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Overuse InjuriesHow to Solve the Challenging Puzzle
Anthony Luke MD, MPH
Primary Care Medicine: Update 2014
Disclosures
• Founder, RunSafe™
• Founder & CEO, SportZPeak Inc.
• Sanofi, Investigator initiated grant
Acute injuries Approach to Overuse Injuries
1. Mechanism of Injury / Pain
2. Location
3. Type of tissue
4. Identify risk factors
5. Education/Modifications to reduce overuse activity
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Overuse Injuries
• Occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.
DiFiori et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine, accepted for publication, 2014.
Key Features
• Repetitive loading (rather than traumatic)
• Overwhelm the ability of the tissue to remodel, resulting in a weakened, damaged structure
• Imbalance between training loads and recovery is a key factor
• Mechanism Preventable?
1. MechanismWhy did I get an injury?
• Too much
• Too hard
• Too fast
…for your body !!
It’s all about Physics…
Newton’s Law #1
• An object in motion, stays in motion
…Unless an external force stops it
• Wind & Road resistance
• Hills
• Metabolic (Fatigue, Dehydration)
STRESS !!!
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Adaptation to stress
Newton’s Law #2
• Force = mass x acceleration
• Force results in stress
Shock Absorption
Newton’s Law #3
• Every force has an equal and opposite force
• “Striking” mass
• “Shock” absorption
2. Location
• Point with One Finger
Windlass Mechanism
Midstance Toe - off
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Achilles Tendinopathy
Mechanism
• Repetitive eccentric load on tendon
• Pushing off, running, sprinting, jumping
Presentation• Tender over
achilles +/- swelling• Pain with resisted
toe off• Pain with passive
ankle dorsiflexion
Risk FactorsKhan KM, et al. Phys Sportsmed 2000.
• Tight Achilles and plantar fascia
• Hyperpronation
• Cavus foot
• Advancing age - decreased blood flow
• Overweight
• Poor footwear
• Weak hip abductors and medial quadriceps
Plantar Fascitis• Tender on insertion on medial aspect of
heel
• Associated with:– Age
– Pes planus and pes cavus
– Obesity (OR =5.6 (95% C.I., 1.9-16.6)
– Poor shoes, working on feet (OR = 3.6 (95% C.I., 1.3-10.1)
– ≤0 degrees of dorsiflexion had OR = 23.3 (95% C.I. , 4.3 to 124.4)
Riddle et al. JBJS-A, 2003
– Limb leg discrepancy (longer leg associated with plantar fasciitis)
Mahmood et al, J Am Podiatr Med Assoc, 2010
Tendinosis
• Hyaline degeneration
• Mucoid degeneration
• Fibrillation of collagen
• Absence of inflammatory cells
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Mechanics
• Usually tendons surrounding joints with high degree of motion
• Usually tendons that cross two joints
• Eccentric overload• Mechanical
impingement• Temperature
breakdown• Angiogenesis?
Conservative Treatment
REDUCE STRESS• Modified activities, ice
• Calf / Achilles stretching
• Hold each stretch for 30 seconds
Soleus stretch
Gastrocnemius stretch
Treatment
• Heel lifts
• Modify footwear
• Custom orthotics
• Night splints
• PT is a major key
Rarely
• Surgical debridement
Physical Therapy for AchillesAlfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med,
1998; 26:3: 360-366.
• RCT – eccentric exercises (3 x 15 reps, 2 times/day, 7 days a week x 12 wks)
• Results: Significant difference in pain levels VAS 81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in 12 weeks
• 81% eccentric satisfied vs 38% concentric satisfied
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Eccentric Drop program Terminology
• Tendinopathy –“tendon injury that originates from intrinsic and extrinsic etiological factors”
• Usually not tendinitis
Classification of Tendon Disorders(Modified from Khan et al. 1999, Clancy 1990)
Pathologic Dx Macroscopic Histopathologic
Tendinosis Intratendinous degeneration
Disorganized collagen, mucoid degen
Tendinitis Degeneration with inflammatory repair response
Fibroblasts, hemorrhage, granulation tissue
Paratenonitis Inflammation of paratenon only
Mucoid degen. if areolar tissue, fibrinous exudate
Paratenonitis with tendinosis
As above As above
Mechanics
• Usually tendons surrounding joints with high degree of motion
• Usually tendons that cross two joints
• Eccentric overload• Mechanical
impingement
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Where does the injury occur?
Insertional• Occurs at
insertions near the joint
• Joint sideTears• At the musculo-
tendinous junction• Areas of friction
3 Basic P/E findings for tendinopathy
1. Tenderness on direct palpation 2. Reproduction of pain with resisted
contraction (eccentric loading)3. Reproduction of pain with passive
stretch
Tendon Healing
• requires around 100 days to synthesize collagen
Mild – 2 to 4 weeksModerate – 4 to 6 weeksSevere – 6 to 12 weeks or longer
Physical therapy for tendons
Stretching• Improves pain and ROM
Strengthening – eccentric loading• Mechanical loading accelerates tenocyte
metabolism
Modalities• Ultrasound and laser increase collagen
synthesis in fibroblasts in animals
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Anti-Inflammatory?
