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The evaluation and management ofchronic overuse sports/athletic in-juries is one of the most pervasive

concerns in sports medicine today.Overuse sports injuries outnumber acute,instantaneous injuries in almost everyathletic activity. Because overuse sportsinjuries are not instantly disabling they at-tract less medical attention than thosethat cause an acute and obvious loss offunction. Therefore, their frequency ofoccurrence is almost always underestimat-ed in surveys of athletic injuries. Thetreatment of overuse sports injuries ismade difficult by various factors, includ-ing an insidious onset which means thatthe problem is usually ignored at the start.When athletes actually present for treat-ment, the injuries are well established andmore difficult to manage successfully. Ad-ditionally, these injuries seem less seriousto the athletes and makes it difficult toconvince them of the importance of in-tensive treatment for correction.

Physicians’ attitudes toward athleteswith chronic overuse sports injuries areoften inappropriate and frequently resultin the athlete seeking inappropriate treat-ment options. All too often the athlete-

patient is told: “If you only abstain fromperforming your sport, the injury will re-solve.” The athlete-patient has soughttreatment not because of the injury, butrather because they are unable to contin-ue the athletic participation. Therefore,the ability to return the athlete to func-tional activity is as much part of the treat-ment as alleviation of the symptoms.

Overuse injuries are almost always a re-sult of change in three general areas: theathlete, the environment, or the activities.Identifying these changes requires pa-tience, precision in history-taking, and agreat understanding of the demands ofthe specific sporting activity. The mostcommon cause of overuse athletic injuriesis continued athletic participation despitethe presence of symptoms associated withanother injury (eg. pitcher who continuesto throw despite persistent elbow ten-donitis). Continued participation with anexisting injury also occurs as the result ofinadequate rehabilitation. Some overusedysfunctions are the result of normalphysiological changes such as rapidgrowth spurts in which musculotendinousflexibility often decreases and indirectlycauses tendonitis (eg. Osgood-Schlatter

ChronicOveruseSportsInjuries

Practical evaluation andtreatment modalities.

By Elmer “Al” Pinzon, MD, MPH, FABPMR, FABPM;and Mick Larrabee, PT, MS, SCS, EMT, CSCS

C h r o n i c O v e r u s e S p o r t s I n j u r i e s

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knee syndrome). Environmental alterations occur in the ath-lete’s personal environment (eg. equipment and clothing) or themore global sports environment (eg. running hills in a trainingregiment previously limited to running flat surfaces). Advanc-ing to a higher level of athletic proficiency involves both quali-ty and quantity of workouts. Even increasing workout time in anabrupt manner can result in overuse athletic injuries, especial-ly when an athlete attempts to perfect a single, isolated skill. Itshould be obvious that discovering the changes that cause over-use problems requires an emphasis on history taking, more sothan the diagnosis and management of acute injuries.

The prevention of recurrences of overuse injuries is the mostimportant aspect of managing overuse injuries thus, the physi-cian’s role becomes one of reinforcing and reminding the ath-lete to identify the appropriate changes to be made in their reg-imen. While overuse injuries may involve bone, ligaments, ormusculotendinous structures, the majority of overuse injuriesinvolve the latter. Muscle fatigue may occur due to relative lackof either strength or endurance. As a result, the muscle unittightens and may undergo physiological structural damage (ie-hemorrhage or localized edema) followed by muscle spasms andshortening. This indirectly leads to muscle weakness so that rein-jury occurs with less provocation. The resulting “overuse-tight-ness-pain-disuse-weakness-easier overuse cycle” continues untilbroken by active treatment interventions.1-5

As society’s emphasis on continued physical activity and ath-letics throughout one’s lifespan has increased, so have the knowl-edge and skill required by the community of health careproviders involved in managing the related injuries. It is essen-

tial for all sports medicine providers to realize that a team ap-proach (physicians, physical therapists, athletic trainers, coach-es, etc.)—and taking advantage of the collective knowledge, tal-ent, and expertise of all these specialists in a collaborative ef-fort—affords the athlete the optimal conditions for successfulreturn to sport.

