lower extremity overuse injuries · • ensure appropriate intake of calcium and vitamin d. •a...

LOWER EXTREMITY

OVERUSE INJURIES

Andrew S. T. Porter, DO, FAAFP

University of Kansas School of Medicine - Wichita

Sports Medicine Fellowship & Family Medicine Residency at

Ascension Via Christi

KAOM CME Conference

11-08-2019

Lower Extremity Overuse Injuries in the Athlete

• Medial Tibial Stress Syndrome

• Chronic Exertional Compartment Syndrome

• Anterior Tibial Stress Fracture

• Posterior Tibial Stress Fracture

• Fibular Stress Fracture

• Navicular Stress Fracture

• Achilles Tendinosis

Medial Tibial Stress Syndrome (MTSS)

• Shin Splints

• Common cause of exercise-induced lower leg pain

• Most often seen in sports where repetitive running &

jumping are required

• Periostitis caused by traction of posterior leg muscles

• Pain along the posterior medial border of the mid tibia

which worsens with activity

• Usually diffuse area that is involved

• Pain improves with rest but often does not completely

resolve

• Imaging

• Plain X-rays

• AP & Lateral Tibia/Fibula with unaffected leg for comparison

• MRI with T2 Fat Sat Views in all plans

• Linear longitudinal edema of the periosteum

• MRI with STIR

• Bone Scan

• Linear diffuse uptake along posterior medial tibia

Anterior Tibia

Posterior Medial

• Treatment• Rest

• Activity modification would be best• Remember time off is lost training & quickly de-train

• Evaluation of training methods

• Formal Physical Therapy• Core strengthening, pelvic stabilization, mid foot strike, posterior tibial

strengthening

• ASTYM• Deep soft tissue friction massage

• Taping to off-load posterior medial tibia

• NSAIDs

• Evaluate shoe wear• Pes planus

• Surgery• Fasciotomy of deep posterior compartment

• Release of soleal bridge

• Reserved for refractory cases

Chronic Exertional Compartment Syndrome (CECS)

• Deep, aching exertional lower leg pain that results in

ischemic like pain

• Improves/resolves with rest but may remain bothersome for quite

some time

• Diagnosed with history and intercompartmental pressure

device

• ≥15 mm Hg at rest

• ≥30 mm Hg within 1 minute after exercise

• ≥20 mm Hg within 5 minutes after exercise

• CECS can turn into Acute Compartment Syndrome

• 22 year old male Army mechanic

• Training for APFT

• Maximum time is 16:36 for 2 mile run

• If he doesn’t pass the APFT he will be put on profile

• While training for APFT he develops exertional lower leg pain

described as fullness/tightness and cramping

• He has troubles lifting his feet up (dorsiflexion) and will often feel

like he is slapping the ground with his feet after he hits the 1.5 mile

• What LE compartment is most likely involved?

Any/all of the 4 lower leg compartments can be involved

• Most common compartment

• Anterior

• 2nd most common compartment

• Deep posterior

• Treatment

• Formal Physical Therapy

• Core strengthening, pelvic stabilization, mid foot strike, posterior tibial

strengthening, eccentric strengthening of LE compartments

• ASTYM to lower extremity compartments

• Deep soft tissue friction massage

• Taping to off-load posterior medial tibia

• Evaluate shoe wear

• Pes planus, pes cavus

Mid Foot Strike

• Treatment

• Percutaneous dry needling of involved compartments & fascia

• Botulinum toxin injections into involved compartments

• Surgery

• Fasciotomy of involved compartments vs all 4 compartments

• Mini-open vs endoscopic vs open

• Reserved for refractory cases

• Convert to cross trainer if able to

• Prepare for APFT run portion with elliptical, swim

• Marathon runner converted into Triathlete

Stress Fractures

• Stress Fractures in general

• Specific treatment recommendations

• Anterior Tibia

• Posterior Tibia

• Fibula

• Navicular

Stress Fractures

• Occur when osteoclastic activity overwhelms osteoblastic activity

• Bone injury unfolds over a continuum of time without intervention

Normal Bone → Stress Reaction → Stress Fracture →Fracture

• Result from excessive stress on normal bone from overactivity

• Result from normal stress on a bone that is deficient (osteoporotic, poor nutrition, or in female athlete triad)