• Little evidence to support use of NSAIDs in management
• Good Analgesic
• Steroid injection?• Needle tenotomy?
How do you exam for lateral epicondylosis ?
3. Type of Tissue
• Muscle‐tendon unit
• Articular cartilage (physis)
• Bone
• Soft tissues (bursa, and/or neurovascular structures)
What is Osteoarthritis?
• OA is a disease characterized by cartilage degeneration
• Cartilage loss and OA symptoms are preceded by damage to the collagen-proteoglycan (PG) matrix
Superficial Zone
Transition Zone
Radial Zone
Tidemark
Calcified cartilage
Subchondral bone plate
Vascular plexus
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Cartilage Damage
Outerbridge Classification, 1961
Arthroscopy
Arthroscopy Osteoarthritis
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Novel MRI Techniques
• 3T MRI provides a higher signal-to-noise ratio and better spatial and spectral resolution
• T1ρ spin-lattice relaxation reflect proteoglycan content
• T2 reflect collagen matrix orientation
(a) a healthy volunteer, male, 30; T1ρ = 40.0511.43 ms
(b) a patient with early OA (post-traumatic OA), female, 27. T1ρ = 50.5619.26 ms
Li et al. Magn Reson Med, 2005.
MR Relaxation Times (in ms)
Luke et al., Am J Sports Med, 2010
T2 T1ρ
Findings
• T1ρ values stay elevated over 3 months, which suggests that this sequence demonstrates more than water shifts
• 2/10 runners and 2/10 controls had abnormal patellar cartilage lesions
• Changes in T1ρ and T2 were greatest in medial compartment and the patellofemoral joints, especially at the trochlea
Luke et al., Am J Sports Med, 2010
Children and Sports injuries
• Almost 1/3 of injuries from all causes due to sports– Bijur PE et al. Arch
Pediatr Adolesc Med. 1995; 149: 1009-1016.
• participation of kids in organized sports
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Why do kids get injured ?
• Kids do what adults do
• Kids get tired faster• Limited strength• Flexibility issues• Excess stress /
overuse leads to failure
Case 1
• Who? 14 year old male football player, also runs track
• When? 8 weeks • What? Right>left knee pain with running,
stairs, bending and especially kneeling• How? Worsening anterior knee pain since
preseason running • Where? Tibial tubercle of the right>left
Case 1
LOOK• Prominent bump over
tibial tubercle R>LFEEL• Tender tibial tubercleMOVE• ROM 10° to 130°SPECIAL TESTS• Popliteal angle 40°• Ely’s test positive
Apophysitis
• Osgood Shlatter’s Disease
• Sever’s Disease (heel)
• Can also occur in the spine, iliac crest, the metatarsals
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Osgood-Schlatter’s Disease
• Most improve in 1-2 years with activity modification
• Rarely operate prior to skeletal maturity
• Goal is to eliminate pain, not for cosmesis
Sinding-Larsen-Johansson
• Common in 10-12 year old boys
• jumping activities/ repetitive stress
• Ant knee pain distal pole of patella
• Xrays: fragmentation of distal pole of patella or small calcifications prox patellar tendon
• Differentiate from Sleeve avulsion!!!
Treatment for Apophysitis
• Rest, modify activity• How long? 6 to 8 weeks• Immobilize if significant pain• Include low impact activity and conditioning• Focus on strength and flexibility while healingExamples:• Hip and quads strengthening program, core
stability• Overhead and Throwing athlete rehab
– Long ball toss, Medicine balls, Rotator cuff, Periscapular exercises
Return to play
Can the athlete return:
• Safely?
• Effectively?
• Relatively painfree?
Avoid the secondary or CHRONIC injury
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Case 5
• Who? 16 year old pre-professional female ballet dancer
• When? 3 months • What? Severe pain with weight
bearing• How? Was dancing 6 hours a day,
worse since jumped and landed • Where? Over right anterior mid tibia
Case 5
Height 5’5” Weight 105 lbsLOOK• Thin build, antalgic gaitFEEL• Point tender over R mid tibia, localized soft
tissue swelling MOVE• Ankle dorsiflexion 0°SPECIAL TESTS• Can’t do a Hop test
4. Identify Risk Factors What are the risk factors?
Training
ImpactBone Health
Gait Mechanics
BONE LOADING
Brukner P, Bennell K, Matheson G. Stress fractures, Blackwell Science, 1999.
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Medial Tibial Stress SyndromeIntrinsic
•Women > Men (1.5-3.5 x higher)
•Excessive foot pronation
•Pes cavus
•Leg length discrepancies
•Higher BMI
•Decreased bone density, disordered eating
•Muscular imbalances– Tight triceps surae
– Weak hip and core muscles
Extrinsic
•Increased activity, intensity, or duration
•Poor footwear
•Overtraining
•Increased mileage (>20 miles/week)
Galbraith et al, Curr Rev Musculoskelet Med, 2009
Stress Fractures
• Stress fracture group showed greater peak hip adduction and greater peak rearfoot eversion angles vs. control group
Milner et al, JOSPT, 2010
Shoes or No shoes ?