This article highlights a few of the most common injuriesseen in athletics with a focus on the overuse/repetitive straininjury. It is important to note that, for most athletes, up to 60%of the “overuse” type injuries are related to training errors. In-teraction with the coach/trainer is critical in solving this prob-lem. Pain will get the athlete into the clinic, but the tricky partmay be figuring out exactly what is causing the pain. The oldacronym RICE (Rest, Ice, Compression, and Elevation) alongwith NSAIDs can do a very nice job of decreasing/eliminatingthe chemical pain associated with the inflammatory response.However, the real challenge is to identify the underlying dys-function.

A thorough physical exam, biomechanical assessment, andfunctional movement analysis can provide great insight intohow the body moves and reveal any joint dysfunction and/ormuscle imbalances. The muscle imbalance leads to changes inthe length-tension relationships of involved muscles. Thischange in force coupling decreases neuromuscular efficiencyand leads to more rapid fatigue. As the muscles fatigue, thereis often a biomechanical compensation which may overload tis-sues not used to the elevated level of stress. Eventually, break-down must occur and the athlete enters the cumulative injurycycle of pain.

Clinical Assessment, Diagnostic Evaluation, and Treatment OptionsWith the heightened interest in personal fitness and athleticparticipation, the physician is expected to see a variety ofsports-related injuries and must be able to recognize these con-ditions in order to institute prompt and proper management.A thorough history, physical examination, radiographic stud-ies, laboratory studies and, occasionally, further imaging stud-ies are essential to establish and confirm the appropriate di-agnosis and institute correct and adequate treatment for theinjured athlete. The mechanism of injury must be establishedin order to proceed on the correct path. Symptoms must beevaluated in detail and categorized as to initial stimulus, loca-tion, intensity, and characterization of the pain pattern (themajor symptom in overuse injuries). The primary purpose ofthe physical examination is to precisely define the anatomicalstructures involved in the overuse injury. With musculoskele-tal injuries, the easiest way to localize the maximally painfularea is to have the athlete assume the position of maximal dis-comfort and point out the most painful location. This usuallyinvolves stretching the involved muscle. While radiographicand other diagnostic testing are occasionally used to evaluateand often exclude other sources of more serious pathology,they should never be used initially to make a diagnosis, but in-stead used as a supplement to the thorough history and phys-ical examination.1-6

Although there exists an indefinite and varied number ofchronic overuse sports injuries, the authors have chosen a se-lect few deemed the most popular and most often treated syn-dromes to address.

FIGURES 1-2. Side-lying hip abduction.

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Iliotibial Band Friction Syndrome (ITBFS)History/Pathogenesis: ITBFS is an inflammatory, nontraumat-ic overuse injury of the knee affecting predominantly long-dis-tance runners, especially with excessive downhill running, orbicyclists who are not conditioned for longer rides. Tendonitisor bursitis occurs when the posterior edge of the ITB impingesagainst the lateral femoral epicondyle. This repeated traumato the soft tissues in that area creates swelling and pain that isaggravated by further knee motion. Pain occurs after foot strikein the gait cycle, usually at about 30 degrees of knee flexion.As the knee flexes, the ITB moves posteriorly and rubs overthe lateral femoral epicondyle causing inflammation and painafter prolonged activity. ITBFS is the second most commonrunning-related injury and accounts for 12% of all overuse in-juries in the running population. It can be exacerbated in arunner with a varus knee deformity, worn-out running shoes,or increased foot supination which, in turn, increases lateralknee force. In the cyclist, the foot position on the pedals andraising the height of the seat to decrease the degree of kneeflexion should be evaluated.1-3,6-8

Signs/Symptoms: lateral knee pain made worse by running,pain when ascending and descending stairs, stiff-legged walk-ing in advanced cases.

Physical Exam: tenderness to lateral femoral condyle anddistal ITB. Possible leg length discrepancy, increased subtalarjoint pronation, SIJ dysfunction, increased Q angle, positiveOber’s test, hip weakness (particularly gluteus medius), andpoor neuro-muscular control during single leg activities (squatand/or step down). Check footwear and appropriateness forfoot type.

Diagnostic tests: if indicated, evaluate with baseline x-rays,MRI, bonescan, or ultrasound.

Differential Diagnoses: lateral meniscal/collateral ligamentinjury, patellofemoral syndrome, occult lesion, or stress fracture.

