Francis G. O’Connor, M.D., FACSM Professor of Military and Emergency Medicine Associate Director, Sports Medicine Fellowship Medical Director, Consortium for Health and Military Performance (CHAMP) Uniformed Services University Of the Health Sciences Diagnosing and Managing Overuse Injuries: A Paradigm for 2012
Case Presentation • John is a 45 y/o runner who presents with pain over his Achilles tendon, that is now interfering with his running. • He describes no recent changes in training. • With the assistance of your US machine, you diagnose mid portion Achilles tendinopathy.
Case PresentationQuestions for 2011 • Can a functional assessment assist you in planning treatment; • Are there treatments that promote healing, or should the focus be control of inflammation and pain control? O'Connor FG, Nirschl RP, Sobel JA: Five-Step Treatment for Overuse Injuries. The Physician and Sports Medicine 1992; 20(10):128-142.
Review the terminology of overuse injuries. Review the epidemiology and etiology of running injuries. Introduce a paradigm for diagnosing and managing overuse injuries in runners: Functional assessments; Promoting healing. Objectives
Athletic Injury Macrotrauma: a specific episode of trauma with acute tissue disruption. Microtrauma: anatomic structure exposed to repetitive, subthreshold, cumulative force where the body’s reparative process is exceeded.
Microtraumatic Injury Sub-clinical injury precedes the moment of perceived injury by the patient. The normal reparative process is aborted for a degenerative cascade. Soft tissue degeneration is noteworthy for a paucity of inflammatory cell lines. “Despite recent advances, the pathophysiologic trigger and process resulting in clinically significant tendinosis are poorly understood.” Kaeding CC, Best TM: Tendinosis: pathophysiology and nonoperative treatment. Sports Health 2009; 1(4): 284-292.
Tendon Nomenclature Tendinitis: symptomatic degeneration with vascular disruption and inflammatory repair. Tenosynovitis: an inflammation of only the paratenon. Tendinosis: intratendinous noninflammatory degeneration from repetitive microtrauama. Just call it a “tendinopathy.” Kaeding CC, Best TM: Tendinosis: pathophysiology and nonoperative treatment. Sports Health 2009; 1(4): 284-292.
What Causes the Pain in Overuse Injuries? Currently unknown Microdialysis, Ultrasound, & Doppler Microdialysis 4 dz Achilles; 4 normal: No difference in prostaglandin E2 Significant increase in glutamate & substance P Vasculo-neural growth appears to be related to the origin of the pain in tendinopathy. Similar results in lateral epicondylitis/patellar tendon Dr. Hakan Alfredson Knee Surg Sports Traumatol Arthrosc. 1999;7(6):378-81 & Br J Sports Med. 2004 Feb;38(1)
Eccentric Exercise Isometric Muscle Force Eccentric Contraction 100% Concentric Contraction Conclusion: heavy loaded, rapid speed eccentric exercise can be a problem! 0 Maximum Muscle Velocity
Summary Overuse injury frequently begins well before the injury becomes painful. Eccentric exercise is a principal culprit that can lead to overuse injury. Degenerative tendinopathy is the most common overuse tendon injury encountered by clinicians. The triggers for tendinopathy remain poorly understood in 2011.
Epidemiology • According to the WHO, musculoskeletal injuries are the most common cause of severe long term pain and physical disability. • Soft tissue injuries represent 45% of all musculoskeletal injuries in the USA. • Up to 70% of runners will sustain an overuse injury during any one year period. Hreljac A: Impact and Overuse Injuries in Runners. Medicine and Science in Sports and Exercise 2004; 36(5): 845-849.
Epidemiology Musculoskeletal (MSK) Injuries in the Military • Injuries from physical training are largest cause of morbidity & mortality in peacetime military • MSK Injuries cause significant morbidity during deployment • Low back pain is #1 complaint noted among soldiers returning from Iraq/Afghanistan Cohen SP et al: Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring freedom: a prospective cohort study. The Lancet 2010; 375:301-309.
