) long.12 Clinicians may utilize orthotics with a modification (as cited above) for long-term maintenance.

How To Resolve Shin Splints In Athletes
Shin splints, also called “medial tibial stress syndrome,” have been described as a dull ache over the posteromedial aspect of the distal third of the tibia. While the cause of shin splints is controversial, it may be related to a periostitis of the FDL or the soleus.13 It is associated with runners who have suddenly changed running surfaces or mileage, or are using worn-out shoes.

Treatment includes relative rest and the correction of any recent transition in training.1 Proper shoe gear is essential to minimize rearfoot valgus and to correct excessive pronation, pes planus or pes cavus. Orthotics are useful in cases that cannot be controlled by shoewear alone. Nonsteroidal antinflammatory drugs and antiinflammatory modalities (iontophoresis and ultrasound) can be useful adjuncts in the rehabilitation of medial tibial stress syndrome. One should encourage these patients to initiate a strengthening and flexibility program with the goal of correcting any muscle imbalances. One should emphasize flexibility of the gastrocsoleus as well as strengthening. A compressive sleeve may provide symptomatic relief.1 Orthoses are helpful in the long-term care of this condition.

A Pertinent Overview Of Plantar Fasciitis Treatment Options The plantar fascia extends from the medial aspect of the calcaneus to the proximal phalanges. It stretches during the gait cycle and may have degenerative changes secondary to repetitive trauma.14 Typically, patients describe pain with the first steps in the morning and with pressure on the medial calcaneal tubercle.

Activity modification is the hallmark of initial treatment so one should decrease the training load. Alternating exercises and decreasing the training level may also help. Stretching prior to activity, using ice for 10 to 15 minutes and NSAIDs can be helpful in minimizing pain and inflammation. Approximately 80 percent of patients stated their conditions improved using night splints. Disadvantages of night splints include mild discomfort, which may interfere with the patient’s or a bed partner’s ability to sleep.14

Steroid injections, physical therapy, immobilization with a cast brace, shoe modification, RICE therapy and custom orthoses are all important in the conservative treatment of this condition. Surgery is indicated when conservative treatment fails. Surgical options include ESWT or an open approach with or without heel spur resection.

In Conclusion
Understanding the etiology and risk factors predisposing athletes to overuse injuries could reduce the time lost to athletic injuries. Functional orthotics, night splints, altered training and physical therapy are just a few modalities used for treating the athlete with a repetitive use injury. Further research into each condition and documentation of the biomechanical structure during initial presentation would aid in the corrective and preventative care of the athlete.


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