Acute Treatment: relative rest; analgesia through appropri-ate doses of NSAIDs and with physical modalities such as ice, ul-trasound, iontophoresis, phonophoresis, topical anesthetic skinrefrigerant (eg. “Gebauer’s Spray and Stretch”) and electricalstimulation (eg. “RS Medical Sequential Stimulator”).

Long-term Treatment/Rehab: Thorough lower quarter exam-ination to identify the cause and help formulate the treatmentplan. For runners it’s a good idea to alternate running on dif-ferent sides of the road or changing direction on the track. Cor-rective exercise for the hip musculature (emphasis on gluteusmedius), manual therapy (to break up fibrotic adhesions, scartissue, and trigger points), stretching (hip flexors, hamstrings,calves, and ITB), self myofascial release techniques, and orthot-ic intervention (if deemed appropriate).9-16 See Figures 1 and 2:side-lying hip abduction.

Elbow Pain—Lateral EpicondylitisHistory/Pathogenesis: Injury of the forearm and wrist extensormuscles which causes pain at the lateral epicondyle and exten-sor forearm at the elbow (ie- ECRB). Usually occurs in the 4thdecade of life, indicating a degenerative process in the tendon,aggravated by repetitive stress and muscular microtears. Com-monly referred to as “tennis elbow”, but present in non-tennisplayers as well.1-3,6,7

Signs/Symptoms: pain at lateral elbow, pain with wrist andforearm motions, pain with gripping objects (eg. screwdriver,

making fist, shaking hands). Pain radiates from dorsum of theforearm to the fingers.

Physical Exam: localized tenderness just anterior and distalto the lateral epicondyle, pain/weakness to resisted wrist exten-sion (especially with extended elbow) and/or middle finger ex-tension. Pathoanatomic changes occur primarily in the ECRBand secondarily at the EDC. Important to rule out C-6/7 radicu-lopathy, especially with paresthesias.

Diagnostic tests: if indicated, evaluate with baseline x-rays,MRI, ultrasound, or EMG.

Differential Diagnoses: medial epicondylitis, intraarticularpathology or stress fracture, gout, cervical spine disease, poste-rior interosseous nerve entrapment.

Acute Treatment: relative rest; equipment modifications (de-crease racquet string tension for tennis player or improve er-gonomics of work station); analgesia through appropriate dosesof NSAIDs, physical modalities such as ice, ultrasound, ion-tophoresis, phonophoresis; counterforce bracing, and/or wristsplinting (especially at night); along with forearm stretching,and topical anesthetic skin refrigerant and electrical stimula-tion.

Long-term Treatment/Rehab: activity modification (improvetechnique through local tennis pro or modify workstation),stretch tight musculature, and strengthen weak musculature.9-16

See Figure 3: forearm extensor strengthening.

Elbow Pain—Medial EpicondylitisHistory/Pathogenesis: Injury of the forearm and wristflexor/forearm pronator muscles causing pain to the medialelbow. Valgus stress lesion of the medial epicondylar physis witha possible avulsion fracture. A catch-all phrase for “little-lea-guer’s elbow” or “golfer’s elbow.” Can mimic Panner’s disease(osteochondritis and/or osteochondrosis of the capitellum).1-3,6,7

Signs/Symptoms: pain in medial elbow accentuated duringearly and late cocking of throwing motion, pain with resistedwrist flexion, pronation, and forearm motions. Mild weaknessis often noted for grasping activities. For pitchers, may notice adecrease in control of pitches.

Physical Exam: look for increased carrying angle (greaterthan 10 degrees in males and 15 degrees in females), pain withpoint tenderness over the tip of the medial epicondyle extend-ing distally 1-2 inches along the common flexor origin (usuallyPT and FCR), pain/weakness of wrist flexors and pronators withelbow extended, possible loss of full extension of elbow (flexion

FIGURE 3. Forearm extensor strengthening.

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contracture consistent with avulsion frac-ture), assess for ulnar collateral ligamentstability, pain/weakness with resisted wristflexion.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI, ultrasound, orEMG.

Differential Diagnoses: lateral epi-condylitis, chronic valgus instability ortears of the medial collateral ligament, in-traarticular pathology or stress fracture,gout, cervical spine disease, ulnar nerveentrapment.

