Overuse Injuries. Overuse injury defined. Overuse Injuries

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1 Overuse Injuries Lisa DeStefano, DO Associate Professor and Chair Department of Osteopathic Manipulative Medicine College of Osteopathic Medicine Michigan State University Overuse injury defined Overuse injuries, otherwise known as cumulative trauma disorders, are described as tissue damage that results from repetitive demand over the course of time. The term refers to a vast array of diagnoses, including occupational, recreational, and habitual activities. Overuse Injuries Involving the muscles include compartment syndromes and muscle soreness Involving the tendons result from a variety of degenerative and inflammatory processes. Overstress of bone results in stress fractures, apophysitis and periostitis. Bursitis and excessive joint stress

2 Overuse Injury Most frequently result from overload or repetitive microtrauma stemming from: extrinsic factors such as training errors poor performance poor techniques inappropriate surfaces intrinsic factors including malalignment and muscle imbalance A significant problem in studying overuse injuries is that there are multiple interactions among the risk factors making it difficult to determine the etiology of the injury. General Treatment Guidelines Rest, often a modification or scaled down exposure to the athlete's usual performance rather than complete abstinence In acutely symptomatic cases pain medications and various measures to control inflammation may be necessary

3 General Treatment Guidelines An exercise program should start early with range of motion exercises and isometric muscle contractions; when pain allows, dynamic muscle and flexibility exercises can resume together with a conditioning program; if possible, eccentric exercises should be performed. The treatment may also include other conservative treatment modalities and surgery in special cases. General Treatment Guidelines An appropriate diagnosis followed by adequate treatment can improve or eliminate most of these conditions. Perhaps even more importantly a proper understanding of overuse syndromes should allow physicians to assist athletes, trainers, and coaches in preventing them. Upper Quarter Overuse Injuries Excessive joint loadings (forces and torques) are known to be a crucial risk factor causing repetitive microtrauma that are responsible for overuse and upper limb joint injuries Shoulder Dyskinesis Alteration of normal scapular physiology, mechanics, and motion Found in association with most shoulder injuries

4 Lower Limb Overuse Injuries Excessive joint loading (forces and torques) are known to be a crucial risk factor causing repetitive microtrauma that are responsible for overuse and lower limb joint injuries Pelvic Dyskinesis Alteration of normal pelvic muscle stability, physiology, mechanics, and motion Found in association with most pelvic, knee and hip injuries

5 Optimal pelvic stability is a key component of all lower and upper extremity function. Subsystems Active Passive Neural

6 Treatment Optimize joint function Stretch the tight postural muscles Slowly return to dynamic function Strengthen after return to dynamic function if necessary Optimize Joint Function - OMT Upper Limb T12 lower trapezius T4-6 rhomboid, serratus anterior T1-2 upper rib cage, SC, AC Lower Limb, Pelvis T10-T12 core, quadratus lumborum L1-L5 frontal plane motion, core Sacrum Gluteus muscles Pubic symphysis lower abdominals

7 Thank you! Optimal scapular and pelvic/hip function is a key component to treatment. It is critical to proper alignment and function of the glenohumeral and acromioclavicular (AC) joints. Physiologically it is important in scapulohumeral rhythm the coupled and coordinated movement between the scapula, the thorax and the arm that allows: placement of the arm in the optimum position achievement of the proper motion to accomplish tasks Biomechanically the scapula provides a stable base for muscle activation and a moving platform to maintain ball-and socket kinematics It also serves as an efficient link between the core, which develops force, and the arm, which delivers the force. Scapular Function

8 Scapular Function Other Intrinsic Muscles The rhomboids assist the trapezius in stabilizing the scapula particularly in regard to controlling medial and lateral translation The pectoralis minor assists the serratus anterior muscle in anterior tilt, internal rotation, and protraction when the arm is in lower levels of elevation (<60 of abduction) Other Extrinsic Muscles Chiefly the latissimus dorsi and pectoralis major, affect scapular motion in their role as prime movers of the arm. Humeral motion also can create scapular motion by placing tension on the glenohumeral capsule and muscles, especially in the presence of glenohumeral internal rotation deficit.

