Overuse Injuries, General Concepts

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By Robert P. Nirschl M.D., M.S.

Sports injuries are classified as either an overuse or an acute injury. Most sports injuries are a result of overuse and they occur when the body has been pushed too hard, too fast or too long. Pain and swelling are the first indications of overuse injury, and, as is the case for acute injury, “PRICEM” is the rule of thumb for general treatment.

Protect the injury or it may easily become an acute injury. Don’t play through the pain. Stop the activity causing discomfort and rest. Put ice on the injured area as soon as possible, but be cautious about direct application that might cause “ice burn." Compression reduces the swelling. Use an elastic bandage around the injury. Spandex clothing, a neoprene sleeve, or an elastic stocking may serve the same purpose and might also offer some limited measure of support and protection. Elevate the injury above the level of your heart and continue to do so even during sleep. 

It is important to let an overuse injury completely heal before subjecting the injured area to additional stress or abuse. Playing hurt has the same effect as ripping a wound open repeatedly before it can heal. It not only won’t heal, but it may result in a very serious or even irreversible problem. It is also important to reduce the irritative chemical inflammation to aid in the healing process. Compression, ice and elevationare all associated with that component, but medication may be needed as well. Frequently, aspirin or ibuprofen (Motrin, Aleve, Advil, etc.) in therapeutic dosages are effective, but cortisone or some other prescription drug may be necessary. Aspirin at that dosage may cause an upset stomach so buffered aspirin is recommended. Aspirin is not recommended for children because of the risk of Reye’s syndrome. It can also retard blood clotting (helpful to prevent strokes and heart attacks) but should not be taken 10 days in advance of surgery. 

Ice is effective in reducing the pain and swelling in an injured area when inflammation is present. Subsequent treatment with heat will facilitate healing by increasing blood flow to the region for removal of excess liquid and toxins that are a by-product of the injury, as well as enhancing nutrition and oxygenation. It is even possible to create a pumping effect with alternate heat (30 minutes) and cold (5-10 minutes) applications. Massage can also be used to aid circulation to the injured area. But care should be taken not to irritate or abuse the injury, and extreme caution should be used with a mechanical massager.

The best way to prevent sports injuries is to follow a good warm-up and conditioning program. A regular exercise program with weights and resistance equipment will help structural development that can better withstand the physical stress that will be encountered during sports. Stretching before and after sports activity will better prepare those muscles and tendons for future use. Some of the more common soft tissue injuries that result from overuse are: 

Sprains: A sprain is an injury to a ligament, a firm band of tissue that supports the joints. Three types of sprains can occur: Grade 1- the ligament is stretched; Grade 2- some of the fibers are torn; Grade 3 – the ligament is totally torn. Sprains are usually the result of twisting trauma, and most commonly occur in the ankle and/or knee joint. 

Strains: A strain is an injury to a muscle-tendon unit. Like sprains, strains can be classified according to severity – stretched, a partial tear, or a complete tear. Strains may occur when muscles lack strength and flexibility. Deficient warm-up or exposure to extreme cold or unusually stressful activity are additional important factors. Strains in the hamstrings and groin adductors (rear and inner muscles of the upper leg) are common, but strains in muscles of the shoulder girdle are becoming recognized as an important contributing factor to shoulder tendinitis as well as primary injury. Strains are always accompanied by weakness. 

Tendinitis/Tendinosis: Tendinosis is a degeneration or injury of a tendon and is generally caused by repetitive trauma. Tendinosis is common in tennis and other sports and repetitive use occupations. Tendinosis, rather than tendinitis, is the correct term as we now know that inflammatory cells are not present in the injured tendons. The most commonly affected tendons are the Achilles tendon, tendons at the knee (runner’s knee), tendons of the posterior tibial muscles-tendon attachment (shin splints), and tendons of the elbow (tennis elbow) and shoulder (rotator cuff tendinosis). Treatment may include medication for pain control, physical therapy to heal, and control of overuse with counter-force bracing. As a last resort, surgery may be an option. Practicing proper sports techniques will also go a long way in preventing tendinosis. 

Bursitis: Bursitis is an overuse injury that results in the inflammation of bursa and is most common in areas near the elbow, shoulder, knee, heel and hip. Bursa are fluid-filled sacs found in regions where friction occurs. Their main function is to minimize friction between bones and tendons, tendons and ligaments or even bone and bone. The condition is frequently found in association with tendinosis. Players with injury to the knee bursa have excessive swelling due to accumulation of fluids in the bursa over and just below the knee cap. Other common bursitis areas include the shoulder, tip of the elbow, outer hip and under the Achilles tendon. The bursa sometimes must be drained or even removed before proper healing can take place. Cortisone is very effective in reducing the bursal inflammation, but other anti-inflammatory drugs maybe sufficient. 

Contusions: A contusion, or bruise, is an injury to soft tissue or bone in which the skin is not broken. A hard direct blow is the most common cause and a collection of blood (a hematoma) may form beneath the skin in the injured muscles, tendons or bone. Icing or some other form of cold application that will contract the blood capillaries will minimize the damage by preventing accumulation of blood and swelling.

Conclusions
It takes a long time for most players to admit to themselves that they are not indestructible, and they usually learn the hard way. Loss of flexibility and dehydration of tendons and ligaments with age make aggressive senior players more subject to injury but even the young are vulnerable. Much of this can be avoided by maintaining good strength and flexibility programs, practicing good pre- and post- work out preparation, becoming well informed about injury potential, and by simply using good judgment and control of abuse by using functional counter-force bracing. Following those principles, young people and should be able to continue active sports through their senior years. The enjoyment of that endeavor should result in maintained good health and physical conditioning that will enhance and extend your quality of life.

If you are dealing with an orthopaedic injury, please give us a call to schedule an appointment. Nirschl Orthopaedic Center is a leader in sports medicine and rehabilitation. Schedule an appointment with an orthopedic doctor today by calling our Arlington, VA location at (703) 525-2200. For more information on tennis injuries and other orthopaedic conditions, visit our website at www.nirschl.com.

Nirschl Orthopaedic Center for Sports Medicine & Joint Reconstruction
1715 N. George Mason Drive, Suite 504
Arlington, Virginia 22205
703-525-2200
www.nirschl.com
@nirschlortho

© Jane Voigt Tennis 2013