Acute Treatment: relative rest; analge-sia through appropriate doses of NSAIDsand physical modalities such as ice, ultra-sound, iontophoresis, phonophoresis,topical anesthetic skin refrigerant andelectrical stimulation. If avulsion fracturewith minimal displacement, apply poste-rior splint for 2-3 weeks then graduallyprogress range of motion (ROM) andstrengthening. If displacement greaterthan 5mm, open reduction, and internalfixation.

Long-term Treatment/Rehab: activitymodification, stretch tight musculature,and strengthen weak musculature. Withyoung baseball players, it is critical topromote good throwing mechanics,limit the types of pitches thrown (espe-cially breaking pitches such as the screw-ball), and keep a cap on the number ofinnings pitched per week (less than 10is a safe recommendation based on thedata).9-16 See Figure 4: forearm flexorstrengthening.

Achilles TendinitisHistory/Pathogenesis: Painful inflamma-tion of the Achilles tendon as a result ofrepetitive stresses. Injury of the lower legmuscles (gastrocnemius/soleus) that leadsto a degenerative tendon condition char-acterized by chronic pain and inflamma-tion on the posterior aspect of the ankle.Predisposing factors include tightness ofthe Achilles tendon, cavus foot, function-al talipes equines, or pronated foot sec-ondary to forefoot or hindfoot varus ortibia varus. Most frequently occurs insports requiring jumping or running, es-pecially in uneven terrain and hill-run-ning.1-3,6,7

Signs/Symptoms: pain/tenderness 2-6cm above the Achilles’ tendon insertionon the calcaneus, but also along thelength of the tendon. Occasionally withwarmth/swelling with crepitus and tendonnodule present. Pain with running (espe-cially sprinting), and standing heel raise.Preactivity and morning stiffness.

Physical Exam: tenderness to palpa-tion 2-6cm above the Achilles’ tendon in-sertion (thickening of the tendon is oftennoted). Pain/weakness with resisted plan-tarflexion and walking on toes. Decreasedankle dorsiflexion. Often, patient willpresent with increased subtalar prona-tion. If chronic, may see atrophy of calfmuscles.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI, or bone scan.

Differential Diagnoses: posterior tib-ialis ligament injury or Achilles tendonavulsion, inflammatory arthritides, plan-tar fasciitis syndrome, occult lesion, orstress fracture of calcaneous, or sural neu-ritis.

Acute Treatment: relative rest (de-crease speedwork, running hills orstairs…general decrease in overall inten-sity, duration, and/or frequency); newshoes to control excessive motion if pres-ent; heel lift; analgesia through appropri-ate doses of NSAIDs together with physi-cal modalities such as ice, ultrasound, ion-tophoresis, phonophoresis, topical anes-thetic skin refrigerant, and electrical stim-ulation; gentle calf stretching; orthoticsor arch supports if significant hyper-pronator; night splints or walking boot (ifsevere).

Long-term Treatment/Rehab: propershoe wear for foot type — orthotic inter-vention, if necessary; gait analysis of run-ning athlete to identify biomechanicalfaults; gastrocnemius/soleus stretching;

gastrocnemius/soleus strengthening withemphasis on eccentric loading of muscu-lature in a sport-specific manner; surgicaldebridement if conservative treatmentfails.9-16 See Figures 5 and 6: multiplanarcalf stretch with use of “Tristretch.”

Patellar TendinitisHistory/Pathogenesis: Symptomatic de-generation of the patellar tendon withvascular disruption and an inflammatoryrepair response. Often triggered by over-use and repetitive overload of the quadri-ceps tendon at its insertion on the upper

FIGURE 4. Forearm flexor strengthening

FIGURES 5-6. Multiplanar calf stretch with useof “Tristretch”

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pole of the patella, or the infrapatellartendon at its origin from the inferior poleof the patella, or its insertion at the tibialtubercle…exacerbated by poor lowerquarter biomechanics. Younger patientsare typically engaged in jumping sports(“jumper’s knee), whereas older patientsmost likely involve a lifting strain orweight gain.1-3,6,7

Sign/Symptoms: Anterior kneepain/tenderness at the inferior pole of thepatella, patellar tendon, and distally to-ward the tibial tuberosity. Patients oftenpoint to a tender spot of concentration.Reported nocturnal pain, as well as dur-ing sitting, squatting, kneeling, or climb-ing stairs. Pain is worse with “loading” ac-tivities such as landing from a jump, run-ning up/down hill, and/or resisted leg ex-tensions.

