4 vineet kumar - journal of bone and joint...

Lower Extremity Overuse Injuries in Unorganized Sports – Role of Malalignment

Vineet Kumar1 1 1 1 1, Ajai Singh , Shah Waliullah , Vikas Verma , Deepak Kumar , Kumar Shantanu1

AbstractBackground: Overuse injury is a very common entity, especially in unorganized sports activities. �e incidence of this injury is many folds than what we expect. In this study, we will be analyzing the clinically diagnosed lower extremity malalignments contributing to these overuse injuries.

Materials and Methods: A total of 84 participants were selected as per the inclusion criteria and assessed clinically for any lower extremity malalignment. Associations of these were then looked in for with overuse injuries.

Results: In this study, the majorities of participants were males (80.95%). �e mean age at diagnosis of overuse injuries was 22.7 years. �e age of onset of overuse injury was earlier in females for all conditions. The most common overuse injury in both genders was sprain ankle (34.5%). �e recreational jogging was the most common unorganized activity in males (30.95%), whereas recreational running was common (8.34%) in females. �e overall pe rcentage of malalignment in total enrolled patients was 64.3% in which the internal tibial torsion had the highest percentage both in male and female patients.

Conclusion: The most common overuse injury in our study was sprain ankle followed by plantar fasciitis which was commonly associated in individual having �at feet (42.86%). �e present study shows that more than half (64.3%) of the overuse injury p atients were also associated with some malalignments, which may imply that the malalignment may be a risk factor for the overuse injuries.

Keywords: Lower extremity, overuse injury, malalignment.

Original Article Journal of Bone and Joint Diseases| Oct-Dec 2017 | 32(3):11-16

© 2017 by Journal of Bone and Joint Diseases | Available on www.jbjdonline.com | doi:10.13107/jbjd.0971-7986.2017.166�is is an Open Access article distributed under the terms of the Creative Commons A�ribution Non-Commercial License (h�p://c reativecommons.org/licenses/by-nc/3.0) which

permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Vineet Kumar Ajai Singh Shah Waliullah Vikas Verma Deepak Kumar Kumar Shantanu

Introduction:�ere are various characteristics that can clue towards overtraining or overuse as the possible underlying cause of injury. Mild discomfort a�er physical activity is common. If the pain appears and exists during sports activity and persists even a�er the activity, then it denotes that the amount of sports activity (whether single shot or a�er multiple episodes of these activities) is perhaps "too much," "too fast," or "too soon" and may cause overuse injury [1]. �e unorganized exercises and physical activities include any sports or related exercises/physical activities being performed without any quali�ed supervision and/or protocol. �ese may include playing at local/university/college/office level, performing during an annual day of university/office / company or college, in a gym, at summer camps, during or before an

interview/selection, during a training period etc. Overuse injuries in the young adults vary from person to person, both anatomically and physiologically. It is difficult to estimate the actual impact of this problem. It has been observed that amongst all patients, approximately 5% of mature athletes seek their treatment for sports-related overuse injuries [2]. Even the incidence of overuse injuries also appears higher in young athletes (about 8% to 10%) [3]. Because of limited studies, the contribution of alignment abnormalities as a risk factor for overuse injuries is unclear. �e rehabilitated players may also suffer re-injury if risk factors are not addressed properly. Most of the unorganized exercise and physical activities are being carried out for a common reason i.e. fun [4]. But unfortunately, these injuries not only take away the concerned person from the fun but also restrict most of

Department of Orthopaedic Surgery, King George’s Medical University, Lucknow, U�ar Pradesh, India.

