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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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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
Overuse Injury types
  • Muscle strain
  • Tendinopathy
  • Enthesopathy
  • Stress fractures
  • Fasciopathy
  • Nerve compression
  • Apophyseal traction injury (adolescents)
key features of overuse injury
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
key concept victim and culprits
  • For every overuse injury (victim) there is an underlying cause (culprit)
risk factors for overuse injury the usual culprits
Risk factors for Overuse Injury:The Usual Culprits
  • Intrinsic abnormalities
  • Extrinsic abnormalities
intrinsic abnormalities
Intrinsic abnormalities
  • Mal-alignment of body parts
  • Instability of joints
  • Imbalance of muscle strength
  • Weakness of muscles
  • Inflexibility
  • Rapid growth
extrinsic abnormalities
Extrinsic abnormalities
  • Training errors
  • Equipment mismatch/failure
  • Technique errors
  • Environment factors

Vicious Injury Cycle of Overload

Tissue overload




Clinical symptoms

Decreased performance



1. Microtears

2. Macrotears

Subclinical adaptations

1. Weakness

2. Inflexibility

3. Scar tissue

4. Strength imbalance


Example of overuse

1. Tensile load on posterior shoulder muscles


tensile overload




4. Alteration of



Clinical symptoms

Decreased performance



2. Micro-tears to


and Teres minor

Subclinical adaptations

3. External rotation

strength imbalance

overuse injury management pyramid
Overuse Injury Management Pyramid



5. Control abuse

4. Fitness exercise

3. Promote healing

2. Control pain

1. Make accurate patho-anatomical diagnosis

tennis leg
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
proximal hamstring strain formerly ischial bursitis
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
hip rotator cuff syndrome formerly piriformis syndrome
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
tendon overuse injuries the spectrum of tendinopathy
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.
achilles tendinopathy
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.
achilles tendinopathy prolotherapy
Achilles Tendinopathy Prolotherapy

Traditional Prolotherapy

Yelland et al. 2011 RCT


Case Series

Sanchez et al. 2005

Sanchez et al 2007

Gaweda et al 2010

Monto 2012


de Vos et al. 2010 RCT

No eccentric training prior!

achilles tendinopathy rct yelland et al 2011
Achilles tendinopathy RCTYelland et al 2011
  • N=43, Dextrose vsEccentricExvs COMBO
  • Success = 20-pt fall in VISA-A at One Year
  • Dextrose and COMBO:
  • One Year: No significant differences between groups
    • underpowered
greater trochanteric pain syndrome gtps formerly troch bursitis
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)
plantar fasciopathy not fasciitis
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
plantar fasciopathy
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
shin splints
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
shin splint management
Shin Splint Management
  • Activity Modification
  • Orthotics
  • Shoe evaluation
  • Strengthening and stretching
  • Shin Sleeve
  • Monitor for other conditions
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
extrinsic factors
  • Increasing volume and intensity
  • Footwear
    • Older shoes
    • Absence of shock absorbing inserts
  • Running Surface?: mixed results
    • Treadmill vs Track
  • Activity type
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
general treatment for low risk stress fractures
    • Reduce pain
    • Promote healing
    • Prevent further bone damage
    • Rest from painful activities 6-8 weeks (or until pain-free for two to three weeks)
    • Cross-training (non-painful exercise)
    • Flexibility, strength balance
high risk stress fractures

High risk for

delayed union, nonunion,


  • 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)

high risk tibial stress fracture
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

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
femoral neck stress fracture
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
femoral neck palpation
Femoral Neck Palpation

Iliopsoas bursa

compression side femoral neck stress fractures
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
tension side femoral neck sf
TENSION-side Femoral Neck SF
  • High propensity to displace
  • Frequent complications
  • Treated acutely with internal fixation
tarsal navicular stress fx
Tarsal Navicular Stress Fx
  • X-rays usually negative
  • MRI or thin-cut CT better than bone scan
sesamoid stress fracture
Sesamoid Stress Fracture
  • Tx: NWB x 6 weeks with cast to tip of great toe to prevent DF
  • Failure: Surgery (excision or grafting)
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
  • 4 muscular compartments
    • Anterior
    • Lateral
    • Superficial posterior
    • Deep posterior
  • Fascial defects
  • 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
differential dx of ecs
Differential Dx of ECS
  • Claudication
    • Buergersdz
  • Popliteal Artery entrapment
  • Strain
  • MTSS
  • Stress Fracture
diagnostic pressures touliopolous and hershman 1999
Diagnostic Pressures(Touliopolous and Hershman, 1999.)
  • 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)

treatment options
Treatment Options
  • Activity modification for symptom relief
  • Correct biomechanical problems
  • Gait retraining: Pose technique (forefoot)
  • ? Deep Tissue Massage
  • Surgery?
osteoarthritis treatment overview all proven in ebm
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
intra articular corticosteroids for oa
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


