Overuse Injury
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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 that are often caused by occupational, recreational, and habitual activities. [1]
The diagnosis of most overuse injuries does not require imaging studies. However, if surgical intervention is considered, imaging studies are vital for the decision-making process.
Radiography is useful for defining bony avulsions, which are relatively common among people who participate in dance, athletic activity, and heavy physical labor.
Stress fractures, calcification of tendons (which occurs in persons with chronic tendonitis), joint mice, myositis ossificans, heterotopic ossification, and atrophy of cartilage generally are revealed with radiography. Bone scanning may reveal stress fractures that are not evident on radiographs.
Typically, magnetic resonance imaging (MRI) is most effective for acute injuries; findings are generally more subtle with chronic injuries. MRI has been quite successful in revealing tendon, ligament, and muscle injuries.
In cases of peripheral nerve compression or trauma, electrodiagnostic testing can provide evidence of the location and severity of the injury.
In the hands of a skilled clinician, ultrasonography (US) can be a quick and effective method in the clinic to assess for fluid collections, impingements, and/or soft tissue tears associated with many overuse injuries. However, US typically is not utilized as much in the surgical planning process as the aforementioned imaging modalities.
Relative rest, particularly avoidance of the inciting activity, is a hallmark component of treatment in overuse injuries. Using the involved area in nonpainful ways often helps to maintain range of motion (ROM). Total bed rest is virtually never advisable for these patients, and participation in a carefully planned physical therapy program is important.
Occupational therapists can help to identify workplace modifications. In cases of individuals with disabilities who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Often, simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself confer relief.
Steroid injections are the most commonly used procedure in the treatment of overuse injuries, although controversy surrounding this therapy is still readily apparent. Tendons and ligaments can become structurally weakened by the use of steroids, predisposing them to rupture. The use of local anesthetics and steroids should be reserved for patients with significant pain who have the ability to change the underlying cause behind their injury. Repeatedly injecting patients who will inevitably return to the same routine that initially caused the injury is not advisable. [2]
Surgical intervention is undertaken if conservative approaches fail and if the injury is amenable to surgery. In overuse injury, decompression of nerves and repair of lax or failed ligaments are the most common problems that lead to surgery. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.
See Common Pediatric Sports and Recreational Injuries, a Critical Images slideshow, to help recognize some of the more common injuries and conditions associated with pediatric recreational activities.
The pathophysiology of overuse injuries is based on the idea that tissues adapt to the stresses placed on them over time. These stresses include shear, tension, compression, impingement, vibration, and contraction. Mechanical fatigue within tendons, ligaments, neural tissue, and other soft tissues results in characteristic changes depending on their individual properties. This fatigue is theorized to initially lead to adaptations of these tissues. As the tissues attempt to adapt to the demands placed on them, they can incur injury unless they have appropriate time to heal. For overuse injuries, the rate of injury simply exceeds the rate of adaptation and healing in the tissue. Evidence also suggests that chemical mediators are involved in the initiation and propagation of overuse injuries.
Nerve tissues are at particular risk for ischemic injuries. This ischemia leads to characteristic changes in the nerve itself. The timeline generally begins with subperineurial edema, followed by thickening of the perineurium, thickening of the internal and external epineurium, thinning of the peripheral myelin, and, eventually, axonal degeneration.
One hypothesis is that the development of muscular pain originates from the nearly continuous activation of low-threshold motor units that occurs in muscles performing continuous or slow, repetitive tasks, causing depletion of adenosine 5′-triphosphate (ATP) in those fibers. With insufficient ATP, sarcoplasmic reuptake of Ca++ could be reduced, resulting in high concentrations in the cytosol, allowing Ca++ –dependent activation of phospholipase, the generation of free radicals, and damage to the muscle fibers involved. This theory has a rational physiologic basis, but it remains to be proven. Multiple studies have shown that patients with more significant work-related, upper extremity disorders exhibit more muscular activity on electromyelography (EMG) findings; however, these studies are observational and not designed to exhibit causality.