Address of Correspondence:Ajay Singh,Department of Orthopaedic Surgery, King George’s Medical University, Lucknow, U�ar Pradesh, India.E-mail: [email protected]

Journal of Bone and Joint Diseases Volume 32 Issue 3 Oct- Dec 2017 1-1611| | | | |

Kumar et al. www.jbjdonline.com

Table 1: Clinical assessment of malalignments [7-12]Clinical assessmentQ-angle Tibial torsionCoxa version Arch index (for �at foot)Heel valgus/varus Genu valgum/varus

Figure 1: Flowchart of methodology.

them to perform similar activities in their future. Regre�ably, due to fear of being removed from these activities or disappointing their parents, teachers and bosses, many young unprofessional players forcefully continue to perform, bearing pain. �ough, all resources are being directed to the athletes who are trained in a controlled environment (sports college/stadium) while the real burden remains with unorganized sports and exercise activities. �e study of these risk factors will open a new scope in the management of these injuries and by identifying these problems at an early stage, overuse injuries can be avoided by explaining the type of activities to be done and not to be done. In this proposed study, I will be trying to bridge this information gap by analyzing the association of mal-alignment with overuse injuries in a wide variety of unorganized sports activities in the young adult population. We hypothesized that if a lower limb malalignment produces abnormal kinetics of the joint, then lower limb malalignment will be associated with overuse injury.

Material and Methods:�is observational study was carried out in OPD of Department of Orthopedics, and DPMR, KGMU from May 2016 to December 2016. �is study analyzed data collected from young age physically active adults who are involved in recreational activities involving unorganized sports activity and who sustain an overuse injury. A total of 84 subjects between the ages of 18 and 30 years old of either sex, involved in unorganized sports activity having BMI <30 were included in the study. Subjects having from any chronic disease (Diagnosed chronic muscular or skeletal disease including arthritis, osteoporosis; diagnosed heart disease or actively seeking treatment for cancer, surgical menopause, oophorectomy, Hepatic and renal diseases, IBD), suffering from certain orthopaedic conditions (lower extremity traumatic ligamentous tears,

reconstructive joint surgery, joint replacement, active lower limb orthopaedic infective), medical co-morbidities (Any systemic disease affecting physical activity of subject eg., COPD etc., psychiatric illness, Obesity) and those who refuse to give consent to be a part of study were excluded from the study. For analysis, participants with all available data and given informed consent involved in unorganized sports activity suffering from overuse injury were included as per inclusion and exclusion criteria. We looked in for following mal alignments (Table-1) in these subjects. We diagnosed this mal-alignment only by standard clinical methods, as restriction of resources was our limitation. Certain characteristics can clue us into the possible overtraining or overuse injuries.Mild discomfort or soreness a�er physical activity, rating no higher than 2 or 3 on a pain scale of 0 to 10, is common. If pain exists during the sports activity and persists even a�er activity rating to higher than 3 / 10 on a visual pain scale (VAS),[1] then that amount of sports activity (whether single shot or a�er multiple episodes of these activities) is perhaps "too much," "too fast," or "too soon" and were considered as overuse injury in that particular adult. A secondary purpose was to determine the shared risk factors among these individuals who sustained any of the common overuse running injuries: anterior knee pain (AKP), medial tibial stress syndrome, Achilles tendinitis, or plantar fasciitis, ankle sprain, a stress fracture in foot bones. Figure 1 shows a schematic of the study designStatistical Analysis: Statistical analysis was performed using SPSS so�ware (SPSS Inc., Chicago, IL, USA) for Windows program (15.0 version). �e continuous variables were

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Table 2: Patients demographic dataParameters n (range)

Male (n=68) Female (n=16) Overall (n=84)Age 23.3 (18-30) 22.1 (18-25) 22.7 (18-30)Weight 67.5 (48-82) 62.3 (45-70) 64.9 (45-82)Height 160.2 (155-174) 157.6 (145 160) 158.9 (145-174)BMI 22.17 21.86 22.01Average duration of unorganized activity 6.5 (5-19) 5.2 (3-12) 5.8 (3-19)BMI: Body mass index

Table 3: Type of overuse injuries among the young adultType of overuse injury n (%)