• Common injuries in athletes & people who are active

• Running sports account for 69% of stress fractures

• Suspect in someone who is active:• + bone pain

• + performs repetitive activities with limited rest or recent increase in activity

Stress Fractures

• Physical exam

• Tests to perform in the area of interest are palpation, the tuning fork test, the fulcrum test, & the hop test

• Palpation

• Pain over affected bone with palpation

• Fulcrum Test

• Pain in fracture site while applying a bending force (e.g., over exam table) to distal extremity while proximal extremity is kept relatively immobilized

• Hop Test

• Hopping 10 times on affected leg reproduces pain at fracture site

• Tuning Fork Test

• Vibrating tuning fork over fracture site results in pain at site

Stress Fractures

• Imaging• If a stress fracture is suspected, x-rays should be obtained

• Takes 2 to 3 weeks for signs of stress fracture (i.e., periosteal reaction, callus formation, fracture line) to show up on x-ray

• Often stress fractures do not show up on x-rays

• If x-rays are negative & diagnosis is needed to help guide care & return to activity a bone scan or MRI should be obtained

• MRI with T2 Fat Sat Views in all planes• Marrow edema & possibly a transverse line of signal change

• CT Scan to further stress fracture line

• Bone scan can stay positive for up to 18 months • Clinical progress should not be monitored with a bone scan

Stress Fractures – Prevention

• Distribute loading forces on the bone with cross training & biomechanical adjustments

• Orthotics, proper shoes, stretches, strengthening, running mechanics)

• Consume sufficient calories to maintain adequate energy availability

• Ensure appropriate intake of calcium and vitamin D.

• A study by Lappe of female Navy recruits showed reductions in stress fractures in those consuming 2000 mg of Calcium & 800 IU vitamin D daily (supplement or diet)

• Lappe J et al. Calcium & Vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 2008;23:741-749.

• Tobacco should be avoided

• Women of child bearing age should try to maintain regular menses by consuming adequate calories & avoiding a negative energy balance

Stress Fractures – Treatment

• Nutrition, medication, & biomechanical recommendations

• Nutrition• Optimizing energy availability in diet

• Ensuring adequate calcium & vitamin D intake• Stress Fracture Prevention: 2000 mg Calcium + 800 IU Vitamin D

• Avoidance of tobacco exposure

• Medication • Acetaminophen PRN

• Avoidance of NSAIDs as they can slow bone healing

• Biomechanical • Offload the affected bone

• Reduce activity to pain-free functioning & pain-free cross-training

• Crutches may be needed to offload the injured area even more than a walking boot/cast or steal shank

• May require NWB • Goal = pain-free ambulation during the initial tx

Stress Fractures – Treatment

• Begin a rehabilitation

program when

tolerated

• Stretch & strengthen

supporting structures

• Start a gradual

increase in activity

when pain free

Factors influencing healing • Age

• Tobacco use• Lowers estrogen resulting in higher osteoclastic activity

• NSAIDs can slow bone healing • Lead to higher rate of non-union

• Menstrual dysfunction• Oligomenorrheic & amenorrhoeic females have decreased estrogen levels = higher osteoclastic activity