Physical Exam: tender point on infe-rior pole of patella or patellar tendon.Frequent tightness to the quadriceps,hamstrings, and tensor fascia lata musclegroups. Check patellar alignment andtracking through long arc extension—normal movement makes a reverse “C”shape as the knee moves from flexion toextension. Pain occurs with a three-quar-ters to full squat.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI, or ultrasound.

Differential Diagnoses: ACL or PCLligament injury, inflammatory or infec-tious condition, patellofemoral syn-drome, occult lesion, or stress fracture.

Acute Treatment: relative rest (de-crease speedwork, running hills or stairs);new shoes to control excessive motion ifpresent; analgesia through appropriatedoses of NSAIDs with physical modalitiessuch as ice, ultrasound, iontophoresis,phonophoresis, and topical anestheticskin refrigerant, and electrical stimula-tion; gentle quadriceps and hamstringstretching; counter-force bracing and/orpatellar taping can be used short-term toallow athlete to perform corrective exer-cises in a relatively pain free manner.

Long-term Treatment/Rehab: Strengthtraining should emphasize closed kineticchain work with eccentric loading.9-16 SeeFigure 7: single-leg wall squat with “Ther-aband ball.”

Shin SplintsHistory/Pathogenesis: Most commonly,this term represents medial tibial stresssyndrome which is a periostitis. Pain oc-curs along the medial distal two-thirds ofthe tibial shaft border at theperiosteal/fascial junction. It is an overusesyndrome of either the posterior or ante-rior tibial muscle-tendinous units. Predis-posing factors involve poor conditioning,running on hard surfaces, and abnormalfoot alignment, especially with hyper-pronation.1-3,6,7

Signs/Symptoms: often insidious andprogressive in nature. Usually related tosudden increase in intensity/duration ofactivity (primarily running), or a change

in playing/running surface (to a harder,less forgiving surface). Early in the course,pain with onset of exertion and usually re-lieved with rest. Later in the progression,pain after cessation of activity, possiblyworse than the pain during activity.

Physical Exam: pain/tendernessalong the middle to distal thirds of thetibia, along the postermedial border. Dif-fuse tenderness often along the tendonof the tibialis posterior and/or soleus.Foot/ankle examination often reveals ex-cessive pronation. In chronic cases, mayfind induration, soft tissue swelling, ornodularity.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI, or bone scan.

Differential Diagnoses: posterior tib-ialis or peroneal ligament injury, peronealmuscle strain or chronic compartmentsyndrome, occult lesion, or stress fracture.

Acute Treatment: NSAIDs andcryotherapy are most beneficial early on(in the acute stage); topical anestheticskin refrigerant and electrical stimula-tion. Complete rest, if possible, otherwise20-50% reduction in mileage/intensitywith gradual progressive return to normalactivity. Cross training with non-impactactivities such as cycling, swimming, aquajogging, and elliptical trainers.

Long-term Treatment/Rehab: Slow,steady, progressive return to run. Eccen-tric strengthening with bands/cords to thefoot/ankle invertors. Proper shoe wear(for foot type and activity) along with or-thotic intervention, if necessary.9-16 SeeFigure 8: Eccentric strengthening with“Theraband cords.”

Plantar FasciitisHistory/Pathogenesis: Inflammatorystress syndrome of the plantar fascia orplantar aponeurosis, usually at its medialcalcaneal origin. It is believed that thissyndrome is related to the stress on theplantar fascia from the weight of an activ-ity combined with weight transfer up ontothe toes and leading to MTP joint exten-sion with a “windlass” effect on the plan-tar fascia. Accounts for approximately10% of all running-related injuries, andthe most common cause of heel pain inrunners.1-3,6,7

Signs/Symptoms: tenderness noted atthe anteromedial calcaneal margin andtightness of the Achilles tendon, withburning pain at the anteromedial aspectof the heel. Worsens with activity (walkingor running), but tends to be worst with the

FIGURE 7. Single-leg wall squat with “Thera-band ball.”

FIGURE 8. Eccentric strengthening with “Ther-aband cords.”

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first few steps in the morning (immedi-ately after getting out of bed). Pain inten-sity increases with prolonged weight bear-ing, especially if walking barefoot or indress shoes.

