managing overuse injuries kevin deweber, md, faafp director primary care sports medicine fellowship...
TRANSCRIPT
![Page 1: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/1.jpg)
Managing Overuse Injuries
Kevin deWeber, MD, FAAFP
Director
Primary Care Sports Medicine Fellowship
MilitarySports Medicine
Fellowship
“Every Warrior an Athlete”
![Page 2: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/2.jpg)
Objectives:
• Discuss the etiology of overuse injuries
• Describe common overuse injury forms
• Describe basic management principles
• Provide case study example of management
![Page 3: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/3.jpg)
Important Concepts(STOMP, STOMP)
• Making an accurate patho-anatomic diagnosis is critical
• For every injury (victim) there are underlying causes (culprits)--not limited to just “overuse”
• Rest and NSAIDs alone do not heal
• Rehabilitative exercise is the cornerstone for healing
![Page 4: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/4.jpg)
![Page 5: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/5.jpg)
Epi%*#!@*! of Overuse Injuries
50-65% of sports injuries seen in primary care are secondary to overuse.
![Page 6: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/6.jpg)
Two types of athletic injury
• Macrotrauma: specific episode of trauma with acute tissue disruption.
• Overuse: microtraumatic injury that results when an anatomic structure is exposed to a repetitive, cumulative force where the body’s reparative efforts are exceeded and local tissue breakdown occurs.
![Page 7: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/7.jpg)
Profile of Microtraumatic Soft-Tissue Injury
Time (weeks)
Pai
n l
evel
Period of abusive training
Subclinical episodes of failed adaptation
Moment of perceivedtissue injury
Attempted return to play
Period of vulnerabilityto recurrent injury
Pain threshold
![Page 8: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/8.jpg)
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
![Page 9: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/9.jpg)
![Page 10: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/10.jpg)
Etiology of Overuse Injuries
![Page 11: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/11.jpg)
KEY CONCEPT: VICTIM AND CULPRITS
• For every overuse injury (victim) there is an underlying cause (culprit)
![Page 12: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/12.jpg)
Examples of Victim and Culprits
• Runner with knee pain– Culprit = inflexible iliotibial band; hill running– Victim = tender lateral femoral condyle
• Athlete with Achilles tendinosis– Culprit = foot hyperpronation; old shoes– Victim = overstretched Achilles tendon
![Page 13: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/13.jpg)
Risk factors for Overuse Injury:The Usual Culprits
• Intrinsic abnormalities
• Extrinsic abnormalities
• Sports-imposed deficiencies
![Page 14: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/14.jpg)
Intrinsic abnormalities
• Mal-alignment of body parts
• Instability of joints
• Imbalance of muscle strength
• Weakness of muscles
• Inflexibility
• Rapid growth
![Page 15: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/15.jpg)
Examples of intrinsic abnormalities
• Foot morphology – high-arch (pes cavus) with highest risk (6x), – flatfoot (pes planus) with moderate risk
• Iliotibial band inflexibility-->ITB syndrome
• Genu valgum --> higher risk of PFS
• Rotator cuff weakness --> impingement
![Page 16: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/16.jpg)
Growth: example of intrinsic risk factor
• Unique to the growing athlete
• Muscle-tendon imbalance during periods of rapid growth
• Increased susceptibility to repetitive microtrauma
• Manifestations: – Apophysitis - Osgood-Schlatter’s, Sever’s– Epiphysial traction injury - e.g. proximal humerus
![Page 17: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/17.jpg)
Extrinsic abnormalities
• Training errors
• Equipment mismatch/failure
• Technique errors
• Environment factors
![Page 18: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/18.jpg)
Examples of Extrinsic risk factors
• Training error: running too fast, too soon
• Equipment mismatch: cycle poorly fitted, seat height incorrect
• Technique error: improper racquet swing
• Environment factor: running on pavement
![Page 19: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/19.jpg)
Sports-Imposed Deficiencies
• Repetitive eccentric overload– Example: pitching posterior structure
damage
![Page 20: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/20.jpg)
Vicious Injury Cycle of Overload
• Tissue overload, leads to...
• Tissue injury, leads to...
• Functional biomechanical deficit, leads to...
• Adaptive change in technique– leads to more tissue overload, and the cycle continues
![Page 21: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/21.jpg)
Clinical symptomsDecreased performance
Subclinical adaptations 1. Muscular weakness2. Inflexibility3. Scar tissue4. Muscle strength imbalance
Substitutebiomechanicalmovements
Muscle damage
1. Microtears2. Macrotears
Musculotendinoustensile overload
Vicious Injury Cycle of overload
![Page 22: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/22.jpg)
Clinical symptomsDecreased performance
Subclinical adaptations 3. External rotation strength imbalance
Substitutebiomechanicalmovements4. Alteration of throwing motions
Muscle damage
Musculotendinoustensile overload
Example of overuse1. Tensile load on posterior shoulder muscles
2. Micro-tears to Infraspinatus and Teres minor
![Page 23: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/23.jpg)
History of Present Illness
• Date of onset
• Changes in routine– intensity of workouts– equipment– location of activity
• Aggravating/relieving activities
• History of interventions
![Page 24: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/24.jpg)
Looking for culprits - think of the risk factors again
• Intrinsic abnormalities
• Extrinsic abnormalities
• Sports-imposed deficiencies
![Page 25: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/25.jpg)
The concept of “Transition”
• “Transition” - some change in the use of the involved body part
• Identify what changed before symptom onset– e.g. increased running mileage preceded knee
pain– e.g. getting a new pair of boots/shoes led to
plantar fascia pain
![Page 26: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/26.jpg)
Evaluating biomechanics
• Limb examination– Flexibility, ROM, strength, ligament stability, leg
length
• Examine patient while standing
• Watch patient walk/run/swing racquet, etc.
