Overuse Injuries How to Solve the Challenging Puzzle Anthony Luke - PDF document

7/23/2015 Overuse Injuries How to Solve the Challenging Puzzle Anthony Luke MD, MPH Essentials of Primary Care 2015 Disclosures • Founder, RunSafe™ • Founder & CEO, SportZPeak Inc. • Sanofi, Investigator initiated grant 1

7/23/2015 Acute injuries Approach to Overuse Injuries 1. Mechanism of Injury / Pain 2. Location 3. Type of tissue 4. Identify risk factors 5. Education/Modifications to reduce overuse activity 2

7/23/2015 Overuse Injuries • Occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place. DiFiori et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine, accepted for publication, 2014. Key Features • Repetitive loading (rather than traumatic) • Overwhelm the ability of the tissue to remodel, resulting in a weakened, damaged structure • Imbalance between training loads and recovery is a key factor • Mechanism  Preventable? 3

7/23/2015 1. Mechanism Why did I get an injury? • Too much • Too hard • Too fast …for your body !! It’s all about Physics… Newton’s Law #1 • Wind & Road resistance • An object in motion, stays in motion • Hills • Metabolic (Fatigue, Dehydration) …Unless an external force stops it STRESS !!! 4

7/23/2015 Adaptation to stress Newton’s Law #2 • Force = mass x acceleration • Force results in stress Shock Absorption Newton’s Law #3 • Every force has an equal and opposite force • “Striking” mass • “Shock” absorption 5

7/23/2015 2. Location • Point with One Finger Windlass Mechanism Midstance Toe - off 6

7/23/2015 Achilles Tendinopathy Presentation Mechanism • Tender over • Repetitive achilles +/- swelling eccentric load on • Pain with resisted tendon toe off • Pushing off, • Pain with passive running, sprinting, ankle dorsiflexion jumping Risk Factors Khan KM, et al. Phys Sportsmed 2000. • Tight Achilles and plantar fascia • Hyperpronation • Cavus foot • Advancing age - decreased blood flow • Overweight • Poor footwear • Weak hip abductors and medial quadriceps 7

7/23/2015 Plantar Fascitis • Tender on insertion on medial aspect of heel • Associated with: – Age – Pes planus and pes cavus – Obesity (OR =5.6 (95% C.I., 1.9-16.6) – Poor shoes, working on feet (OR = 3.6 (95% C.I., 1.3-10.1) – ≤ 0 degrees of dorsiflexion had OR = 23.3 (95% C.I. , 4.3 to 124.4) Riddle et al. JBJS-A, 2003 – Limb leg discrepancy (longer leg associated with plantar fasciitis) Mahmood et al, J Am Podiatr Med Assoc, 2010 Tendinosis • Hyaline degeneration • Mucoid degeneration • Fibrillation of collagen • Absence of inflammatory cells 8

7/23/2015 Mechanics • Usually tendons surrounding joints with high degree of motion • Usually tendons that cross two joints • Eccentric overload • Mechanical impingement • Temperature breakdown • Angiogenesis? Conservative Treatment REDUCE STRESS Gastrocnemius stretch • Modified activities, ice • Calf / Achilles stretching • Hold each stretch for 30 seconds Soleus stretch 9

7/23/2015 Treatment • Heel lifts • Modify footwear • Custom orthotics • Night splints • PT is a major key Rarely • Surgical debridement Physical Therapy for Achilles Alfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, 1998; 26:3: 360-366. • RCT – eccentric exercises (3 x 15 reps, 2 times/day, 7 days a week x 12 wks) • Results: Significant difference in pain levels VAS 81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in 12 weeks • 81% eccentric satisfied vs 38% concentric satisfied 10

7/23/2015 Eccentric Drop program Terminology • Tendinopathy – “ tendon injury that originates from intrinsic and extrinsic etiological factors ” • Usually not tendinitis 11

7/23/2015 Classification of Tendon Disorders (Modified from Khan et al. 1999, Clancy 1990) Pathologic Dx Macroscopic Histopathologic Tendinosis Intratendinous Disorganized collagen, degeneration mucoid degen Tendinitis Degeneration with Fibroblasts, inflammatory repair hemorrhage, response granulation tissue Paratenonitis Inflammation of Mucoid degen. if paratenon only areolar tissue, fibrinous exudate Paratenonitis with As above As above tendinosis Where does the injury occur? Insertional • Occurs at insertions near the joint • Joint side Tears • At the musculo- tendinous junction • Areas of friction 12