Increasing data in in vitro and in vivo human and animal models show that there are tissue-level changes associated with repetitive stress. Prostaglandin E2 has been found to be present in high quantities in overuse tissues in rat and chicken models. [3] This mediator has been suggested to influence cell proliferation, increase collagenase, and decrease collagen synthesis. Increasing loads on these tissues alters the amount of nitric oxide and prostaglandin E2. However, another hypothesis based on rat-model observations suggests that overuse may lead to an understimulation of tendon cells, rather than to overstimulation. [4]
Alterations in the regulation of genes within tendons undergoing overuse have been shown in the rat model. [5] These changes include upregulation of genes associated with cartilage, and down-regulation of genes associated with tendon. This suggests that overuse may cause a morphologic alteration of tendon tissue, causing it to become more cartilaginous.
Moderate (40 N) and high (60 N) cyclic loads are reported to create an acute neuromuscular disorder characterized by delayed hyperexcitability in the lower back. This delay is characteristic of an inflammatory state. Microtears within muscle tissue have been shown to be related to higher repetition loads and cyclic rate. [6, 7, 8, 9]
Psychosocial factors have been implicated in overuse injuries for decades. [10] A partial list includes work satisfaction, perceived physical health, perceived mental health, coping mechanisms of the patient and his/her family, perception of work-readiness, and anxiety.
A review of the English-language literature revealed specific articles focusing on ultrasonographers, equestrian athletes, ballet dancers, [11] bicyclists, baseball players, swimmers, triathletes, golfers, bull riders, martial artists, sign language interpreters, skeletally immature patients, [12] college students, heavy computer users, assembly line workers, tailors (seamstresses), surgeons, dentists, and nurses. This list dramatizes the point that at least the perception exists that many common and some uncommon ailments are associated with repetitive motion.
The Medscape Reference topic Nerve Entrapment Syndromes may also be of interest.
United States
The incidence of overuse injuries as a whole is nearly impossible to estimate given the sheer volume of included diagnoses, as well as the difficulty in establishing clear diagnostic criteria. [13] However, several long-term, retrospective, work-related studies have estimated the annual incidence of upper extremity disorders at 4.5-12.7% per year. The frequency of injury in each diagnostic category is more appropriately left to more focused literature.
A study by Roos et al indicated that compared with high school sports in the United States, the rate of overuse injuries in college sports is 3.28 times greater. The study, which used data from the National Collegiate Athletic Association Injury Surveillance System and the High School Reporting Information Online (High School RIO) sports injury surveillance system, also found that in sex-comparable sports, the rate of overuse injuries was higher in females than in males by ratios of 1.25 (college sports) and 1.55 (high school sports). [14]
In the pediatric and adolescent population, the overwhelming majority of musculoskeletal injuries related to physical activity and sport are overuse injuries. [15] A study by Schroeder et al found that in US high school sports, the highest rates of overuse injuries were associated with girls’ track and field and girls’ field hockey. The study, using data from the High School RIO surveillance system, also demonstrated that 50.0% of overuse injuries resulted in less than seven days away from activity. Only 7.6% of all overuse injuries in the study resulted in greater than three weeks away from sport. [16]
Overuse injuries are not associated with direct mortality. Morbidity, however, is significant. The impact of these injuries varies from the occasional annoyance to loss of function as a result of frank tissue destruction. In many performing artists, musicians, craftsmen, and workers, loss of function at even a minor level can result in a significant loss of livelihood (leading to the various difficulties associated with this loss). The direct economic impact of overuse injury in the workplace is immense. The indirect impact is nearly incalculable if the number of health care dollars involved is considered. Of particular note, one interesting review of worker demographic data suggested that workers with cumulative trauma disorders were subjected to employment discrimination. Depression and quality-of-life issues have been described after a diagnosis of chronic overuse injury.