• Consider referral– Video gait analysis– Ergonomist evaluation– Professional coach/trainer
![Page 27: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/27.jpg)
Assessing equipment
• Wear pattern of shoe soles
• How well a device fits the user
• Proper use of device
![Page 28: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/28.jpg)
Common Overuse Injury Forms
• Musculoskeletal– Bone
– Tendon
– Muscle
– Cartilage
– Joint capsule
– Nerve
– Ligament
– Bursa
• Non-Musculoskeletal– Overtraining
Syndrome
– Female Athlete Triad
![Page 29: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/29.jpg)
![Page 30: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/30.jpg)
Normal tendon
![Page 31: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/31.jpg)
Tendinosis: collagen disruption and neovascularization
![Page 32: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/32.jpg)
Examples of muscle overuse injury
• Muscle strains– Culprits
• prolonged overtraining
• weakness
• opposing muscle tightness
![Page 33: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/33.jpg)
Example of cartilageoveruse injury
• Patellofemoral syndrome culprits:– hamstring inflexibility– relative quad weakness– hyperpronation– lateral patellar retinaculum tightness– overtraining
![Page 34: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/34.jpg)
Examples of nerveoveruse injuries
• Tarsal tunnel syndrome culprits:– hyperpronation– overtraining– ganglions/lipomas
![Page 35: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/35.jpg)
Examples of ligamentoveruse injury
• Plantar fasciitis culprits: – Achilles inflexibility– pes cavus/planus, hyperpronation– worn-out running shoes– leg length discrepancy– overtraining– intrinsic foot muscle weakness
![Page 36: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/36.jpg)
Examples of bursa overuse injuries
• Trochanteric bursitis culprits:– iliotibial band inflexibility– relative adductor weakness
![Page 37: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/37.jpg)
Example of mixedoveruse injury
• Rotator cuff impingement– Muscle, tendon, bursa injury– Culprits:
• RC weakness relative to deltoid
• improper arm movements
• overtraining
• hooked acromion
• Scapular dyskinesis
![Page 38: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/38.jpg)
Management of Overuse Injuries
![Page 39: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/39.jpg)
Clinical symptomsDecreased performance
Subclinical adaptations 1. Muscular weakness2. Inflexibility3. Scar tissue4. Muscle strength imbalance
Substitutebiomechanicalmovements
Muscle damage
1. Microtears2. Macrotears
Musculotendinoustensile overload
BREAK the Vicious Injury Cycle of overload
![Page 40: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/40.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
Activityparticipation
![Page 41: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/41.jpg)
1. Make accurate patho-anatomic diagnosis
• Accurate history
• Thorough physical examination
• Biomechanical evaluation
• Selected diagnostic tests
![Page 42: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/42.jpg)
Possible diagnostic tests
• Plain radiographs
• Stress testing
• Selected lab tests
• Specialized tests– Bone scan– MRI
![Page 43: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/43.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
Activityparticipation
![Page 44: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/44.jpg)
2. Control of inflammation:“PRICEMM”
• P - Protect
• R - Rest (relative)
• I - Ice
• C - Compression
• E - Elevation
• M - Medications
• M - Modalities
![Page 45: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/45.jpg)
PRICEMM:Protection
• Protect body part from further injury– *Splint– *Padding– *Orthotic
![Page 46: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/46.jpg)
PRICEMM:Relative Rest
• Cease abusive activity temporarily
• Should be active rest
• Limit immobilization to minimum– Prevents atrophy and loss of ROM
![Page 47: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/47.jpg)
PRICEMM:Ice
• Minimizes swelling
• Decreases pain
• Application:– 20 min– Every 3 hours– 3 days
![Page 48: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/48.jpg)
PRICEMM:Medications
• NSAIDs– No scientific support for long-term benefit in
overuse injury– Adverse reactions common– Probably only benefit is analgesic
• consider other analgesics
– 7-14 days probably enough
![Page 49: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/49.jpg)
PRICEMM:Medications (cont.)