Physical Exam: pain localized to theanteromedial aspect of the calcaneus.Tightness to the gastrocnemius/soleuscomplex. PROM displays hypermobility tothe subtalar joint, the midfoot complex,and the 1st ray. Gait evaluation revealsoverpronation at the midfoot with exces-sive calcaneal eversion at heel lift. Pain onpassive toe extension with the foot in dor-siflexion.

Diagnostic tests: if indicated, evaluatewith baseline x-rays (calcaneal spur is notdiagnostic) , MRI, or ultrasound.

Differential Diagnoses: posterior tib-ial ligament injury, tarsal tunnel syn-drome, occult lesion, or stress fracture.

Acute Treatment: relative rest; newshoes to control excessive motion if pres-ent; analgesia through appropriate dosesof NSAIDs with physical modalities suchas ice, ultrasound, iontophoresis,phonophoresis, topical anesthetic skin re-frigerant, and electrical stimulation; calfstretching (early morning and through-out the day); manual therapy tech-niques/deep soft tissue work to the gas-trocnemius and soleus along with deeptransverse friction massage to the archand insertion point; soft gel heel cups;arch taping during athletic activities.

Long-term Treatment/Rehab: Conser-vative therapy may last 4-12 months. Cus-tom orthotic intervention may be neces-sary. Night splinting may be helpful.9-16

See Figures 9 and 10: plantar fascialstretch.

Rotator Cuff TendinitisHistory/Pathogenesis: The rotator cuff iscomposed of four muscles: supraspinatus,infraspinatus, teres minor, and subscapu-laris. These muscles form a cover aroundthe head of the humerus and whose func-tion is to rotate the arm and stabilize thehumeral head against the glenoid. Repet-itive shoulder activity (especially over-head) causes breakdown in the cuff mus-culature (especially the supraspinatus)from tensile overload, poor blood supply,aging, subacromial impingement, and re-sults in tendonitis. Weakness in the rota-tor cuff muscles results in altered gleno-humeral movement and causes impinge-ment of the cuff muscles under theacromion and thereby enhancing the painand inflammation.1-3,6,7

Signs/Symptoms: shoulder pain withoverhead activity; weakness in the shoul-der musculature; numbness/paresthesias(usually between the lateral neck to theelbow); and night pain. In young patients,impingement is usually related to laxitycaused by an instability, in those 25-40years of age there is generally an overuseof the rotator cuff, and for those over 40,the impingement is generally caused byoverloading the cuff muscles beyond theirthreshold.

Physical Exam: first, must rule out cer-vical spine dysfunction by checking cervi-cal ROM and any radicular findings.Painful active range of motion (AROM),especially above 90° of forward elevation.

Pain/weakness to shoulder flexors, abduc-tors, internal rotators, and/or external ro-tators. Frequently, one sees positive find-ings with impingement testing (Hawkins-Kennedy or Neer’s). May see scapulardyskinesis.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI, or arthrogram.

Differential Diagnoses: bursitis-ten-dinitis with impingement, adhesive cap-sulitis, DJD of the AC or GH joint, thoracicoutlet syndrome, cervical spondylosis,Pancoast tumor, or stress fracture.

Acute Treatment: NSAIDs; short courseof prednisone; subacromial injection;physical modalities such as ice, ultra-sound, iontophoresis, phonophoresis,topical anesthetic skin refrigerant andelectrical stimulation; relative rest (limitoverhead work); and flexibility exercisesto regain full ROM.

Long-term Treatment/Rehab: strengthand conditioning of the entire shouldergirdle (deltoid, rotator cuff, biceps, tri-ceps, and scapular stabilizers) throughoutfull ROM. Progressive return to overheadactivity. Sport-specific retraining for over-head athletes (especially throwers andswimmers). Retraining of the scapula-humeral rhythm and peri-scapular mus-cles.9-16 See Figure 11: shoulder rotatormuscle strengthening.

Low Back PainHistory/Pathogenesis: Acute pain is feltin the low lumbar, lumbosacral, or sacroil-iac/pelvic region. Often accompanied bysciatica or radiculopathy with pain radi-

FIGURES 9-10. Plantar fascial stretch.