9 Shoulder Dyskinesis The alteration of motion reduces the efficiency of shoulder function in several ways: Changes in 3D glenohumeral angulation AC joint strain Decrease in subacromial space dimensions Overuse of intrinsic and extrinsic muscles Increase in anterior glenohumeral capsular strain with arm motion Causative Factors Thoracic kyphosis Clavicular non-union or mal-union High-grade AC instability AC arthrosis and instability Glenohumeral joint internal derangement Cervical radiculopathy Long thoracic or spinal accessory nerve palsy The most common causative mechanisms of scapular dyskinesis involve alterations in the soft tissues Weakness/Inhibition - Posterior Lower trapezius Serratus anterior Tightness/Facilitation Anterior Pectoralis minor Subscapularis Latissimus Dorsi

10 Loss of the Force Couple Serratus anterior activation and strength are reduced resulting loss of posterior tilt and upward rotation of the scapula Delayed onset of activation in the lower trapezius muscle alters upward rotation and posterior tilt of the scapula Windup of the scapula on the thorax Tightness and facilitation of the pectoralis minor and short head of the biceps muscles create anterior tilt and protraction as a result of their pull on the coracoid. glenohumeral internal rotation deficit with arm internal rotation or horizontal abduction Implications Decreased subacromial space and increased impingement symptoms Decreased demonstrated rotator cuff strength Increased strain on the anterior glenohumeral ligaments Increased risk of internal impingement increased strain on the intrinsic and extrinsic scapular muscles

11 Evaluation static and dynamic Scapular malposition Inferior medial border prominence Coracoid pain and malposition dyskinesis of scapular movement early scapular elevation or shrugging on arm elevation and/or rapid downward rotation on lowering of the arm Evaluation With a 3- to 5-lb weight in each hand, the patient raises the arms in forward flexion to maximum elevation and then lowers them to the starting position. This exercise is done three to five times. Lower Limb Overuse Injuries Excessive joint loading (forces and torques) are known to be a crucial risk factor causing repetitive microtrauma that are responsible for overuse and lower limb joint injuries Pelvic Dyskinesis Alteration of normal pelvic muscle stability, physiology, mechanics, and motion Found in association with most knee and hip injuries

12 Optimal pelvic stability is a key component of all lower and upper extremity function. Subsystems Active Passive Neural Form Closure Refers to a stable situation with closely fitted joint surfaces, in which no extra force is needed to maintain the state of the system. Passive subsystem The structural (osseous, cartilaginous, and ligamentous) contribution to stabilization.

13 Force Closure Both lateral forces and friction are needed to withstand vertical load. The active subsystem Dynamic stabilization of the SIJ offered by the musculofascial system. Latissimus dorsi, gluteus maximus, multifidus, biceps femoris, and abdominal obliques

14 When walking, as the right leg swings forward the right ilium rotates backward in relation to the sacrum. Simultaneously, the sacrotuberous and interosseous ligamentous tension increases to brace the sacroiliac joint (SIJ) in preparation for heel strike. Just before heel strike, the ipsilateral hamstrings are activated, thereby tightening the sacrotuberous ligament (into which they merge) to further stabilize the SI joint. Vleeming et al Movement, Stability and low back pain. 1st Edition Churchill Livingstone, Edinburgh. Posterior oblique system: When latissimus and contralateral gluteus maximus contract there is a force closure of the posterior aspect of the SIJ Movement, Stability and low back pain. 1 st Edition Churchill Livingstone, Edinburgh Cross-section of the SIJ on the level of S1 Force application indicated, mainly by the transverse and internal oblique muscles (Fo) Producing tension dorsally both to the SIJ ligaments and the composite of the thoracolumbar fascia; (Fi) A larger reaction force ensues (Fj) into the articular portion of the SIJ.

15 Pelvic Function Optimized pelvic function allows for efficient pronation and supination. The stable hip is able to contribute to the success of the knee, foot, low back, thoracic spine, shoulder and neck. Motion of a joint turns on the mechanoreceptors, the proprioceptors turn on the muscle. Pelvic Function Dyskinesis Muscle inhibition or latency Gluteus maximus sagittal plane Gluteus medius frontal plane Lower abdominal function transverse plane Causative Factors Arthrogenic inhibition Joint dysfunction Inflammation Abdominal surgeries

16 Optimal pelvic stability is a key component of all lower and upper extremity function. Loss of Forced Couple Subsystems Active Passive Neural Implications Excessive rear foot motion shin splints Achilles tendonitis Plantar fasciitis Recurrent hamstring strains Implications Patellofemoral syndrome Iliotibial band syndrome

17 Evaluation Optimal pelvic stability is a key component of all lower and upper extremity function. Subsystems Active Passive Neural Treatment Optimize joint function Stretch the tight postural muscles Slowly return to dynamic function Strengthen after return to dynamic function if necessary

18 Optimize Joint Function - OMT Upper Limb T12 lower trapezius T4-6 rhomboid, serratus anterior T1-2 upper rib cage, SC, AC Lower Limb, Pelvis T10-T12 core, quadratus lumborum L1-L5 frontal plane motion, core Sacrum Gluteus muscles Pubic symphysis lower abdominals