Epidemiology • Yearly incidence rates for injuries approach 90% in runners training for marathons. • More experienced runners appear to be less prone to injury. • A threshold for increased risk for injury appears to be 40 miles/week • Patellofemoral pain appears to be the most common injury followed by illiotibial band, tibial stress syndrome, plantar fasciitis and Achilles tendinopathy. Frederickson M et al: Epidemiology and etiology of marathon running injuries 2007; 37(4-5):437-9.
Epidemiology • Herring estimates that over 50 % of sports injuries encountered by primary care physicians are secondary to overuse. • Clinics in Sports Medicine 6: 1987. • Bruckner reports encountering overuse 2x as often as acute injuries. • Clinical Journal of Sports Medicine 1: 1997. • Butcher et al report subacromial impingement and patellofemoral pain as most commonly encountered overuse injuries. • Journal of Family Practice. 6: 1996.
Extrinsic Abnormalities Training errors Equipment Technique Environment Etiology • Intrinsic Abnormalities • Malalignment • Flexibility deficits • Muscle imbalance • Instability • Personality Most of the time… too much, too soon, too fast!
Etiology • Multiple variables have been studied, to include anthropometric measurements, static alignment, dynamic kinematic variables, and training variables. • Study methodology, injury definition, and populations have varied greatly making assessments challenging. • Most studies consistently implicate training volume and prior injury as consistent risk factors. Wen DY: Risk factors for overuse injuries in runners. Current Sports Medicine Reports 2007; Oct 6(5):307-13.
Pathoanatomical Diagnosis O'Connor FG, Nirschl RP, Sobel JA: Five-Step Treatment for Overuse Injuries. The Physician and Sports Medicine 1992; 20(10):128-142.
Pathoanatomical Diagnosis “You find what you look for, and diagnose what you know!” Jack Hughston MD Founder, Hughston Clinic
Evaluation • History • Medications and Supplements • Biomechanical Assessment • Site-specific Examination • Dynamic Examination • Shoe Examination • Selected Ancillary Testing
Pathoanatomical Diagnosis History and Physical Examination “The Principle of Transition” “Too much, too soon, too fast!” Concept of “Victims and Culprits” Presenting injury is the victim, while the primary dysfunction is the culprit!
Range of Motion • Assessment of the entire lower extremity kinetic chain: • Spine • Hip flexors • Quadriceps • Illiotibial band • Patellofemoral joint • Gastrocsoleus
Functional Movement Screening • Series of movements designed to screen for: • Flexibility • Body movement asymmetry • Core muscle weakness • Screening can potentially predict injury: • If we can predict it, we can prevent it • Find the weak link and fix it!
What is FMS? • 7 fundamental movement patterns • Graded by trained examiner • Each movement graded 0 to 3 • Able to target problem movements • Creates individual functional baseline • Simple, quick, reproducible • Proprietary: http://www.functionalmovement.com
Deep Squat Hurdle Step In-Line Lunge Shoulder Mobility Straight Leg Raise Push-Up Rotational Stability 7 Movements
NFL Kiessel et al: Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scand J Med Sci Sports. 2009 Dec 18. US Army Special Operations Goss DL et al: Functional training program bridges rehabilitation and return to duty. Spec Oper Med. 2009 Spring;9(2):29-48. Who has Successfully Implemented FMS?
The Quantico FMS Project O’Connor FG et al: Functional Movement Screening: Predicting Injuries in Officer Candidates. Medicine and Science in Sports and Exercise 2011 May 20.
FMS Score Distributions Total FMS score vs. number of candidates with each score. 10.1% of the 934 participants had a score of ≤ 14.
FMS Score Association with Injury Rate Marines in both the Long and Short Cycles with FMS scores <14 had nearly twice the risk of injury.
Step-Down Test • Simple, defined, objective test with acceptable reliability to assess dynamic hip stability and related neuromuscular dysfunction. • Standardized Protocol: • Patient asked to stand in single leg support with hands on waist, knee straight and foot positioned close to edge of 20 cm step; • The contralateral leg is over the floor with leg extended; • Subject then bends the tested knee as contralateral foot gently touches floor and reextends to straight position; • Maneuver is repeated five times.
