Medical Interventions Effectively Treat Overuse Injuries In Adult Endurance Athletes

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July 31, 2007 — A series of medical interventions may effectively treat overuse injuries in adult endurance athletes, according to a review published in the July 15 issue of American Family Physician.

"Participants in endurance sports span all ages, and although elite-level endurance athletes are typically in their 20s or 30s, the largest group of participants in many races are master level athletes in the 35- to 50-year age group," write David D. Cosca, MD, and Franco Navazio, MD, PhD, from the University of California Davis Sports Medicine Program in Sacramento. "These athletes have the time and inclination to pursue an intensive training regimen and consequently are at risk for overuse injuries or exercise-related medical conditions.... Most injuries in endurance athletes are the result of overuse."

To improve performance, endurance athletes typically alternate periods of intensive physical training with periods of rest and recovery. If training is overly intensive and recovery time inadequate, tissue repair mechanisms may become less efficient, resulting in overuse injuries.

Because overuse injury of tendons is usually degenerative rather than inflammatory, tendinopathy often resolves slowly and is seldom improved with use of anti-inflammatory agents.

Runners and other endurance athletes often develop overuse injuries such as patellofemoral pain syndrome, iliotibial band friction syndrome, medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, and/or lower extremity stress fractures. Relative rest and a program of rehabilitative exercise may be helpful for these injuries.

Additional measures that may benefit cyclists may include evaluation while they are on their bicycles, to maximize adjustment of seat height, cycling position, or pedal system.

Exercise-associated medical conditions seen in increased frequency in endurance athletes may include exercise-induced asthma, exercise-associated collapse, and overtraining syndrome. Suitable medical interventions may help treat or prevent these conditions. Athletes taking part in marathons and triathlons are particularly vulnerable to dilutional hyponatremia, which is caused by overhydration with hypotonic fluids. Education regarding appropriate fluid intake during athletic events may help prevent dilutional hyponatremia.

Physicians evaluating adult endurance athletes should perform a thorough medical history to improve their knowledge base regarding the physical demands of running, cycling, rowing, cross-country skiing, or whatever their patient's chosen sport may be.

Specific treatment recommendations are as follows:

  • For most overuse injuries, relative rest and modification of activities are recommended. Symptom duration and severity and patient response to treatment should help guide specific interventions (level of evidence, C).
  • In cyclists, unsuitable seat height or bicycle position, or improperly adjusted pedal systems, may cause patellofemoral knee pain and iliotibial band friction syndrome. Examining the cyclist on the bicycle can facilitate appropriate intervention, such as change in seat height, stem length, or pedal placement (level of evidence, C).
  • For the treatment of patellofemoral pain syndrome, exercise therapy may be helpful. Use of knee sleeves and taping should be individualized (level of evidence, B).
  • Achilles tendinopathy may respond to progressive eccentric exercises combined with relative rest and stretching (level of evidence, B).
  • For plantar fasciitis, limited evidence supports the use of prefabricated silicone inserts and stretching. Two clinical trials suggested that tension night splints may be helpful (level of evidence, B).
  • Physicians should advise long-distance runners to replace fluid losses at the rate of about 400 to 800 mL/hour, because overhydration with hypotonic fluid may cause exercise-associated collapse.

Overtraining syndrome can be considered a systemic overuse injury, which occurs when the training program overwhelms the athlete's ability to adapt to the physical strain and to recover from muscle strain and fatigue. Typical symptoms may include decreased performance, generalized fatigue, mood disturbance, sleep problems, "heavy legs," and increased susceptibility to illness and injury, which persist even after 2 weeks of rest.

Although increased basal heart rate was once thought to be a sign of overtraining syndrome, this has not been confirmed by recent prospective studies, nor are there any specific serologic markers to make the diagnosis. Other medical causes of fatigue should be ruled out. For athletes who have had baseline exercise testing, overtraining syndrome can be diagnosed from a sports-specific exercise test, continued until exhaustion, that shows a decrement in performance. Treatment of overtraining syndrome consists of several weeks' to months' rest, followed by a gradual resumption of training.

Specific treatment suggestions for common overuse injuries are as follows:

  • For patellofemoral pain syndrome, relative rest, activity modification, icing, nonsteroidal anti-inflammatory drugs (NSAIDs; for pain relief rather than to speed recovery), and a patellar tracking exercise program consisting of straight leg raises and short arc quad isometric exercises are recommended. Selected patients may benefit from use of a knee sleeve or patellar taping, usually started by the physical therapist. Cyclists should undergo specific evaluation as indicated above.
  • Iliotibial band friction syndrome may benefit from relative rest and activity modification, icing, NSAIDs, hip abductor strengthening, and iliotibial band stretching. Corticosteroid injection may rarely be indicated. Cyclists should undergo specific evaluation and intervention as indicated above.
  • Medial tibial stress syndrome (shin splints) should be treated with relative rest, icing, NSAIDs, and stretching. Athletes with significant pes cavus or hyperpronation may benefit from use of insoles or orthotics.
  • For Achilles tendinopathy, relative rest, icing, NSAIDs, stretching, and heel lifts are recommended, with eccentric strength training the cornerstone of treatment. Severe cases may require use of a short-term walking boot.
  • Plantar fasciitis may benefit from relative rest, ice massage, NSAIDs, prefabricated shoe inserts, stretching of the heel cord and plantar fascia, and tension night splints. Corticosteroid injection is occasionally needed.
  • Relative rest is indicated for stress fracture, with additional treatment individualized for specific fractures, such as stiff-soled shoe for metatarsal shaft fracture. More specialized care and consultation are needed for fractures of the femoral neck, anterior tibia, tarsals, and proximal fifth metatarsal.

