Overuse Injuries How to Solve the Challenging Puzzle Anthony Luke - - PDF document

7/23/2015 1

Overuse Injuries

How to Solve the Challenging Puzzle

Anthony Luke MD, MPH Essentials of Primary Care 2015

Disclosures

• Founder, RunSafe™
• Founder & CEO, SportZPeak Inc.
• Sanofi, Investigator initiated grant

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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?

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• 1. Mechanism

Why 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

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• 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 Factors

Khan 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

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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

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Treatment

• Heel lifts
• Modify footwear
• Custom orthotics
• Night splints
• PT is a major key

Rarely

• Surgical debridement

Physical Therapy for Achilles

Alfredson 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

• riginates from

intrinsic and extrinsic etiological factors”

• Usually not

tendinitis

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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

Where does the injury occur?

Insertional

• Occurs at

insertions near the joint

• Joint side

Tears

• At the musculo-

tendinous junction

• Areas of friction

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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 weeks Moderate – 4 to 6 weeks Severe – 6 to 12 weeks or longer

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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

Anti-Inflammatory?

• Little evidence to

support use of NSAIDs in management

• Good Analgesic
• Steroid injection?
• Needle tenotomy?

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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)

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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

Cartilage Damage

Outerbridge Classification, 1961

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Arthroscopy Arthroscopy

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Osteoarthritis 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 = 40.0511.43 ms (b) a patient with early OA (post- traumatic OA), female, 27. T1ρ = 50.5619.26 ms Li et al. Magn Reson Med, 2005.

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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

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Why do kids get injured ?

• Kids do what adults

do

• Kids get tired faster
• Limited strength
• Flexibility issues
• Excess stress /
• veruse leads to

failure

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

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 healing

Examples:

• Hip and quads strengthening program, core

stability

• Overhead and Throwing athlete rehab

– Long ball toss, Medicine balls, Rotator cuff, Periscapular exercises

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Return to play

Can the athlete return:

• Safely?
• Effectively?
• Relatively painfree?

Avoid the secondary or CHRONIC injury

• 4. Identify Risk Factors

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What are the risk factors?

Training Impact Bone Health Gait Mechanics

BONE LOADI NG Brukner P , Bennell K, Matheson G. Stress fractures, Blackwell Science, 1999.

Medial Tibial Stress Syndrome

Intrinsic

• 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,
• r duration
• Poor footwear
• Overtraining
• Increased mileage (>20

miles/week)

Galbraith et al, Curr Rev Musculoskelet Med, 2009

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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

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How stress fractures occur?

• Failure of bone

to adapt to stress

• Microinjury/

microcracks in the bone

Bone remodeling

• Causes relative

weakness

• Osteoclastic activity

faster than osteoblasts

• Excess stress

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Bone Response to Stress

Complete Fracture Complete Fracture

Stress Fracture Stress Fracture

Stress injury Stress injury

Stress reaction Stress reaction Accelerated remodeling Accelerated remodeling

Normal remodeling

Brukner 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.

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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

Diagnostic Imaging

Grade X-ray Bone Scan MRI 1

Normal Small, ill-defined cortical area, mild increase Positive STIR image

2

Normal Better defined cortical area, moderate increase + STIR + T2 weighted

3

Periosteal reaction Wide to fusiform cortical-medullary area of high activity + T1, T2, STIR No cortical break

4

Injury of periosteal rx Transcortical area

• f increased

activity + injury line on T1 or T2 scans

Arendt, Griffiths, Clin Sports Med, 1997.

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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 > 1year

Chang, Harris, AJSM, 1996

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Who and Where?

• Common locations

for stress fractures

• Who does it

happen to?

Who and Where?

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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

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Femoral Neck ORIF?

Indications

• Grade 4 changes
• n Bone Scan or

MRI

• Tension side
• Displaced
• 5. Education – Putting it all

together

Photo credit: Michael Chow / USA TODAY Sports

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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

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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

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Medications

• Oral contraceptive

pills

• SSRI

antidepressants

Conservative treatments

• Activity modifications (painfree)
• 1. NWB, swimming or biking
• 2. Nonimpact upright activities
• 3. Sport-specific drills; limited sports
• 4. Full activities no restrictions
• Pneumatic brace
• Adjunct modalities
• Manage expectations

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TEAM approach

• Psychologist /

psychiatrist

• Nutritionist
• Family
• Coach
• Sports Physician
• Family Physician
• OB/ GYN

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

7/23/2015 37

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?

10th UCSF Primary Care Sports Medicine Conference: ABC’s of Musculoskeletal Care December 11‐12, 2015 Hyatt Regency San Francisco California