• Hormonal abnormalities

•Low growth hormone

•Low Testosterone

• Bone Quality

• –Nutritional • Adequate energy balance & protein intake

• Epcorates, UpToDate (Caloric intake)• Weight, exercise level

• Vitamin D and calcium

Return to Play

• Work on what the athlete can do

• Athlete is losing training time so readiness to RTP is not

just based on stress fracture healing

• Allow athlete to return to activities that are non-painful

• Lose Cardio respiratory fitness, muscle strength, balance,

& proprioception fast

Stress Fractures

High Risk vs Low Risk • Because of their propensity for delayed healing &

nonunion, certain stress fractures are considered high

risk, necessitate prompt treatment, & may ultimately

require surgical fixation

• Navicular

• Anterior Tibia

• Low-risk stress fractures have a lower incidence of

delayed healing & nonunion

• Posterior Tibia

• Fibula

Stress Fractures

Low Risk vs High Risk • Biomechanical forces along the bone with activity are

used to classify tibia stress fractures as either

compression-sided or tension-sided

• When running, the tibia compresses posteriorly so the posterior

aspect of the tibia is considered compression sided

• These variable forces on different parts of the bone affect

the potential for delayed healing & nonunion

Stress Fractures – Specific Tx

• LOW-RISK STRESS FRACTURE INITIAL TREATMENT

• Posterior Tibia

• WBAT Boot for 2-12 weeks (longer with cortical break) then transition to

pneumatic tibial brace

• Fibula

• WBAT 1-4 weeks

• +/- Cam Walker Boot

Stress Fractures – Specific Tx

• HIGH-RISK STRESS FRACTURE INITIAL TREATMENT• Anterior Tibia (Tension Sided)

• NWB for 6-8 weeks → PWB → FWB over next 6-12 weeks

• Can consider Orthopaedic Surgical Referral at diagnosis or if clinical & radiographic

healing are not achieved

Anterior Tibial Stress Fracture

• 21 year old female presented with 9 months of pain in

anterior tibia

• As she recalled, the pain started after she was kicked in

the shin

• Played full college basketball season with the pain

• Presented to me after the season at Fall PPE’s

• X-rays were performed

Anterior Tibia Stress Fracture8/2/19958/2/1995

21 YEAR21 YEAR

Page: 2 of 2Page: 2 of 2

XR Tibia/Fibula RightXR Tibia/Fibula Right

TIB-FIB LATTIB-FIB LAT

8/23/2016 4:57:05 PM 8/23/2016 4:57:05 PM

000XR16170496000XR16170496

------

IM: 1002IM: 1002Compressed 69:1Compressed 69:1

W: 1638W: 1638C: 2048C: 2048Z: 0.50Z: 0.50S: 136S: 136

8/2/19958/2/1995

21 YEAR21 YEAR

8/23/2016 4:57:05 PM 8/23/2016 4:57:05 PM

000XR16170496000XR16170496

------

W: 1638W: 1638C: 2048C: 2048Z: 0.50Z: 0.50S: 136S: 136

Further Work-Up & Treatment

• CT Scan had small fracture line that involved only the anterior cortex of the tibia (<15% width)

• MRI had edema in the area of stress fracture

• Vitamin D 25 OH was low at 15

• Conservative treatment initiated• WBAT during the day

• Activity modification

• Limited practice reps & time

• Adequate calorie intake

• 2000 mg calcium daily

• 50,000 IU Vitamin D weekly for 12 weeks

• Goal Vitamin D 25 OH > 40

• Bone stimulator 20 minutes daily to stress fracture site

2 months tx8/2/19958/2/1995

21 YEAR21 YEAR

10/31/2016 9:09:48 AM000XR16218794000XR16218794

------

W: 1638W: 1638C: 2048C: 2048Z: 0.41Z: 0.41S: 129S: 129

8/2/19958/2/1995

21 YEAR21 YEAR

10/31/2016 9:09:48 AM000XR16218794000XR16218794

------

W: 1638W: 1638C: 2048C: 2048Z: 0.41Z: 0.41S: 129S: 129

2 months NWB s/p ACL tear8/2/19958/2/1995

21 YEAR21 YEAR

1/3/2017 2:09:22 PM000XR17001450000XR17001450

------

W: 1609W: 1609C: 2114C: 2114Z: 0.41Z: 0.41S: 126S: 126

8/2/19958/2/1995

21 YEAR21 YEAR

1/3/2017 2:09:22 PM000XR17001450000XR17001450

------

W: 1609W: 1609C: 2114C: 2114Z: 0.41Z: 0.41S: 126S: 126

Case Continued

• ACL reconstruction progression continued

• Resumed WBAT to FWB then RTP basketball progression

• Sat out remainder of year to rehab and work out with

• Played full Senior College Basketball season

• No sequelae

NAVICULAR STRESS FRACTURE

• Most common tarsal bone stress fracture

• Central part is under the most stress as the “keystone” of the arch

• Linear fracture line usually occurs in the central avascular 1/3 of the bone & extends from the proximal dorsal pole to the distal plantar pole

• Mostly seen in athletic population

• HISTORY

• Aching pain in the dorsal midfoot that may radiate to the medial

arch & is VAGUE!!!

