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Overuse injuries

GP Dr Anthony Annan provides invaluable advice gained from his experience as a sports and exercise medicine physician

GP Dr Anthony Annan provides invaluable advice gained from his experience as a sports and exercise medicine physician

1 Consider overuse injury in a patient with persistent limb pain

Overuse injuries are often missed in GP surgeries. They are characterised by chronic pain in a limb or part of a limb, often due to inflammation that has been caused by frequent minor injuries. The patient is usually not aware of any cause for the pain and there is usually no recent trauma in the history. Suspect this typically in a regularly exercising patient. In my view chronic pain in a limb plus exercising patient equals overuse injury in most cases.

2 Know the types of overuse injuries

Overuse injuries can be grouped as bony overuse injuries (stress fractures, osteitis, periostitis or apophysitis), musculotendinous overuse injuries (focal tissue thickening or muscle soreness, tendinosis, tendonitis, paratenonitis) and others, such as bursitis, nerve entrapment syndromes and skin blisters. GPs should keep these anatomical areas in mind if suspecting an overuse injury in a patient, especially one who exercises regularly.

3 A cause must be sought for all overuse injuries by taking a careful history

In most cases, patients are not aware of the cause of the symptoms, which is usually chronic pain in a limb during exercise.

The causes or predisposing factors can simply be divided into internal and external factors. External factors include training errors, such as exercise fatigue, faulty techniques and a sudden change in the type of training.

Other external factors include hard, soft or irregular surfaces, poor shoe wear, poor equipment, environmental conditions, psychological factors and inadequate nutrition. Internal factors include leg length discrepancy, malalignment of limbs (genu valgum or varus), muscle imbalance and weakness, and poor flexibility (muscle tightness).

Other factors such as sex, body composition and size, genetic and endocrine factors may also play a part.

4 Examination is the key to clinical suspicion

Careful examination usually reveals which anatomical structure is involved. It often helps to ask the patient to perform a manoeuvre that reproduces the pain and/or discomfort.

GPs have very little time to examine patients, so the advice is to examine the suspected site of injury while exploring the likely aetiology of the suspected overuse injury.

5 Stress fracture is one of the commonest injuries among sports or exercising individuals

It can occur in any bone and is due to microtrauma from repetitive physical loading. It commonly affects the metatarsals, tibia, fibular and navicular bone. MRI scan is the investigative tool of choice, as findings are often normal on X-ray.

Osteitis is caused by impaction trauma with inflammation of the bone; a typical example is osteitis pubis, which causes pain and/or discomfort with tenderness at the symphysis pubis.

Periostitis is an inflammatory process which occurs commonly at the medial border of the tibia (shin splints).

Apophysitis describes separation and inflammation occurring where tendons are attached to growth areas – such as Osgood-Schlatter's disease (attachment of the patellar tendon to the tibial tuberosity) and Sever's disease (attachment of the tendo-Achilles to the calcaneus).

6 Muscle soreness usually occurs after a strain, especially after severe unaccustomed exercise

There is usually pain or muscle soreness after about 24-48 hours.

Examples include tendonitis (inflammation of the tendon), paratenonitis (which involves a single layer of areolar tissue covering the tendon called peritendinitis or tenosynovitis) and tenovaginitis (which involves the double layer tendon sheath).

A common example of paratenonitis is de Quervain's tenosynovitis at the wrist.

7 Bursitis describes inflammation of bursae around the body, which are between bony surfaces and overlying tendons

Examples are subacromial bursitis around the shoulder, which is associated with local tenderness, pain and swelling on specific movements.

Nerve entrapment syndromes occur when swelling develops in the surroundings of soft tissues which affects nerve, for example between the third and fourth interdigital nerves, a condition called Morton's neuroma.

Skin blisters are also overuse injuries, but involve friction of the skin; they can occur at any site of friction with an external aggravating factor.

8 Are there websites GPs can refer to for information?

Sports Injury Clinic contains a lot of valuable information for GPs and patients.

9 What are the treatment options?

Treatment options involve rest and avoiding aggravating factors, using ice compression and drugs, such as NSAIDs. Other options include physiotherapy and a range of electrotherapeutic modalities.

10 When and where can GPs refer patients with suspected overuse injuries?

Suspected overuse injuries, especially in exercising individuals, with failure of basic treatment can be referred to sports and exercise medicine specialists. Unfortunately, there is a current paucity of them on the NHS.

But this is set to change as structured specialist training has already begun on the NHS this year to rectify this problem. There are, however, sports physicians practising privately in the UK, and they can be contacted through the British Association of Sports and Exercise Medicine (BASEM)

Anthony Annan is a GP in Essex and a sports and exercise medicine physician. He is a member of the British Association of Sports and Exercise Medicine (BASEM) and medical director of LIPH Sports Medicine Clinic, London

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