Lateral Step Down Test • Scoring: • Arm strategy: subject uses arms to recover balance, 1 point • Trunk movement: to either side, add 1 point • Pelvis plane: rotated or elevated, add one point • Knee deviation: tibial tubercle beyond 2nd toe add one point, beyond medial border of foot add two points • Maintain steady unilateral balance, add one point • Grading: • 0-1: good quality movement • 2-3: medium quality; • 4 or higher is poor quality. • Reliability: • Interobserver reliability testing: .39 to .67 Weir A et al: Core stability: inter- and intraobserver reliability of 6 clinical tests. Clinical Journal of Sports Medicine 2010 Jan;20(1):34-8.
Pathoanatomical Diagnosis Biomechanical evaluation Dynamic physical assessment Equipment assessment Professional assessment Selected diagnostic tests advanced testing only as indicated
Video Gait Analysis • Excellent tool to reproduce findings of exertional compartment syndrome, vascular or nerve entrapment. • Biomechanical tool for: • Gait asymmetries • Excessive pronation • Early heel-off • Gluteal weakness
Pathoanatomical Diagnosis Overuse Injury Staging Grade I: post activity soreness Grade II: activity pain; no affect on performance Grade III: activity pain; affect on performance Grade IV: ADL pain The most important aspect of diagnosis is current “function.” Puffer JC, Zachaewski JE: Management of Overuse Injuries. American Family Physician 1988.
Control of Inflammation PRICEMM Protection Rest Ice Compression Elevation Medications Modalities
Control of Inflammation - NSAIDs One of the most widely prescribed medications in the US, with over 100 million prescriptions per year Prostaglandin-related and nonprostaglandin effects Over 50 reported studies at role of NSAIDs in Sports Medicine, with only 11 being RCT quality: 8 with modest benefit vs. placebo 3 with no difference with placebo 0 quality trials evaluating overuse injuries Weiler JM: Medical Modifiers of Sports Injury: The Use of NSAIDs in Sports Soft-Tissue Injury.Clinics in Sports Medicine 1992.
Medication: remains to be determined if NSAIDS and corticosteroids change the natural history of overuse injuries. Modalities: undetermined role in management of overuse injuries. NSAIDs in Sports Medicine Almekinders LC: Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Medicine and Science in Sports and Exercise, 1998.
Anti-inflammatory Therapy in Sports Injury. The Role of Nonsteroidal Drugs and Corticosteroid InjectionLeadbetter WB: Clinics in Sports Medicine 1995 Apr;14(2):353-410. To quote the great Oriole baseball pitcher, Jim Palmer: “Cortisone is a Miracle Drug… …for a week”
What do we mean by the term “Inflammation”? A contemporary Basic Science Update for Sports Medicine Scott A, Khan KM, Cook JL, Durino v: British Journal of Sports Medicine 2004;38:372-380. “As surprising as it may seem, there has not been an abundance of high quality, adequately powered randomized studies to provide the clinician with strong evidence about the role of (NSAIDs and corticosteroids) in common conditions.”
Corticosteroid Injections • Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. • 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. • We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. Coombes BK et al: Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials Lancet.2010 Nov 20;376(9754):1751-67.
Promotion of Healing Therapeutic exercise Normal ROM, strength, and propioception Central aerobics neurologic stimulus increasing regional perfusion Surgical intervention failed quality rehabilitation
Promotion of Healing Eccentric Exercise: as many overuse injuries are postulated to have their etiology in eccentric overload, thought to be core to the rehabilitative effort. Curwin SL, Stanish WD: Tendinitis: Its etiology and treatment. Toronto, Collamore Press, 1984.
Chronic Achilles Tendinosis: Recommendations for Treatment and Prevention. Alfredson H, Lorentzen R. Sports Medicine 2000. Prospective uncontrolled study of 15 patients with chronic Achilles tendonitis. 12 week program of graduated heavy loaded eccentric exercise. Two year follow-up only 1 of the 15 required surgery.