Race is not a differentiating factor for overuse injury incidence.
For a variety of hypothesized reasons, differences in sex play a role in certain overuse injuries. [17] Most notably, researchers found a significant female predominance in carpal tunnel syndrome. This has a variety of possible causes, including anatomical differences in the carpal tunnel, hormonal differences, and, importantly, differences in the activities performed by men and woman. Other biomechanical differences have also been implicated; elbow carrying angles, Q-angles, femoral anteversion, and lean body mass are the most commonly stated. Psychosocial and cultural phenomena also play roles.
Age would be expected to be an independent risk factor for overuse injury; however, given the dependence of overuse injury on activity and the changes in activity that typify aging, the contribution of age as a risk factor is difficult to determine. [18]
Iqbal ZA, Alghadir AH. Cumulative trauma disorders: a review. J Back Musculoskelet Rehabil. 2017 Apr 21. [Medline].
Cartwright MS, White DL, Demar S, Wiesler ER, Sarlikiotis T, Chloros GD, et al. Median nerve changes following steroid injection for carpal tunnel syndrome. Muscle Nerve. 2011 Jul. 44(1):25-9. [Medline].
Flick J, Devkota A, Tsuzaki M, et al. Cyclic loading alters biomechanical properties and secretion of PGE2 and NO from tendon explants. Clin Biomech (Bristol, Avon). 2006 Jan. 21(1):99-106. [Medline].
Arnoczky SP, Lavagnino M, Egerbacher M. The mechanobiological aetiopathogenesis of tendinopathy: is it the over-stimulation or the under-stimulation of tendon cells?. Int J Exp Pathol. 2007 Aug. 88(4):217-26. [Medline].
Archambault JM, Jelinsky SA, Lake SP, et al. Rat supraspinatus tendon expresses cartilage markers with overuse. J Orthop Res. 2007 May. 25(5):617-24. [Medline].
Devkota AC, Tsuzaki M, Almekinders LC, et al. Distributing a fixed amount of cyclic loading to tendon explants over longer periods induces greater cellular and mechanical responses. J Orthop Res. 2007 Aug. 25(8):1078-86. [Medline].
Le P, Solomonow M, Zhou BH, et al. Cyclic load magnitude is a risk factor for a cumulative lower back disorder. J Occup Environ Med. 2007 Apr. 49(4):375-87. [Medline].
Moore A, Wells R. Effect of cycle time and duty cycle on psychophysically determined acceptable levels in a highly repetitive task. Ergonomics. 2005 Jun 10. 48(7):859-73.
Nakama LH, King KB, Abrahamsson S, et al. Effect of repetition rate on the formation of microtears in tendon in an in vivo cyclical loading model. J Orthop Res. 2007 Sep. 25(9):1176-84. [Medline].
Bongers PM, Kremer AM, ter Laak J. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist?: A review of the epidemiological literature. Am J Ind Med. 2002 May. 41(5):315-42. [Medline].
Sobrino FJ, Guillen P. Overuse Injuries in Professional Ballet: Influence of Age and Years of Professional Practice. Orthop J Sports Med. 2017 Jun. 5 (6):2325967117712704. [Medline]. [Full Text].
Arnold A, Thigpen CA, Beattie PF, Kissenberth MJ, Shanley E. Overuse Physeal Injuries in Youth Athletes. Sports Health. 2017 Mar/Apr. 9 (2):139-47. [Medline].
Melhorn JM. Cumulative trauma disorders and repetitive strain injuries. The future. Clin Orthop. 1998 Jun. (351):107-26. [Medline].
Roos KG, Marshall SW, Kerr ZY, et al. Epidemiology of Overuse Injuries in Collegiate and High School Athletics in the United States. Am J Sports Med. 2015 Jul. 43 (7):1790-7. [Medline].
Patel DR, Yamasaki A, Brown K. Epidemiology of sports-related musculoskeletal injuries in young athletes in United States. Transl Pediatr. 2017 Jul. 6 (3):160-6. [Medline].