• “Doc – I must have tweaked my ankle but I do not remember

anything.”

• PHYSICAL EXAM

• Painful hop test on toes

• Pain at the “N” spot – nickel size area between extensor hallucis

longus & anterior tibial tendons on dorsum of foot (present 81% of

time in 1 study by Torg JBJS 1982)

• IMAGING

• XR

• Hard to see vertical fracture line & may need CT (only + 33% of

time in known fractures)

• CT - gold standard to evaluate the extent of the fracture

& evaluate for widening & sclerosis

• MRI – may show edema of stress fracture but should be

followed with CT

• BONE SCAN – may show stress fracture but should be

followed with CT

Bone Scan

9/6/19979/6/1997

20 YEA R20 YEA R

A Q M: 192\256A Q M: 192\256

TE: 76.78TE: 76.78

TR: 2300TR: 2300

FA : 90FA : 90

EC : 1EC : 1

NEX:2NEX:2

Q UA DKNEEQ UA DKNEE

MRI LE Non Joint w/o C ontras t LeftMRI LE Non Joint w/o C ontras t Left

FT LO NG A XIS T2 FSFT LO NG A XIS T2 FS

9/22/2017 5:52:17 PM 9/22/2017 5:52:17 PM

018MR17020174018MR17020174

------

LO C : -16.62 LO C : -16.62

THK: 3 SP : 4THK: 3 SP : 4

FFSFFS

IM: 17 SE: 12IM: 17 SE: 12

C ompressed 15:1C ompressed 15:1

DFO V :22x22cmDFO V :22x22cm

W: 934W: 934

C : 467C : 467

Z: 2Z: 2

9/6/19979/6/1997

20 YEA R20 YEA R

A Q M: 192\192A Q M: 192\192

TE: 64.85TE: 64.85

TR: 3416.66TR: 3416.66

FA : 90FA : 90

EC : 1EC : 1

NEX:1NEX:1

FT SHO RT A XIS IRFT SHO RT A XIS IR

9/22/2017 5:11:34 PM 9/22/2017 5:11:34 PM

018MR17020174018MR17020174

------

LO C : 48.58 LO C : 48.58

THK: 4 SP : 5 .50THK: 4 SP : 5 .50

FFSFFS

IM: 34 SE: 5IM: 34 SE: 5

W: 1008W: 1008

C : 358C : 358

Z: 2Z: 2

9/6/19979/6/1997

20 YEA R20 YEA R

A Q M: 192\192A Q M: 192\192

TE: 27.34TE: 27.34

TR: 3566.66TR: 3566.66

FA : 90FA : 90

EC : 1EC : 1

NEX:1NEX:1

FT SA G IRFT SA G IR

9/22/2017 5:34:44 PM 9/22/2017 5:34:44 PM

018MR17020174018MR17020174

------

LO C : -44.89 LO C : -44.89

THK: 3 SP : 4THK: 3 SP : 4

FFSFFS

IM: 15 SE: 9IM: 15 SE: 9

W: 969W: 969

C : 445C : 445

Z: 2Z: 2

NON-OEPRATIVE9/6/19979/6/1997

20 YEA R20 YEA R

A cq no: 1A cq no: 1

KV p: 120KV p: 120

mA : 100mA : 100

------

C T Lower Extremity w/o C ontras t LeftC T Lower Extremity w/o C ontras t Left

ReformattedReformatted

9/26/2017 12:06:22 PM

002C T17052740002C T17052740

------

THK: 3THK: 3

FFSFFS

IM: 59 SE: 104IM: 59 SE: 104

DFO V :23.4x23.4cmDFO V :23.4x23.4cm

W: 1847W: 1847

C : 936C : 936

Z: 1Z: 1

9/6/19979/6/1997

20 YEA R20 YEA R

A cq no: 1A cq no: 1

KV p: 120KV p: 120

mA : 100mA : 100

------

C T Lower Extremity w/o C ontras t LeftC T Lower Extremity w/o C ontras t Left

ReformattedReformatted

9/26/2017 12:06:22 PM

002C T17052740002C T17052740

------

THK: 3THK: 3

FFSFFS

IM: 48 SE: 105IM: 48 SE: 105

DFO V :23.4x23.4cmDFO V :23.4x23.4cm

W: 2000W: 2000

C : 350C : 350

Z: 1Z: 1

OPERATIVE

• TREATMENT

• If non-sclerotic margins & no widening >1mm on CT – NWB cast X

6 weeks

• If widening > 1mm on CT or marked sclerotic & irregular borders to

fracture – Screw +/- bone graft

• If athlete & quick return to play is an issue – consider screw for all

complete fractures

Achilles Tendinosis

• Tendinopathies• Tendonitis

• Tendinosis

• Tendinitis • Painful overuse tendon conditions

• Inflammation is present

• Tendinosis • Most common pathology in chronic painful tendons

