Rest and analgesia are often insufficient in treating sports overuse injuries. A multidisciplinary approach, with a focus on activity modification, offers the greatest benefit in rehabilitating the injury and preventing it from recurring. Efficient diagnosis and treatment in the primary setting is important to this process.

A significant proportion of sports injuries are termed ‘overuse injuries’, occurring due to repetitive loading. The musculoskeletal system undergoes remodelling as a response to stresses imposed on it, but when there is a sudden increase in loading, and/or the body is given insufficient time to recover, overuse injuries occur. Overuse injuries are common in the young and old.

Many factors may place one at risk of overuse injuries, including a sudden increase in training time, change in terrain, as well as muscular tightness or weakness. In tendinopathy, graduated loading of the tendon plays an important role in rehabilitating the injury.

As such, rest is sometimes insufficient to treat these injuries. In addition, complete abstinence from exercise or sports is often detrimental and unnecessary.

Hence, the focus should be on activity modification.


COMMON OVERUSE INJURIES
Some common overuse injuries seen

1. Plantar Fasciitis

Plantar Fasciitis  - SingHealth Duke-NUS Sport & Exercise Medicine
The plantar fascia is a thick fibrous tissue that originates from the calcaneum and attaches to the forefoot. Acute plantar fasciitis may be a result of inflammation at the calcaneal insertion to the calcaneum, or in chronic cases due to degeneration. Heel spurs do not appear to be the cause of pain.

Plantar fasciitis may occur in those who stand or walk for prolonged periods, as well as those who do a lot of running or jumping in their sports. Other risk factors for plantar fasciitis include pes planus, pes cavus and tight calves.

Patients typically complain of pain that is worst with the first steps in the morning and/or after prolonged sitting, but some patients may also experience pain worst after prolonged walking.

Diagnosis
Most patients will experience tenderness on palpating the medial calcaneal tubercle, though some may have tenderness more laterally. Bedside ultrasound reveals a thickened plantar fascia insertion.

Treatment
Initial treatment involves analgesia, advice for proper footwear, plantar fascia massage as well as plantar fascia and calf stretches. Physiotherapy and podiatry referral may be required at times.

Some patients may require further treatment. Although corticosteroid injection to the plantar fascia is an option, the condition often recurs. For recalcitrant plantar fasciitis that does not respond to initial treatment, an alternative to corticosteroid injection is extracorporeal shockwave therapy (ESWT).

Extracorporeal shockwave therapy is available at the Changi General Hospital Sport & Exercise Medicine Department, and is a non-invasive bedside procedure carried out over two sessions, with a one to two weeks interval between sessions.

In the majority of patients, an improvement in the pain score is observed within two weeks of the procedure, though it may take up to three months to see maximal pain relief.

2. Tennis Elbow
(Lateral Epicondylopathy of Elbow)

Tennis Elbow  - SingHealth Duke-NUS Sport & Exercise Medicine
Tennis elbow refers to tendinopathy of the extensor carpi radialis brevis (ECRB) tendon at its attachment to the lateral epicondyle of the elbow. It is due to overuse of the wrist extensor tendons as a result of repetitive gripping of the hand, wrist extension or forearm pronation.

Diagnosis
On examination, there is tenderness on palpation of the lateral epicondyle. There may be pain on wrist flexion with the elbow extended and forearm pronated (Mill’s test), as well as on resisted wrist extension (Cozen’s test) and resisted middle finger extension (Maudsley’s test).

Treatment
Common treatment modalities include analgesia and using a tennis elbow strap over the proximal forearm. Wrist extensor stretching and strengthening also helps. As incorrect techniques in certain sports may cause tennis elbow, such as improper backhand technique in tennis or improper weightlifting techniques, physiotherapy may be warranted to work on technique optimisation.

Corticosteroid injection can be considered, butthose concerned about its risks, or who have had a recent corticosteroid injection to the lateral epicondyle, may consider ESWT as a highly effective adjunctive treatment modality.

3. Golfer’s Elbow
(Medial Epicondylopathy of Elbow)

Golfer's Elbow  - SingHealth Duke-NUS Sport & Exercise Medicine
Golfer’s elbow is similar to tennis elbow, and is due to tendinopathy of the wrist flexor tendons as a result of repetitive wrist flexion or forearm pronation.

Diagnosis
Tenderness of the medial epicondyle is elicited on palpation. Reverse Mill’s test (pain on wrist extension with elbow extended and forearm supinated) and/or reverse Cozen’s test (pain on resisted wrist flexion) may be positive.

Treatment
Common treatment modalities include analgesia, using a tennis elbow strap over the proximal forearm, wrist flexor stretching and strengthening, as well as physiotherapy and corticosteroid injections. ESWT is a frequently used treatment modality.

4. Runner’s Knee
(Patellofemoral Pain Syndrome)

Patellofemoral pain syndrome (PFPS) refers to anterior knee pain that occurs with activities that involve weighted knee flexion such as running, squatting, climbing stairs, and sometimes cycling. This is due to increased forces across the patellofemoral joint, and is often multifactorial.

Intrinsic risk factors include muscular imbalance (lack of flexibility, strength or control, or poor muscular activation), overpronation of the feet, and patella position while extrinsic risk factors include change in training surfaces, improper
footwear and increased training load.

Patients with PFPS can experience pain in the above mentioned activities, or on standing up after prolonged sitting (positive moviegoer’s sign).

Diagnosis
Physical examination of the knee may be normal, although there may be tenderness of the patellar facets and/or a positive Clarke's test and/or patellar grind test.

Treatment
In PFPS, rest and analgesia alone are often insufficient to treat the condition, as symptoms often recur on resumption of activity. Physiotherapy and podiatry referral may be warranted. A review by a sport and exercise medicine practitioner is useful for those who require specific activity modification so that they can continue with sports training or exercise.

5. Jumper’s Knee
(Patellar Tendinopathy)

Jumper's Knee  - SingHealth Duke-NUS Sport & Exercise Medicine
Symptoms
Individuals with jumper’s knee often present with anterior knee pain on jumping, deceleration activities, early to mid-phase of a squat, or in activities that involve a change in direction. The pain is due to patellar tendinopathy, which may involve inflammation or degeneration.

Tenderness is often at the patellar tendon’s proximal attachment at the inferior pole of the patella, but may also be at the tendon body or its distal attachment at the tibial tuberosity.

Treatment
Treatment modalities include analgesia and taping, as well as physiotherapy and podiatry referral. In cases that present with persistent pain, ESWT may be a useful treatment modality.

CONCLUSION

Overuse injuries are generally a result of multiple predisposing risk factors and not because of a single traumatic event. As such, rest and analgesia are often not sufficient to treat the condition.

A multidisciplinary approach, targeting the correction of these predisposing or risk factors, will be most useful in rehabilitating the injury and preventing it from recurring.

Adj Asst Prof Ivy Lim is a Sports Physician at Changi General Hospital, and the current Director for Singapore Sport & Exercise Medicine Centre @ CGH. Her clinical interests include sports- and exercise-related injuries, pre-participation screening, sports safety, exercise in women and the role of physical activity in chronic disease management.

GPs who would like more information about this topic, please contact Prof Ivy at 6936 5682.

GPs can call the SingHealth Duke-NUS Sport & Exercise Medicine Centre for appointments at the following hotlines:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000