FIGURE 11. Shoulder rotator muscle strength-ening.

ating distally down the distribution of thesciatic nerve or specific radicular nerve.90% of people experience low back painin their lifetime, and 5-10% will experi-ence chronic pain. Spondylolysis involvesa defect in the pars interarticularis of thevertebral complex. The defect rangesfrom a stress reaction to a traumatic frac-ture. Spondylolysthesis results from ante-rior displacement of a vertebral body onthe subjacent vertebra. Back pain fromspondylolysis and/or spondylolysthesisoccurs most frequently in the young ath-letic population (10-18 years of age) andis most common in sports emphasizingextension activities, e.g., gymnastics, bal-let, volleyball, weight lifting, football, andwrestling.1-3,6,7,17

Signs/Symptoms: pain in the low backexacerbated by movement and often ac-companied by focal muscle spasm in thelumbar extensors. Patients tend to preferto stand in a semi-flexed position andmove slowly rather than sit still. Disco-genic pain tends to be sharp or burningand often shoots into the lower leg.Spondylolysis and spondylolysthesis pa-tients tend to have pain into the buttockswhich is worse with extension and lateralside-bending.

Physical Exam: pain, tightness, andoften spasm to the lumbar paraspinals.Repeated movement testing (flexion andextension) can be very useful to identifydisogenic pain. Quadrant testing to iden-tify instabilities. Straight leg raise andslump test to assess dural inflammation.Assess strength/endurance of core trunk

musculature. Myotomal and dermatomalscan to differentiate level of nerve root in-volvement. Special questions regardingbowel/bladder changes, “saddle” anaes-thesias, or visceral disease.

Diagnostic tests: if indicated, evaluatewith baseline x-rays, MRI or CT, or EMG.

Differential Diagnoses: facet os-teoarthritis, musculoskeletal-ligamentousstrain, occult lesion, infection, stress/com-pression fracture or pars interarticularisdefect.

Acute Treatment: relative rest; analge-sia through appropriate doses of NSAIDsand with physical modalities such as ice,ultrasound, topical anesthetic skin refrig-erant and electrical stimulation. “BackSchool” or “McKenzie Method” empha-sizing self-correction, proper posture,body mechanics, and self-managementtechniques. Encourage active approach toproblem with movement-based therapy.

Long-term Treatment/Rehab: improveoverall strength and conditioning (specialemphasis to the core stabilizers: transver-sus abdominus, internal obliques, multi-fidus, and lumbar transversospinalis). Im-prove strength to the gluteus maximus/hamstrings for hip extension. Nutrition-al counseling and weight managementcan help “unload” the spine during nor-mal activities of daily living (ADL’s).9-17 SeeFigure 12: prone-lying press up with“McKenzie method.”

Conclusion and SummaryThe unprecedented level in popularityover the last few decades of increased par-ticipation in athletic sporting events hasled directly to an increase in chronic over-use sports injuries. Sports provide manybenefits including improvement in healthstatus and physical fitness, relaxation, en-tertainment and, for a select few, someprestige and a good source of income. In-directly, the burgeoning population ofelite athletes and the “weekend warriors”will see an exponential increase in thenumber of sports overuse injuries. Injuryoccurs when cumulative forces exceed thetissue’s ability to withstand such forces—either due to isolated macrotraumaticevents or repetitive microtraumaticevents. Often, specific biomechanical orphysiological factors predispose an ath-lete to injury. It remains in themedical/health personnel’s domain toproperly identify and assist the athlete incorrecting these conditions to treat, pre-vent, and possibly reverse the detrimen-

tal effects. As always, prevention is alwaysthe best treatment but, failing that, thenext best thing is proper and successfulrehabilitation. n

Elmer “Al” Pinzon, MD, MPH; FABPMR,FABPM is fellowship-trained in non-surgicalspinal procedures and musculoskeletal/elec-trodiagnostic medicine. Dr. Pinzon practicesat SpineKnoxville and Tennessee Or-thopaedic Clinics in Knoxville, Tenn. Emailpinzoneg@tocdocs.com.

Mick Larrabee, PT, MS, SCS, EMT, CSCS isa board-certified clinical sports physical ther-apist and USA Triathlon Coach-Level I at theTennessee Orthopaedic Clinics in Knoxville,Tenn. Email larrabeemp@tocdocs.com.

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Practical PAIN MANAGEMENT, May/June 2006©2006 PPM Communications, Inc. Reprinted with permission.

FIGURE 12. Prone-lying press up with“McKenzie method.”