7/23/2015 3 Basic P/E findings for tendinopathy 1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch Tendon Healing • requires around 100 days to synthesize collagen Mild – 2 to 4 weeks Moderate – 4 to 6 weeks Severe – 6 to 12 weeks or longer 13

7/23/2015 Physical therapy for tendons Stretching • Improves pain and ROM Strengthening – eccentric loading • Mechanical loading accelerates tenocyte metabolism Modalities • Ultrasound and laser increase collagen synthesis in fibroblasts in animals Anti-Inflammatory? • Little evidence to support use of NSAIDs in management • Good Analgesic • Steroid injection? • Needle tenotomy? 14

7/23/2015 How do you exam for lateral epicondylosis ? 3. Type of Tissue • Muscle ‐ tendon unit • Articular cartilage (physis) • Bone • Soft tissues (bursa, and/or neurovascular structures) 15

7/23/2015 What is Osteoarthritis? • OA is a disease characterized by Superficial Zone cartilage Transition Zone degeneration • Cartilage loss and Radial Zone OA symptoms are preceded by damage to the collagen- Tidemark Calcified cartilage proteoglycan (PG) Subchondral bone plate matrix Vascular plexus Cartilage Damage Outerbridge Classification, 1961 16

7/23/2015 Arthroscopy Arthroscopy 17

7/23/2015 Osteoarthritis Novel MRI Techniques • 3T MRI provides a higher signal-to-noise ratio and better spatial and spectral resolution • T1 ρ spin-lattice relaxation reflect (a) a healthy volunteer, male, 30; proteoglycan content T 1 ρ = 40.05  11.43 ms • T2 reflect collagen (b) a patient with early OA (post- traumatic OA), female, 27. matrix orientation T 1 ρ = 50.56  19.26 ms Li et al. Magn Reson Med, 2005. 18

7/23/2015 MR Relaxation Times (in ms) T2 T1 ρ Luke et al., Am J Sports Med, 2010 Findings • T1 ρ values stay elevated over 3 months, which suggests that this sequence demonstrates more than water shifts • 2/10 runners and 2/10 controls had abnormal patellar cartilage lesions • Changes in T1 ρ and T2 were greatest in medial compartment and the patellofemoral joints, especially at the trochlea Luke et al., Am J Sports Med, 2010 19

7/23/2015 Why do kids get injured ? • Kids do what adults do • Kids get tired faster • Limited strength • Flexibility issues • Excess stress / overuse leads to failure Apophysitis • Osgood Shlatter ’ s Disease • Sever ’ s Disease (heel) • Can also occur in the spine, iliac crest, the metatarsals 20

7/23/2015 Osgood-Schlatter ’ s Disease • Most improve in 1- 2 years with activity modification • Rarely operate prior to skeletal maturity • Goal is to eliminate pain, not for cosmesis Treatment for Apophysitis • Rest, modify activity • How long? 6 to 8 weeks • Immobilize if significant pain • Include low impact activity and conditioning • Focus on strength and flexibility while healing Examples: • Hip and quads strengthening program, core stability • Overhead and Throwing athlete rehab – Long ball toss, Medicine balls, Rotator cuff, Periscapular exercises 21

7/23/2015 Return to play Can the athlete return: • Safely? • Effectively? • Relatively painfree? Avoid the secondary or CHRONIC injury 4. Identify Risk Factors 22

7/23/2015 What are the risk factors? Gait Mechanics Training BONE LOADI NG Bone Health Impact Brukner P , Bennell K, Matheson G. Stress fractures, Blackwell Science, 1999. Medial Tibial Stress Syndrome Intrinsic Extrinsic •Women > Men (1.5-3.5 x •Increased activity, intensity, higher) or duration •Excessive foot pronation •Poor footwear •Pes cavus •Overtraining •Leg length discrepancies •Increased mileage (>20 miles/week) •Higher BMI •Decreased bone density, disordered eating •Muscular imbalances – Tight triceps surae – Weak hip and core muscles Galbraith et al, Curr Rev Musculoskelet Med, 2009 23

7/23/2015 Stress Fractures • Stress fracture group showed greater peak hip adduction and greater peak rearfoot eversion angles vs. control group Milner et al, JOSPT, 2010 Shoes or No shoes ? • Heel strike causes a force impact Saw-toothed force profile with High rate of loading 400-500 bw/sec • Forefoot striking reduces the peak impact force Lieberman et al, Nature, 2010 24

7/23/2015 How stress fractures occur? • Failure of bone to adapt to stress • Microinjury/ microcracks in the bone Bone remodeling • Causes relative weakness • Osteoclastic activity faster than osteoblasts • Excess stress 25