• Occurs after repetitive injuries to a tendon that results in intertendinous scarring, disorganization of tendon fibers & degeneration.

• NO inflammatory component

• Bottom Line• Early on in a tendon injury, there is inflammation resulting in tendinitis, but after

about 6 weeks this generally evolves into tendinosis

• Almekinders LC: Anti-Inflammatory Treatment of Muscular Injuries in Sports. Sports Med. 1993;15(3):139-145.

Normal Tendon

• Type-I collagen bundles

packed tightly along the

tendon axis with sparse

fibroblasts between the

collagen rows

Tendinosis

• Collagen fiber disorientation

occurs with dense

populations of fibroblasts &

scattered vascular

hyperplasia (angiofibroblastic

hyperplasia)

Tendinopathy – Treatment

• Tendonitis

• STOP the inflammation

• NSAIDs (oral or topical)

• Rest

• Early activity modification

• PT

• Treatment may prevent the development of tendinosis

• Usually the first ~6 weeks

Tendinopathy – Treatment

Tendinosis• Healing is facilitated by creating an inflammatory

response

• To create inflammation

• Eccentric strengthening

• Deep soft tissue massage with tools (e.g., gua sha, Graston®, or

ASTYM®)

• Nitroglycerin patches (Nitro-Dur)1

• MSK US percutaneous needle tenotomy(with or without injection of

autologous blood, prolotherapy, or platelet-rich plasma)

1 = Not FDA Approved

ASTYM Tools

Tendinosis Treatment

• +/- NSAIDs

• NSAIDs will prevent an inflammatory response

• Concept of tendinosis diagnosis & treatment can be

utilized for tendons throughout hip & pelvis

• Most commonly applied to the Iliotibial (IT) band, Piriformis,

Gluteus Medius, Iliopsoas & Hamstrings

• Refractory Cases

• Tendon debridement for refractory cases

Achilles Tendinosis Diagnosis

• Best seen on Musculoskeletal Ultrasound (MSK US)

• Can also be seen on MRI

• 32 year old Triathlete with 6 months refractory Left Achilles tendon pain

• No improvement with conservative care• NSAIDs

• Rest

• Activity modification

• Deep soft tissue friction massage

• HEP

• Night sock

• Performed percutaneous needle tenotomy (PNT) with autologous blood injection (ABI) under MSK US with 6 week RTP progression

PRE POST

Left Achilles Tendon Right Achilles Tendon

Achilles Tendinosis Case

• Patient got back to full activities (Ironman Triathlons) with

no restrictions & no pain

• Limited

• Some small controlled & observational studies of patients with refractory medial & lateral epicondylosis who received MSK ultrasound-guided PNT with ABI reported improvement in symptoms & in MSK U/S appearance of tendons

• Suresh SP, et al. British Journal of Sports Medicine. 2006;40(11):935.

• Connell DA, et al. Skeletal Radiology. 2006;35(6):371.

• Patella & Other Tendons Studies• Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for

the treatment of chronic tendinosis. J Ultrasound Med. 2009;28(9):1187-1192. Reference 13.

• James SL, Ali K, Pocock C, et al. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007;41(8)518-521.

• Ryan M, Wong A, Rabago D, Lee K, Taunton J. Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study. Br J Sports Med. 2011;45(12):972-977.

• Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee. Injury. 2009;40(6):598-603.

Studies?

QUESTIONS

THANK YOU

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