Overuse Injuries --
Evaluation, Treatment and Prevention
- James J. York, M.D.
An overuse injury is an accumulation of many tiny injuries of
muscle, bone or ligament tissue which causes pain and loss of function. Overuse injuries are more common than acute
injuries and yet are more subtle and difficult to diagnose.
They occur gradually over time and therefore usually do not begin to appear until
several weeks into a training program. They
occur in the most commonly used muscles, ligaments or bones used in training. This could be a shoulder for a throwing sport, but
in most sports, the legs are effected. Overuse
injuries are treated with ice, reduced levels of training and activity, anti-inflammatory
medications as needed and referral to an orthopedic surgeon if they do not subside by
themselves.
Whenever we train or workout there is a normal amount of microscopic tearing that
occurs in muscle tissue, tendons and ligaments. Also,
tiny microscopic cracks appear in the bony crystals that make up the building blocks of
our bones. A ligament is a dense tissue that
connects one bone to another at the joint. For
example, when someone sprains their ankle they sustain a stretch or partial tearing injury
to one of the ligaments that connects the two bones together that make up the ankle joint. A tendon is the dense “leader” or
gristle-like tissue that connects muscle to bone. The
tendon acts like a cable which transfers the muscle motion over to the bone. This microscopic tissue damage is a normal
phenomenon. In fact, this microscopic damage
is the stimulus that the body uses to build up and strengthen muscles, ligaments and
bones. We are very familiar with the
strengthening process of training muscle. The
microscopic damage causes the body to respond by repairing the damage and then adding more
muscle power enzymes and muscle power units so that over time the muscle becomes
physically larger. A similar process occurs
within the ligaments and bone. The process of
the bone strengthening that occurs from training would be analogous to making the bone
more like reinforced concrete. When the
“tear down” process outstrips the body’s ability to repair and build back
up again, the multiple sites of microscopic injury begin to add up. This creates an injury
which is very similar to a fresh, acute or sudden tear of a ligament, tendon or small
crack in a bone.
What are some examples of an overuse injury?
In the lower extremities, pain in the front thigh (quadriceps) or back of the thigh
(hamstrings) or shin splints (inside of the lower leg), are common overuse injuries. Aching that occurs in the ankle ligaments or knee
joint ligaments are seen frequently as well. Athletes
can get stress fractures, the overuse injury of bone, in their feet or legs. It is often difficult to tell the difference
between a shin splint and a stress fracture on the tibia (lower leg bone).
What are signs and symptoms of an overuse
injury?
The earliest and most subtle sign of overuse injury is loss of performance.
A goalkeeper who is not punting as far, or a player who is limping and not running as fast
as last week or two weeks ago could have overuse injuries.
Initially, it is difficult to tell whether the athlete is having “a bad
day” or a true overuse injury. Inquiring
after the player as to what is wrong will frequently bring responses of “Oh, I don’t know, it’s just a
little bit sore, I don’t remember getting hurt.”
When the problem persists and, in particular if it slowly gets worse, it is
probably an overuse injury. There is a normal
amount of soreness and aching that can occur after practice sessions or games,
particularly after difficult or strenuous practice sessions. This soreness should usually go away within
one-two days. When the soreness and aching or
limping lasts three days or more then we must be suspicious of an overuse strain (injury
to muscle), overuse sprain (injury to the ligament of a joint) or a stress fracture. Because this process takes awhile to accumulate,
overuse injuries are not usually seen early in the season. They generally become evident 3
to 4 weeks into the season.
How do we treat overuse injuries?
Reduce the level of training. Substitute
the player out more frequently. Have this
player rest frequently during practice, have shorter easier drills and perhaps sit out
part of practice. It may be necessary to have
the player sit out one or more practices and then gradually reintroduce the player back
into drills and training sessions. If it is
not treated the injury will gradually get worse. The
more severe it is, the longer it takes to treat because the body needs the extra time to
repair the damage.
A muscle affected by an overuse strain tends to be tighter, more irritable
and more prone to an acute strain. For this
reason this player needs to stretch much more than the rest of the team. I recommend that someone with an overuse strain
of a muscle stretch first thing when getting up in the morning, before practice, after
practice and then again in the evening. Acute
worsening or worsened soreness after a practice session should be treated with ice. Ice doubled bagged into a sandwich or food storage
bags then wrapped on with an ace wrap works very well.
The ice should be on for approximately twenty minutes and off for forty
minutes. These cycles can be repeated several
times to reduce inflammation and pain. Heat
is best avoided for the first several days after an acute injury or worsening of an
overuse injury. Use of aspirin or generic
over the counter Ibuprofen or other over the counter anti-inflammatory and “pain
relieving” medications can assist with the discomfort but should not be used for the
purpose of masking pain or permitting play on
an injured limb. If the pain, limping and
stiffness resolves after several days then the player can be brought gradually back to a
full training and competitive level. If the
problem persists for a week or more then evaluation by an orthopedic surgeon or primary
care physician familiar with sports medicine is recommended. In this way a more precise diagnosis as to the
type of injury can be made. The most
appropriate treatment can then be started with either a special home exercise and
stretching program or a prescription written for a short period of physical therapy.
A physical therapist is trained to guide the athlete on the narrow path between
exercising enough to maintain as much conditioning as possible, but not so much that
injury will be prolonged. Physical therapy
can consist of ice, heat, ultrasound and other modalities as well as specialized
theraputic exercise training to assist in bringing the injured area back to more rapid
health while minimizing loss of conditioning.
Who is more likely to sustain an overuse injury?
The athletes at either end of the training spectrum are at most risk. The athletes who are newer at the sport or who are
“out of shape” are more likely to sustain overuse strains, sprains or stress
fractures. On the other hand, your high
performance athletes who play multiple sports are also at risk. Although their endurance, strength and overall
conditioning are high, the demands on them are so high that an overuse injury may occur. Should this happen it may be necessary to suspend
playing or training at one of the sports and reduce the level of training at the remaining
sports until the injury can heal.
Prevention is the best medicine. Early
in the season make a note of the players with less conditioning or the players who are
involved with multiple sports. Keep an eye on
them for signs of trouble. Allow plenty of
time for warm ups, stretching before practice and stretching and cool-downs at the end of
practice or competition. Most coaches will
have their players stretch before practice. However,
spending a few minutes after practice to cool-down and stretch helps to decrease
the risk of injury, particularly in a tournament situation when multiple games are played
over one or two days.
By teaching our athletes the importance and benefits of warm-up, cool-down and
stretching they will understand that this is an integral part of training and play. This
will help to reduce the risk of injuries over a lifetime.
Understanding overuse injuries can guide you to designing your training to reduce
the risk of injury and help you to recognize and treat them as they inevitably occur.
Good
luck and have a safe and successful season!
Dr. James York is an Orthopedic Surgeon
with Chesapeake Orthopedics and Sports Medicine Center in Glen Burnie, MD. For over ten years, he has coached soccer for
select club teams and for the Maryland State District Development Program. He has a US
Soccer Federation “D” License. Dr. York and Chesapeake Orthopedics provide
medical support for athletic programs at several area High Schools. He also provides
Sports Medicine seminars and instruction to youth athletic programs.