The authors have disclosed no relevant financial relationships.

Am Fam Physician. 2007;76:237-244.

Clinical Context

According to the authors of the current review, although elite-level endurance athletes are typically in their 20s and 30s, the largest group of participants in many races are master-level athletes in the 35- to 50-year age group and they are subject to risk for overuse injuries and exercise-related medical conditions. Most running injuries, for example, are related to overuse associated with a training error such as overrapid escalation in weekly mileage with known predictors of lower extremity injury including history of prior injury and running more than 20 miles per week. Anatomic factors such as leg length discrepancy and patellar malalignment should also be sought on physical examination, according to the authors. For cyclists, training habits as well as positioning on the bicycle are both factors to consider in the evaluation of overuse injuries. Tendinopathies believed to be secondary to acute inflammation may be caused by degenerative disease and may be slow to recover and unresponsive to NSAIDs or injected corticosteroids.

This is a review of the most common injuries encountered in endurance athletes and the diagnostic, testing, and management strategies recommended for optimal recovery.

Study Highlights

  • Common types of injuries
    • Patellofemoral pain syndrome, or "runner's knee," is treated with training modification, icing, NSAIDs, and taping or use of orthotic devices with readjustment of bicycle position or height for some cyclists.
    • Iliotibial band syndrome may benefit from relative rest, and activity modification, icing, NSAIDs, hip abductor strengthening, and iliotibial band stretching. Corticosteroid injection may rarely be indicated. Cyclists should undergo specific evaluation and intervention as indicated.
    • Medial tibial stress syndrome (shin splints) should be treated with relative rest, icing, NSAIDs, and stretching. Athletes with significant pes cavus or hyperpronation may benefit from use of insoles or orthotics.
    • Treatment includes activity modification, stretching, icing, NSAIDs, and attention to biomechanic factors corrected with orthotics or antagonistic muscle strengthening.
    • Achilles tendinopathy presents with insidious pain onset in the Achilles tendon and tenderness proximal to the insertion. Crepitus suggests tenosynovitis.
    • Treatment comprises rest, use of walking boot, heel lifts, gentle stretching, icing, NSAIDs, and eccentric calf strength training.
    • Plantar fasciitis is secondary to traction and overuse, and pes planus and pes cavus are predisposing factors.
    • Radiography is not usually indicated; ultrasonography and magnetic resonance imaging (MRI) may be helpful if ruptured tendon is suspected.
    • Treatment of plantar fasciitis consists of rest, icing, stretching, NSAIDs, prefabricated shoe inserts, and avoidance of flat shoes or bare feet. Surgery for plantar fasciitis is only considered after failed conservative therapy and refractory symptoms of 6 to 12 months.
    • Stress fracture is caused by repeated microtrauma to bone and may occur at the femoral neck, tibia, fibula, calcaneus, talus, tarsal navicular, metatarsals, and sesamoids.
    • The key symptom is focal musculoskeletal pain, and progressive limp with pain on passive movement and local tenderness may accompany femoral neck stress fractures.
    • Radiography results are initially negative in 50% to 75% of stress fractures, and bone scan and MRI should be performed if a high-risk fracture is suspected.
    • Treatment comprises rest, NSAIDs, and short-term use of a walking boot or crutches.
  • Common medical conditions in endurance athletes
    • Exercise-induced asthma may have a higher prevalence in endurance athletes with running most and swimming least likely to provoke the condition.
    • Helpful interventions include adequate warmup, use of short vigorous bursts of exercise before the endurance activity, and use of inhaled ?-agonists.
    • Exercise-related collapse and hyponatremia are becoming more common.
    • The most common cause is transient hypotension caused by pooling of blood in the legs after cessation of exercise, with feet and leg elevation the appropriate treatment.
    • Collapse resulting from hyponatremia is more likely to be seen in women and slower, inexperienced runners, and overhydration is a primary cause, with current recommendations being to restrict hydration to 150 to 300 mL of fluid at 15 to 20 minutes not to exceed 1 L/hour.
    • No more than 400 to 800 mL of fluids per hour is recommended by other experts.
    • Overtraining syndrome is a systemic form of overuse and presents with fatigue, decreased performance, mood disturbance, and increased injury.
    • Rest for weeks to months followed by gradual resumption of activities is the recommended treatment.

Pearls for Practice

  • Overuse injuries associated with endurance sports include patellofemoral pain syndrome, iliotibial band syndrome, medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, and stress fracture.
  • Medical conditions common in endurance athletes are asthma, collapse resulting from hypotension or hyponatremia, and overtraining syndrome

Submitted by DMorgan on Mon, 08/20/2007 - 12:03pm.