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

intra articular hyaluronic acid iaha viscosupplement
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
knee osteoarthritis
Knee Osteoarthritis
  • Traditional prolo
    • Reeves & Hassanein 2000 RCT
    • Rabago et al, 2012 series
  • PRP
    • Sanchez et al. 2008 case/cont
      • Knee OA, PGRF vshyaluronan
    • Kon 2010 and Filardo 2011, series
    • Sampson et al 2010 series
    • Wang-Saegusa et al 2011 series
    • Filardo at al 2011 series
    • Gobbi et al 2012 series
    • Kon/Mandelbaum et al. 2011 PRP vsVisco
    • Spakova et al 2012 PRP vsVisco
    • Patel et al 2013 PRP vs placebo

Image from: Sun Y, Feng Y, Zhang CQ et al. The regenerative effect of platelet-rich plasma on healing in large osteochondral defects. International Orthopedics 2009. Online April 18, 2009

knee osteoarthritis prp rct spakova et al 2012
Knee Osteoarthritis PRP: RCTSpakova et al 2012
  • Non-blinded, 120 pts
  • Weekly inj x 3
    • PRP 4.5x plt w/ leuk
    • HA (Erectus, med MW)
  • WOMAC at 3 & 6 mos
  • 3 mos: both signif better
    • PRP signif better than HA
  • 6 mos: both still better
    • PRP signif better than HA
knee osteoarthritis prp db pc rct patel et al 2013
Knee Osteoarthritis PRP: DB, PC-RCTPatel et al 2013
  • DB-RCT
  • 78 pts w bialt OA (156 knees)
    • 26 PRP x1
    • 25 PRP at wks 0 and 3
    • 23 saline
  • WOMAC and VAS pain at 3 wks, 3 and 6 mos
  • PRP was leuk-free, 3x plt
  • 3 wks: both PRP grpssltly better
  • 3 mos: both PRP grps markedly better, saline worse
  • 6 mos: both PRP grps still markedly better (slt regression), saline worse
hip osteoarthritis prp series
Hip osteoarthritis PRP series
  • Sanchez et al 2012 series
    • 40 pts with unilateral severe hip OA
    • Three PRP inj weekly
    • 57% had at least 30% reduction in pain, most by 7 weeks
    • Negligible side-effects

CASE: 35 yo runner training for a marathon c/o chronic anterolateral knee pain, worse w/ running or prolonged sitting, no h/o trauma. Exam: TTP lateral patellar facet, + patellar grind and patellar shrug, neg apprehension. Hams/quads are tight. Diagnosis?

  • Plica syndrome
  • ITB syndrome
  • MCL sprain
  • Patellofemoral syndrome
pfs treatments
Reduce painful activities

Non-painful aerobics

Patellar retinaculum stretching

Hamstring stretching

Quad strengthening (VMO)

Eval for hyperpronation

Hip abductor strengthening

(Physical therapy)

Consider knee sleeve

PFS Treatments
nerve entrapments in runners
Nerve Entrapments in Runners
  • Peroneal nerve
    • Superficial
    • Deep
  • Saphenous nerve
  • Sural nerve
  • Tibial nerve
  • First branch of Lateral Plantar Nerve
  • Medial plantar nerve
  • Interdigital nerve (Morton’s neuroma)
symptoms of nerve entrapment
Symptoms of Nerve Entrapment
  • Neuropathic pain
    • Deep, aching
    • Sometimes burning
    • Often poorly localized
    • Usually DISTAL to site of entrapment
      • May affect only a portion of the distal nerve
      • May radiate proximally (Villeix phenomenon)
  • Often w/ tingling or cramping
  • Numbness occasionally
  • Symptoms worst during or after running
treatment principles the r s
Treatment Principles: “the R’s”
  • Relative Rest
  • Rehab exercise
  • Relieve pressure/irritation
  • Restore biomechanical abnormalities
  • Referral to specialists if unsure of dx or condition refractory to tx
common peroneal nerve entrapment
Common Peroneal Nerve Entrapment
  • Usually at fibular head
  • Etiologies
    • Compression: Leg crossing, casts, orthoses
    • Contusions
    • Fibular head dislocation
    • Tumors
    • Tib-fit joint ganglion
    • Baker’s cyst
    • Genuvarum, recurvatum
    • Compartment syndrome
common peroneal nerve entrapment1
EXAM & TEST FINDINGSCommon Peroneal Nerve Entrapment
  • ?laxity of tib-fib joint
  • ?Knee laxity
    • Lateral
    • Posterolateralrotatory
  • ?Tumors
  • + Tinel’s after running
  • + Weakness of ankle eversion, dorsiflexion
  • X-rays, MRI, EDT useful
  • if refractory


