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LOWER Extremity Overuse Injuries

Kevin deWeber , MD, FAAFP, FACSM Director, Military Sports Medicine Fellowship Assoc. Professor of Family Medicine, USUHS March 2013 . LOWER Extremity Overuse Injuries. Overuse Injury types. Muscle strain Tendinopathy Enthesopathy Stress fractures Fasciopathy Nerve compression

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LOWER Extremity Overuse Injuries

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  1. Kevin deWeber, MD, FAAFP, FACSM Director, Military Sports Medicine Fellowship Assoc. Professor of Family Medicine, USUHS March 2013 LOWER Extremity Overuse Injuries

  2. Overuse Injury types • Muscle strain • Tendinopathy • Enthesopathy • Stress fractures • Fasciopathy • Nerve compression • Apophyseal traction injury (adolescents)

  3. Key features of overuse injury • Sub-clinical injury occurs before the patient feels it • The normal soft-tissue repair process is aborted • Degeneration cycle begins instead • Soft-tissue degeneration is NOT inflammatory

  4. KEY CONCEPT: VICTIM AND CULPRITS • For every overuse injury (victim) there is an underlying cause (culprit)

  5. Risk factors for Overuse Injury:The Usual Culprits • Intrinsic abnormalities • Extrinsic abnormalities

  6. Intrinsic abnormalities • Mal-alignment of body parts • Instability of joints • Imbalance of muscle strength • Weakness of muscles • Inflexibility • Rapid growth

  7. Extrinsic abnormalities • Training errors • Equipment mismatch/failure • Technique errors • Environment factors

  8. Vicious Injury Cycle of Overload Tissue overload Substitute biomechanical movements Clinical symptoms Decreased performance Tissue damage 1. Microtears 2. Macrotears Subclinical adaptations 1. Weakness 2. Inflexibility 3. Scar tissue 4. Strength imbalance

  9. Example of overuse 1. Tensile load on posterior shoulder muscles Musculotendinous tensile overload Substitute biomechanical movements 4. Alteration of throwing motions Clinical symptoms Decreased performance Muscle damage 2. Micro-tears to Infraspinatus and Teres minor Subclinical adaptations 3. External rotation strength imbalance

  10. Overuse Injury Management Pyramid Activity participation 5. Control abuse 4. Fitness exercise 3. Promote healing 2. Control pain 1. Make accurate patho-anatomical diagnosis

  11. Tennis Leg • Painful pop w eccentric load • Neg Thompson Test • Treatment: • Short term immobilization prn • Progressive strength ex. • Recovery 2-8 weeks • Strain of Medial Gastroc

  12. Proximal Hamstring Strain(formerly ischial bursitis) • Hamstring origin, ischial tuberosity • Chronic strain • S/Sx: • Pain with prolonged sitting, running • TTP just distal to I.T. @ hamstring origin • Pain w/ resisted knee flexion & hip ext. • Tx • Hamstring stretching and strengh (PT) • Prolotherapy inj: great results

  13. Hip Rotator Cuff Syndrome(formerly piriformis syndrome)

  14. Hip Rotator Cuff Syndrome(formerly piriformis syndrome) • Overuse injury • Cause: trauma, prolonged sitting, running, • S/Sx: • Dull, deep buttock pain • TTP over mid-buttock • Pain worse with passive IR or resisted ER • Tx: relative rest, IR stretch, ER strength • Steroid Inj: short-term • Prolotherapy inj: long-term

  15. Tendon Overuse InjuriesThe spectrum of “tendinopathy” • Tenosynovitis - inflammation in tendon sheath • Paratenonitis - inflammation of only the loose areolar tissue surrounding tendon • Achilles tendon • Tendonitis - symptomatic degeneration with vascular disruption and inflammatory repair. • Tendinosis - intra-tendinous degeneration from repetitive microtrauma; NON-inflammatory intra-tendinouscollagen degeneration.

  16. Tendinosis: collagen disruption and neovascularization Normal tendon

  17. Achilles Tendinopathy • Paratenonitis: acute only • Tendinosis: most common • NOT inflammatory • S/Sx: • incr pain with walking/running • Thickening of tendon • Tx: relative rest, stretch calf, eccentric leg exercises, prolotherapy inj.