Male (n=68) Female (n=16) Overall (n=84)Planter fasciitis 17 (20.2) 13 (15.5) 30 (35.7)Osgood – Schla�er disease 06 (7.1) 01 (1.2) 07 (8.3)Osteochondritis 02 (2.4) 00 02 (2.4)Sprain ankle 25 (29.8) 04 (4.8) 29 (34.5)Sinding-Larsen Johansson syndrome 01 (1.2) 01 (1.2) 02 (2.4)Sever’s disease 03 (3.6) 01 (1.2) 04 (4.8)Stenosing tenosynovitis ankle 04 (4.8) 01 (1.2) 05 (5.9)Retrocalcaneal tendonitis 07 (8.3) 01 (1.2) 08 (9.5)Anterior knee pain 06 (7.1) 01 (1.2) 07 (8.3)

Table 4: Common unorganized activity among the young adultType of unorganized activity n (%)

Male (n=68) Female (n=16) Overall (n=84)Recreational running 24 (28.6) 07 (8.3) 31 (36.9)Short running (100 m) 18 (21.4) 05 (6.0) 23 (27.4)Longer running (>100 m) 06 (7.1) 01 (1.2) 07 (8.3)Recreational jogging 26 (30.9) 05 (6.0) 31 (36.9)Recreational playing 19 (22.6) 04 (4.8) 23 (27.4)Cricket 13 (15.5) 02 (2.4) 15 (17.9)Football 03 (3.6) 00 03 (3.6)Badminton 02 (2.4) 01 (1.2) 03 (3.6)Lawn tennis 01 (1.2) 01 (1.2) 02 (2.4)

Table 5: Type of malalignment among the young adultType of malalignment

n (%)Male (n=41) Female (n=13) Overall (n=54)

Heel varus 05 (9.2) 03 (5.5) 08 (14.8)Heel valgus 06 (11.1) 03 (5.6) 09 (16.7)Flat feet 09 (16.7) 06 (11.1) 15 (27.8)Internal tibial torsion

18 (33.3) 08 (14.8) 26 (48.1)

External tibial torsion

11 (20.4) 02 (3.7) 13 (24.0)

Abnormal Q angle

09 (16.7) 02 (3.7) 11 (20.4)

evaluated by a mean (±standard deviation) or range value when required. For comparison of the means between the two groups, analysis by Student's t-test (unpaired) with 95% con�dence interval. �e correlation analysis was done using Spearman correlation coefficient. A p-value < 0.05 or 0.001 was regarded as signi�cant.

Results:A total of 84 prospective cases of overuse injuries was seen during the study period from May 2016 to December 2016. All the demographic data of the enrolled patients, divided on the basis of their gender show statistically non-signi�cant difference (Table 2).Out of total patients with overuse injuries, majorities of these were males (80.95%). �e mean age at diagnosis of overuse injuries was 22.7years.�e age of onset of overuse injury was earlier in females for all conditions. �e most common overuse injury in both genders was sprain ankle

(34.5%) (Table-3)�e recreational jogging was the commonest unorganized activity in males (30.95%), whereas recreational running was common (8.34%) in females (Table-4).Amongst all patients, most of the unorganized activity was performed on a hard surface (n=65; 77.38%) than on so� surface (n=19; 22.62%). Of these cases with unorganized

Journal of Bone and Joint Diseases Volume 32 Issue 3 Oct- Dec 2017 Page 11-1613 | | | |


Table 6: Association of overused injuries with malalignmentMalalignments Overuse injuries

PF (30) OS (07) OC (01) SA (29) SLJ (02) SD (03) ST (05) RT (08) AKP (07)Heel varus (08) 2 5 1Heel valgus (09) 6 2 1Flat feet (15) 9 2 3Internal tibial torsion (26) 6 16 3External tibial torsion (13) 1 1 1 2 1 9Abnormal Q angle (11) 3 1 7AKP: Anterior knee pain, PF:Planter fasciitis, OS:Osgood – Schla�er disease, OC:Osteochondritis, SA:Sprain Ankle, SLJ:Sinding-Larsen Johansson syndrome,

activities performed on the hard surface, 45 (67.7%) had overuse injuries whereas only 02(10.5%) cases had overuse injury while performing an unorganized activity on the so� surface. �e overall percentage of mal-alignment in total enrolled patients was 64.3%, in which the internal tibial torsion had the highest percentage both in male and female patients (Table-5).

