Download Overuse syndrome

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
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
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
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
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
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
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
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.
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
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
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
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.
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
▪
▪
▪
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. 1997 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.
▪
1997 Movement, Stability and low back
pain. 1st 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.
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
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
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
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