Neuropathic pain in anterolateral leg, extending into dorsal foot and toe web spaces


steppage gait

foot slap

Recurrent ankle sprains

superficial peroneal nerve entrapment
Superficial Peroneal Nerve Entrapment
  • Most commonly entrapped at crural fascia penetration site
  • Etiologies
    • Muscular herniation
    • Contusion
    • Fibular fracture
    • Edema
    • Varicose veins
    • Tight boots
    • Tumors, ganglia
superficial peroneal nerve entrapment1
EXAM & TEST FINDINGSSuperficial Peroneal Nerve Entrapment
  • Fascial defect in 60%
  • ? Muscular herniation
    • 10-13 cm above LM
  • Provocative maneuvers
    • pain over exit site during resisted ankle DF/Eversion
    • Pain over exit site during passive ankle PF/Inversion
  • ? Hypoesthesia
  • X-rays, EDT usually normal
  • MRI useful for mass lesions


Diffuse ache over sinus tarsi, dorsal foot

Numbness/tingling in 1/3

? Proximal radiation

deep peroneal nerve entrapment
Deep Peroneal Nerve Entrapment
  • Arises from CPN at fibular head
  • Traverses inside anterior compartment
    • Innervates TA, EHL, EDL
  • Passes deep to Superior and Inferior Extensor Retinacula
    • Common sites of compression
  • Follows DP artery
  • Innervates EDB muscle
  • Sensation to 1stwebspacde
deep peroneal nerve entrapment1
EXAM & TEST FINDINGSDeep Peroneal Nerve Entrapment
  • + Tinel’s
  • Provoked w/ ankle DF or PF
  • EDB weakness or atrophy subtle
  • X-rays to reveal osteophytesor accessory ossicles
    • Os intermetatarseum
  • EDT may help localize
  • MRI sometimes useful


Deep aching dorsal midfoot pain

Worse w/ pressure from shoes


Shoe pressure


Osteophyte compression




tibial nerve entrapment tarsal tunnel syndrome
Tibial Nerve Entrapment“Tarsal Tunnel Syndrome”
  • 90%: TN divides within flexor retinaculum
    • Medial Plantar Nerve
    • Lateral Plantar Nerve
    • Medial Calcaneal Nerve
  • Can involve TN, MPN, LPN, MCN; variable presentations
  • Etiologies
    • Mass lesions (ganglia, tumors, venous stasis, tenosynovitis, os trigonum)
    • Trauma
    • Biomechanical compressions
      • hyperpronation
    • Systemic disease
    • Idiopathic
tibial nerve entrapment
EXAM & TEST FINDINGSTibial Nerve Entrapment
  • Inspection for foot deformities
  • Palpate TT for masses
  • + Tinel’s
  • Provocation w/ passive foot eversion, great toe DF
  • ? Weak toe flexion
  • X-rays to r/o ossicles
  • MRI for mass lesions
    • 88% of cases have lesions
    • Use in refractory cases
  • ? Labs to r/o DM, thyroid dz, rheum dz, anemia
  • EDT usually abnormal


Neuropathic pain, tingling medial ankle, medial foot, and/or plantar foot

1/3 w/ Villeix phenomenon

Hyperpronation: running on banked surfaces exacerbates

tibial nerve entrapment1
Tibial Nerve Entrapment


Activity modification

Pronation control

Intrinsic foot & medial arch, and ankle stability strength exercise

Achilles stretching

NSAIDs, neuromod meds


Surgical decompression

tibial nerve entrapment2
Tibial Nerve Entrapment


Activity modification

Pronation control

Intrinsic foot & medial arch, and ankle stability strength exercise

Achilles stretching

NSAIDs, neuromod meds


Surgical decompression

interdigital neuroma
  • TTP involved inter-MT space
  • + Forefoot squeeze test
    • Distal radiating pain
    • ? Mulder’s click
  • Biomechanical eval
  • X-rays to r/o osseous dz
  • MRI, EDT only to aid in DDx
  • Tx: steroid inj., surgery

Neuropathic pain between 3/4th toes

Worse running, standing, walking/ toe DF, squatting

medial plantar nerve entrapment jogger s foot
Medial Plantar Nerve Entrapment“Jogger’s Foot”
  • Sensory medial sole & plantar toes 1-3 ½
  • Motor: abductor hallucis, flexor hallucisbrevis, FDB, 1stlumbrical
  • Etiologies:
    • Footwear compression in the arch
    • Valgus running
    • Hyperpronation
medial plantar nerve entrapment
Medial Plantar Nerve Entrapment


  • Pronation control
  • Medial arch strength
  • Reduce valgus running
  • Modify footwear/orthotics to reduce compression
  • Injection
  • Surgical release

Neuropathic pain in medial arch and plantar aspect of 1-3rd toes

Medial sole paresthesias

TTP at navicular tuberosity,

+ Tinel’s

Provocation w/ forced heel eversion

Gait analysis: ? Valgus running