• Heel strike causes a force impact Saw-toothed force profile with High rate of loading 400-500 bw/sec
• Forefoot striking reduces the peak impact force
Lieberman et al, Nature, 2010
How stress fractures occur?
• Failure of bone to adapt to stress
• Microinjury/microcracks in the bone
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Bone remodeling
• Causes relative weakness
• Osteoclastic activity faster than osteoblasts
• Excess stress
Bone Response to Stress
Complete FractureComplete Fracture
Stress FractureStress Fracture
Stress injuryStress injury
Stress reactionStress reaction
Accelerated remodelingAccelerated remodeling
Normal remodelingBrukner P, Bennell K, Matheson G. Stress fractures, Blackwell Science, 1999.
Compression vs Tension
• Delayed union rate estimated at 5%Orava, Hulkko. Acta Orthop Scand, 1984.
When to return to sports
• N=53• Length of recovery
and MRI Grade 1-4 Pearson r= 0.627, p= 0.001)
• Grade 3 takes 12 weeks, Grade 4 takes 16 weeks
• Bone remodeling takes around 180 d
Arendt et al., AJSM, 2003
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Diagnostic Imaging
Grade X-ray Bone Scan MRI
1 Normal Small, ill-defined cortical area, mildincrease
Positive STIR image
2 Normal Better defined cortical area, moderate increase
+ STIR+ T2 weighted
3 Periosteal reaction
Wide to fusiform cortical-medullary area of highactivity
+ T1, T2, STIRNo cortical break
4 Injury of periosteal rx
Transcortical area of increased activity
+ injury line on T1 or T2 scans
Arendt, Griffiths, Clin Sports Med, 1997.
Treatment of Stress Fractures
• Avoid stress to the bone
• Allow the remodeling process to occur
• Immobilize or remove stress completely if traction
• If non-union or elite high demand athlete, consider surgical fixation
ORIF?
• Excision and Bone graft
• I.M. Nailing considered case by case
• Suggested after failure of conservative treatment > 1yearChang, Harris, AJSM, 1996
Who and Where?
• Common locations for stress fractures
• Who does it happen to?
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Who and Where? Base of the 5th Metatarsal
• At risk due to strong ligamentous support and poor vasculature
• Non-union rate with conservative treatment 7 to 28%
• Refracture rate after ORIF still 10-40%
Femoral Neck
• MRI 100% sensitive (gold standard)Shin et al. AJSM, 1996
If displaced,• Risk of AVN 42%
(n=5/12)Visuri et al. J Trauma, 1990
• 30% required major surgery for complications (n=7/23)Johansson et al. AJSM, 1990
Femoral Neck ORIF?
Indications• Grade 4 changes
on Bone Scan or MRI
• Tension side• Displaced
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Women in Sports (Title IX) Female Athlete Triad
• Disordered eating, loss of periods (amenorrhea), and thin bones (osteoporosis)
• Often presents with stress fractures• Caloric imbalance• Can be very dangerous
Female Athlete Triad
Warning signs• Irregular periods or delayed menarche• Recurrent stress fractures• Vegetarian at young age• Avoids eating with others• Skips meals• Trains excessively• Using dieting methods inappropriately
Amenorrhea
• B-Hcg• LH/FSH• sTSH• PRL
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Osteoporosis
• DEXA bone density• Increased risk of stress fractures if
low BMD• Effects on BMD may be irreversible
Nutritional and metabolic factors
• Calcium – If poor diet or
low bone density– 1200-1500 mg/d
• Vitamin D– Deficiency
common?– 800 IU/day
Make ours doubles
Medications
• Oral contraceptive pills
• SSRI antidepressants
TEAM approach
• Psychologist / psychiatrist
• Nutritionist• Family• Coach• Sports Physician• Family Physician• OB/GYN
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Conservative treatments
• Activity modifications (painfree)1. NWB, swimming or biking 2. Nonimpact upright activities3. Sport-specific drills; limited sports4. Full activities no restrictions
• Pneumatic brace• Adjunct modalities• Manage expectations
Manage
• Patient states irregular periods• Counsel, consider oral contraceptive
pills• Calcium 1200-1500 mg, Vit D 400-
800 IU• If recurrent history of stress
fractures, consider bone density• Consider referral to “TEAM”
• Can modify activity to avoid pain
Approach to Overuse Injuries
1. Mechanism of Injury / Pain
2. Location
3. Type of tissue
4. Identify risk factors
5. Education/Modifications to reduce overuse activity
Key Features
• Repetitive loading (rather than traumatic)
• Overwhelm the ability of the tissue to remodel, resulting in a weakened, damaged structure
• Imbalance between training loads and recovery is a key factor
• Mechanism Preventable?
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9th UCSF Primary Care Sports Medicine Conference: ABC’s of Musculoskeletal Care
December 5‐6, 2014San Francisco, California