Discussion: In simple terms, overuse injuries can be de�ned as the product of an activity performed “Too much, Too fast, Too soon”. How much is too much? How fast is too fast? How soon is too soon? �e answers vary from person to person. �e acute injuries draw immediate a�ention, but as overuse injuries occur slowly and are not debilitating at an early stage, so these injuries are o�en neglected or misdiagnosed. It is difficult to estimate the actual magnitude of this problem. We have no official Indian data available as of now. Recent American data indicates that 30% to 50% of all sports injuries are due to overuse. �e contributions of alignment abnormalities to overuse injuries are unclear as there are very few prospective studies. Players a�er rehabilitation may suffer re-injury, if risk factors not diagnosed and addressed. All resources are being directed to the athletes who are trained in a controlled environment (sports colleges/stadium) while the real burden remains with un-organized sports and exercise activities. �e study of these risk factors will open a new scope of management of these lesions and by identifying these abnormalities early, overuse injuries can be avoided by explaining the type of activities to be done and not to be done. Overuse injuries occur when a tissue is injured due to repetitive submaximal loading. �e process starts when repetitive activity fatigues a speci�c structure such as tendon or bone. With sufficient recovery, the tissue adapts to the demand and is able to undergo further loading without injury. Without adequate recovery, microtrauma develops and stimulates the body's in�ammatory response, causing the release of vasoactive substances, in�ammatory cells, and enzymes that damage local tissue [4]. Cumulative

microtrauma from further repetitive activity ultimately causes clinical injury. In chronic or recurrent cases, continued loading produces degenerative changes leading to weakness, loss of �exibility, and chronic pain [37]. �us, in overuse injuries, the problem is o�en not acute tissue in�ammation, but chronic degeneration (i.e. tendinosis instead of tendinitis). In the present study, we have been trying to �nd out the association of mal-alignment as a risk factor for overuse injuries in a wide variety of unorganized sports activities in the young adult population. �e unorganized exercises and physical activities need more a�ention because of the following reasons, i.e. �e incidence of these overuse injuries in unorganized activities is many folds more than the organized sports and affect a large proportion of the population; No documented protocol is available or being followed during these activities and its real impact/burden on the society is not well documented [38]. In the present study, the percentage of most of the overuse injury patients were male (80.95%). We found that most of the overuse injuries are of lower extremity was ankle sprain (34.5%). �e similar observation was made by Bruns et al. (2000) and Leok Lim Lau et al.(2008). Plantar fasciitis was the most common injury of the plantar fascia in other studies [39-42]. In the present study, we also landed up with the same conclusion and it was the second most common overuse injury next to sprain ankle. It was commonly associated in an individual having �at feet (42.86%). �e present study shows that more than half (64.3%) of the overuse injury patients were also associated with some mal-alignments (Table 6), which may imply that the mal-alignment may be a risk factor for the overuse injuries. We observed that reliable �ndings will be obtained by designing the case-control study. �is study had some limitations. Firstly, it was an observational study and secondly, the sample size was less. Both of the above-mentioned limitations affected the proper knowledge and reliability of the present study.


SD:Sever’s Disease, ST: Stenosing tenosynovitis ankle, RT:Retrocalcaneal tendonitis


Conclusion:We thus conclude that overuse injuries in young adults are frequently associated with mal-alignments. An adequate understanding of the anatomy of the adults may assist in be�er primary care treatment. It is also recommended that

health professionals should be aware of organized and unorganized activities as well as their risk and safety factor.

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Con�ict of Interest: Nil. Source of Support: None

How to Cite this Article

Kumar V, Singh A, Waliullah S, Verma V, Kumar D, Shantanu K . Lower Extremity Overuse Injuries in Unorganized Sports – Role of Malalignment. Journal of Bone and Joint Diseases Oct - Dec 2017;32(3):11-16.

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