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

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