  18. Achilles Tendinopathy Prolotherapy Traditional Prolotherapy Yelland et al. 2011 RCT PRP Case Series Sanchez et al. 2005 Sanchez et al 2007 Gaweda et al 2010 Monto 2012 RCT de Vos et al. 2010 RCT No eccentric training prior!

  19. Achilles tendinopathy RCTYelland et al 2011 • N=43, Dextrose vsEccentricExvs COMBO • Success = 20-pt fall in VISA-A at One Year • Dextrose and COMBO: • FASTER RESULTS • One Year: No significant differences between groups • underpowered

  20. Greater Trochanteric Pain SyndromeGTPS (formerly troch bursitis) • Pain in posterolateral aspect of greater trochanter • PATHO: Tendinosis of hip ABd/ExtRot • Treatment: • ITB, GlutMed stretch • Core strength (send to PT) • Steroid inj ( short-term) • Prolotherapy (long-term)

  21. Greater TrochanterGluteus Medius and Minimus

  22. Plantar fasciopathy(not fasciitis) • Micro-tears, degenerative changes, non-inflammatory • S/Sx: pain upon rising in AM, worse as day goes on. Focal TTP medial calcaneal tubercle • Tx: • PF and calf stretch, intrinsic foot muscle strength, night splint, orthotics • Steroid inj: quick result, good as prolo @6mos • Prolotherapy inj: long-term • ESWT

  23. Plantar Fasciopathy • Autologous Blood Inj (ABI) • Lee and Ahmad 2007 DB-RCT vs CSI • Kalaci et al. 2009 RCT vs CSI • PRP • Barrett/Erredge 2004 series • Peerbooms: RCT underway

  24. Shin Splints • Usually at posterior edge of tibia (aka Medial Tibial Stress Syndrome, MTSS) • Occas. anterior tibia • Etiology: periostitis, muscle fatigue, ? • S/Sx: dull ache med./ant. Tibia, diffuse TTP

  25. Shin Splint Management • Activity Modification • Orthotics • Shoe evaluation • Strengthening and stretching • Shin Sleeve • Monitor for other conditions

  26. STRESS FRACTURES:INTRINSIC RISK FACTORS • History of prior stress fracture • Low level of physical fitness • Female Gender • Menstrual irregularity • Diet poor in calcium and dairy • Poor bone health • Poor biomechanics

  27. EXTRINSIC FACTORS • Increasing volume and intensity • Footwear • Older shoes • Absence of shock absorbing inserts • Running Surface?: mixed results • Treadmill vs Track • Activity type

  28. Stress Fx IMAGING • X-ray: Poor sensitivity • ~ 30% positive on initial examination • Bone Scan: sensitive, not specific • Soft tissue injuries + too • MRI: sensitive, specific • Harder to get • CT: best bone detail, most radiation • rarely needed • Sesamoids, navicular, spine

  29. GENERAL TREATMENT for LOW-RISK STRESS FRACTURES • PROTECTION • Reduce pain • Promote healing • Prevent further bone damage • ACTIVITY MODIFICATION • Rest from painful activities 6-8 weeks (or until pain-free for two to three weeks) • Cross-training (non-painful exercise) • REHABILITATIVE EXERCISE • Flexibility, strength balance • BIOMECHANICAL CORRECTIONS

  30. HIGH RISK STRESS FRACTURES High risk for delayed union, nonunion, refracture • Talus • Tarsal navicular • Proximal fifth metatarsal • Great toe sesamoid • Base of second metatarsal • Medial malleolus • Pars interarticularis • Femoral head • Femoral neck (tension side) • Patella • Anterior cortex of tibia (tension side)

  31. High-Risk Tibial Stress Fracture • Anterior, middle-third stress fractures are very concerning • Tension side of bone • May present like shin splints • If you see “dreaded black line” on x-ray, poor prognosis • Treatment • 4-6 months relative rest, +/- immobilization • Surgical rod if not healing