• Corticosteroids - potent anti-inflammatory– Decrease collagen production and weaken tendons
– Unclear role in overuse injury
– Consider for:• Severe pain that limits rehabilitation
• Refractory pain after other treatments
– Limitations• Never into a tendon
• Up to 3 times a year in one place
![Page 50: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/50.jpg)
PRICEMM:Modalities
• Vague theoretic principles
• Analgesia
• ? Affect on inflammation
• May limit muscle spasm/atrophy
![Page 51: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/51.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
Activityparticipation
![Page 52: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/52.jpg)
3. Promote healing
• Therapeutic exercise– correct weakness or imbalance
• Healing injections
• Select surgical intervention
![Page 53: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/53.jpg)
Therapeutic exercise
• Strength
• Flexibility
• Proprioception
![Page 54: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/54.jpg)
Strength exercise types
• Isometric - useful if ROM poor
• Isotonic– Concentric - good initially once ROM restored– Eccentric - enhances strength, repairs tendons
• Isokinetic
![Page 55: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/55.jpg)
“Chronic Achilles tendinosis: recommendations for treatment
and prevention.”
Alfredson H et al. Sports Medicine 2000 Feb (29): 135-146.
![Page 56: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/56.jpg)
• Patients had failed other treatments such as PRICEMM, casting, rest, stretching, etc.
• Progressive heavy-load eccentric heel cord exercises BID, 7d/wk, 12 weeks
• 2-year f/u: 14 of 15 patients able to resume running without pain
![Page 57: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/57.jpg)
Therapeutic Injections
• Autologous blood
• Platelet-rich plasma
![Page 58: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/58.jpg)
Surgical Intervention--Indications
• Failed quality rehabilitation
• Unacceptable quality of life
• Persistent pain
![Page 59: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/59.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
Activityparticipation
![Page 60: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/60.jpg)
4. Fitness exercise
• Aerobic exercise
• Transition exercise
• Sport-specific exercise
![Page 61: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/61.jpg)
Aerobic exercise
• Enhances peripheral oxygenation to speed healing
• Enhances psychological well-being
• Enhances return to sport
![Page 62: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/62.jpg)
Aerobics
![Page 63: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/63.jpg)
• Activities closer to the goal activity
• Less stress on injured body parts
Transition exercise
![Page 64: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/64.jpg)
Sport Specific Exercise• Training to fit the
demands of sport, occupation, or hobby
![Page 65: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/65.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
Activityparticipation
![Page 66: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/66.jpg)
5. Control Abuse
• Modify extrinsic overload– technique– training
• Bracing and taping
• Proper equipment
![Page 67: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/67.jpg)
Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
3. Promote healing
4. Fitness exercise
5. Control abuse
ActivityParticipation
![Page 68: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/68.jpg)
![Page 69: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/69.jpg)
The goal:
Activity Participation• Sports
• Recreation
• Fitness exercise
• Maintain ongoing rehab program
![Page 70: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/70.jpg)
Case Study:
28 year old elite taekwondo athlete with heel pain
• 2 months right heel pain
• Dramatically increased running 1 mo ago
• Pain worst on rising in AM, better when running on forefoot
• Pain with ADLs
• Competes in Nationals 2 months
![Page 71: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/71.jpg)
1. Make accurate patho-anatomic diagnosis
• History: abnormal transition increase in training volume (>10% per week)
• Physical exam: pain at insertion of plantar fascia near medial calcaneal tubercle
• Diagnosis: plantar fasciitis
![Page 72: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/72.jpg)
But on closer exam:
• Gastro-soleus inflexibility and weakness
• Pes planus
• Excessive pronation
• Weak toe flexors
• Running shoes old, excessive wear on medial aspect of sole
![Page 73: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/73.jpg)
Clinical symptomsDecreased performance
Subclinical adaptations
SubstitutebiomechanicalmovementsForefoot running, slower pace,decreased distance
Tissue damage
Musculotendinoustensile overload
Gastro-soleus inflexibility & weakness, pes planus, hyperpronation. Excessive eccentric overload of plantar fascia
Excessive tensionon calcanealinsertion
![Page 74: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/74.jpg)
2. Control inflammation(PRICEMM)
• Ice massage TID x 15 minutes
• 1 week course of NSAID
![Page 75: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/75.jpg)
3. Promote healing
• Gastro-soleus stretching & strengthening
• Toe flexor strengthening
![Page 76: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/76.jpg)
4. Fitness exercise
• Deep-water running– Pain with walking and palpation gone 2 wks
• Resume running– No hills or speed work at first– Increase mileage 10% per week– Cross train in pool
![Page 77: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/77.jpg)
5. Control abuse
• Stop running initially; deep water running instead
• Fitted for orthotics
• New running shoes
![Page 78: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/78.jpg)
Returned to full training at 1 month
• Continue flexibility and strength exercises
• Won national championship 2006
![Page 79: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/79.jpg)
Summary/Review
• Overuse injuries are the most common and most challenging in athletics
• For every “victim” there is a “culprit”
• The H&P remain the key elements in management (1. Make accurate patho-anatomic diagnosis)
• Rest and NSAIDs alone do not heal
• Rehabilitative exercise is the cornerstone for healing
![Page 80: Managing Overuse Injuries Kevin deWeber, MD, FAAFP Director Primary Care Sports Medicine Fellowship Military Sports Medicine Fellowship Every Warrior an](https://reader034.vdocuments.site/reader034/viewer/2022051412/551794c855034645368b575a/html5/thumbnails/80.jpg)
USA Boxing National Champion
DeAndrey Abron