Schroeder AN, Comstock RD, Collins CL, Everhart J, Flanigan D, Best TM. Epidemiology of overuse injuries among high-school athletes in the United States. J Pediatr. 2015 Mar. 166 (3):600-6. [Medline].
Hart DA, Archambault JM, Kydd A, et al. Gender and neurogenic variables in tendon biology and repetitive motion disorders. Clin Orthop. 1998 Jun. (351):44-56. [Medline].
Paterno MV, Taylor-Haas JA, Myer GD, Hewett TE. Prevention of overuse sports injuries in the young athlete. Orthop Clin North Am. 2013 Oct. 44(4):553-64. [Medline]. [Full Text].
Pritchard MH, Pugh N, Wright I, et al. A vascular basis for repetitive strain injury. Rheumatology (Oxford). 1999 Jul. 38(7):636-9. [Medline].
Battery L, Maffulli N. Inflammation in overuse tendon injuries. Sports Med Arthrosc. 2011 Sep. 19(3):213-7. [Medline].
Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire. Br J Sports Med. 2013 May. 47(8):495-502. [Medline].
Nilsson T, Wahlstrom J, Burstrom L. Hand-arm vibration and the risk of vascular and neurological diseases-A systematic review and meta-analysis. PLoS One. 2017. 12 (7):e0180795. [Medline].
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Andersen JH, Harhoff M, Grimstrup S, et al. Computer mouse use predicts acute pain but not prolonged or chronic pain in the neck and shoulder. Occup Environ Med. 2008 Feb. 65(2):126-31. [Medline].
Banks KP, Ly JQ, Beall DP, et al. Overuse injuries of the upper extremity in the competitive athlete: magnetic resonance imaging findings associated with repetitive trauma. Curr Probl Diagn Radiol. 2005 Jul-Aug. 34(4):127-42.
Meltzer KR, Standley PR. Modeled repetitive motion strain and indirect osteopathic manipulative techniques in regulation of human fibroblast proliferation and interleukin secretion. J Am Osteopath Assoc. 2007 Dec. 107(12):527-36. [Medline]. [Full Text].
Hölmich P, Nyvold P, Larsen K. Continued significant effect of physical training as treatment for overuse injury: 8- to 12-year outcome of a randomized clinical trial. Am J Sports Med. 2011 Nov. 39(11):2447-51. [Medline].
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Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep. 50 (17):1030-41. [Medline]. [Full Text].
Kozinc Z, Sarabon N. Effectiveness of Movement Therapy Interventions and Training Modifications for Preventing Running Injuries: A Meta-Analysis of Randomized Controlled Trials. J Sports Sci Med. 2017 Sep. 16 (3):421-8. [Medline].
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Scott R Laker, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Medical Director, Lone Tree Health Center
Scott R Laker, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society
Disclosure: Nothing to disclose.
Johnathon R Blake, MD, MHSA Resident Physician, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine
Johnathon R Blake, MD, MHSA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
William J Sullivan, MD Associate Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine
William J Sullivan, MD is a member of the following medical societies: Association of Academic Physiatrists, North American Spine Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: North American Spine Society (NASS) Executive Committee<br/>Received income in an amount equal to or greater than $250 from: NASS Editor SpineLine Journal.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital
Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
Ryan O Stephenson, DO Associate Professor of Clinical Practice, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Medical Director of Polytrauma and Brain Injury (Polytrauma Network Site), Department of Physical Medicine and Rehabilitation, Eastern Colorado Veterans Affairs Medical Center
Ryan O Stephenson, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists
Disclosure: Nothing to disclose.
Teresa L Massagli, MD Professor of Rehabilitation Medicine, Adjunct Professor of Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists
Disclosure: Nothing to disclose.
Scott Strum, MD
Scott Strum, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists
Disclosure: Nothing to disclose.
Overuse Injury
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