  32. CASE: 20 y/o female distance runner with 7 weeks of vague, deep right hip pain, insidious onset, no trauma, worse w/ wt-bearing activity, better w/ rest • Insp: antalgic gait • Palp: ttp over anterior hip jt area • ROM: pain w/ IR and deep flexion • Strength: mild decr flexion/IR/ER • N-V: normal • SpTests: • + Hop test, + FAbER (anterior pain) • negGaenslen

  33. Question: what injury must be ruled out immediately in this patient?

  34. Femoral Neck Stress Fracture • Vague anterior or medial groin/hip pain • Early diagnosis critical • Anterior hip tenderness • Log-roll pain • Pain with straight-leg-raise • If x-rays negative, order MRI • Crutches/NWB until ruled out! • MRI diagnostic imaging of choice for femoral neck stress fractures

  35. Femoral Neck Palpation Iliopsoas bursa

  36. COMPRESSION-side Femoral Neck Stress Fractures • Inferior part of femoral neck • Less likely to become displaced • Complications possible • Treatment: • Fatigue line <50% neck width: Crutches/NWB until asymptomatic, then relative rest 4-6 wks • Fatigue line >50% neck width: surgical fixation

  37. TENSION-side Femoral Neck SF • High propensity to displace • Frequent complications • Treated acutely with internal fixation

  38. Tarsal Navicular Stress Fx • X-rays usually negative • MRI or thin-cut CT better than bone scan

  39. Sesamoid Stress Fracture • Tx: NWB x 6 weeks with cast to tip of great toe to prevent DF • Failure: Surgery (excision or grafting)

  40. PREVENTION of STRESS FRACTURES • Small incremental increases in training • Shock absorbing shoe/boot inserts • Calcium 2000mg, Vit D 800 IU (27% decr.) • Increased dairy products • 62% decreased risk SF for each cup of skim milk • Modification of female recruit training: • Lower march speed • Softer surface • Individual step length/speed • Interval training instead of longer runs • ??: OCPs (sig increase in bone mineral density, no impact on stress fracture rate) • NO: HCP selection of military recruits’ running shoes based on foot morphology • 3 prospective studies by Knapik et al

  41. Exertional Compartment Syndrome

  42. Anatomy • 4 muscular compartments • Anterior • Lateral • Superficial posterior • Deep posterior • Fascial defects

  43. Pathophysiology • Normal exercise • Muscle volume increases by 20% • Intramuscular pressures exceed 500 mm Hg with contractions • Etiology probably multifactorial; controversial • Thickened, inelastic fascia • Muscle hypertrophy • Poor vascular outlet • S/Sx: slow-onset ache in lower leg, +/- paresthor numbness; resolution w/ rest over several minutes

  44. Differential Dx of ECS • Claudication • Buergersdz • Popliteal Artery entrapment • Strain • MTSS • Stress Fracture

  45. Diagnostic Pressures(Touliopolous and Hershman, 1999.) • POSITIVE FINDINGS: • Resting pressure > 15 mm Hg • 1 minute post exercise > 30 mm Hg • 5 minute post exercise > 20 mm Hg **Baseline pressure does not return for > 15 minutes. (suspicious) (Garcia-Mata et al., 2001)

  46. Treatment Options • Activity modification for symptom relief • Correct biomechanical problems • Gait retraining: Pose technique (forefoot) • ? Deep Tissue Massage • Surgery?

  47. OSTEOARTHRITIS: Treatment Overview(all proven in EBM) • Nonpharmocologic Measures • Education, Weight loss, Exercise, & Bracing • Pharmacologic Measures • NSAID/Acetamin., Glucosamine, Hyaluron. inj • Alternative Therapies • Acupuncture, Magnets, Balneotherapy, Thermotherapy • Surgery

  48. Intra-articular Corticosteroids for OA • Beneficial in KNEE • LOE 1a • Beneficial in HIP • LOE 1b • Short-duration benefits: 2-4 weeks • Every 3 mos OK; not effective at 2 years

  49. X To Guide…………………………….or not to Guide—THAT is the question!

  50. Intra-Articular Hyaluronic Acid (IAHA)“viscosupplement” • Effective in knee and hip • LOE 1a for knee pain, fxn, & stiffness • Possibly effective in ankle, shoulder (LOE lower) • Delayed effect (4 weeks) • Long duration (6 months) • 1-5 weekly injections

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