Overuse Injuries

Etiology and Pathogenesis

Overuse injuries in football are defined as having an insidious onset of symptoms, without any (macro)trauma. ⁵ A typical example of the early stages of musculoskeletal overuse is the experiencing of pain during the warm-up before physical activity, with the pain then disappearing (or being substantially reduced) during the activity itself, but then recurring with increased intensity after the activity has finished. The player often continues playing, without seeking medical advice at an early stage, and there is a substantial risk that the player will enter a vicious pain circle, where the continued activity will cause further tissue microtrauma and more pain ( ▶ Fig. 8.1).

Fig. 8.1 Vicious pain circle in the presence of an overuse injury.

There is almost always no single identifiable cause in the etiology of overuse injuries, ⁶ and they usually occur as a result of a combination of intrinsic (player-related) and extrinsic (environmental) factors ( ▶ Table 8.1).

**Table 8.1** Intrinsic and extrinsic factors associated with overuse injuries
Intrinsic factors	Extrinsic factors
Previous injury Insufficient rehabilitation Anatomical malalignment Age (either old or young) High or low body mass Female Psychological factors	Heavy load High intensity High frequency Monotonous training Inadequate technique Equipment or footwear Weather or surface conditions

Insufficient rehabilitation following a previous injury, combined with a premature return to football, is a common factor if the player takes his/her own decisions. Training errors (e.g., excessive increases in load, intensity, and/or frequency) are also very common.

Note: “Too much, too soon” is a common training error leading to a variety of overuse injuries.

8.3 Clinical Examination

Overuse injuries are often a diagnostic challenge, with a number of differential diagnoses to consider, and the diagnostic basis is (as always) a thorough patient history, combined with a clinical examination. It is important to find out if there has been any change in training load, footwear, or playing surface. A careful pain history is also required, including questions such as “When does it hurt?”, “Where does it hurt?”, “What provokes the pain?”, and “What alleviates the pain?”.

In the physical examination, it is important not only to examine the affected body part, but also to use a more systematic approach in order to identify any underlying anatomical malalignment, such as leg length discrepancy, genu valgum, or excessive foot pronation. The player sometimes needs to be examined after physical activity, for example, after running on a treadmill. This is particularly valuable for conditions such as runner’s knee and chronic exertional compartment syndrome (CECS).

8.4 Radiological Examination

Radiographs rarely add diagnostic value, except in the case of manifest osteoarthritis or stress fractures. A stress fracture, however, is not usually seen on radiographs during the first 3 to 4 weeks. On the other hand, ultrasonography allows the investigation of a variety of differential musculotendinous diagnoses and can therefore be valuable in the radiological examination of tendinopathies. Magnetic resonance imaging (MRI) is also highly sensitive, allowing the observation not only of musculotendinous pathologies, but also of occult bony injuries such as stress fractures and bone marrow edemas. Historically, bone scans were used to complement radiographs in order to demonstrate increased bony uptake in stress fractures, with radiographs proving negative at an early stage. Nowadays, however, bone scans have been completely replaced by MRI, which also show this pathology at an early stage.

Note: Magnetic resonance imaging is now the gold standard in terms of examining stress fractures, but the difference between excessive bone stress and an incomplete stress fracture is sometimes still not clear.

8.5 Treatment of Overuse Syndromes

Regardless of the pathology suspected, alternative training is always recommended, followed by more structured and specific exercises. Alternative training (i.e., “relative rest”), such as cycling and pool exercises, can often be initiated immediately, whereas absolute rest and immobilization should be avoided. Analyses of training methods and the anatomy of the lower limbs are important in order to correct any training errors and anatomical malalignment.

Note: The cornerstone of the treatment of overuse injuries is alternative training and avoidance of pain-inducing activities until symptoms ease, affected tissues heal, and strength is restored.

8.5.1 Anti-Inflammatory Drugs

Anti-inflammatory drugs, usually referred to as Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), and corticosteroid injections may be useful to treat certain conditions such as bursitis and paratenonitis. However, in general there is no reason to initiate or continue using NSAIDs in long-standing complaints. This is because NSAIDs can aggravate the vicious circle by removing pain, and true inflammation is most often not involved in the condition at this stage.

Recent studies during the Federation of International Football Associations (FIFA) international tournaments have shown an alarmingly high use of NSAIDS among football players. ⁷^, ⁸ In the light of the described potential adverse effects of frequent use of NSAIDs, which include anaemia, ⁹ decreased renal blood flow, ¹⁰ potential negative effect on bone healing, and musculoskeletal injuries ¹¹^, ¹²—combined with the fact that NSAIDs have no effects on the majority of overuse injuries and may even aggravate some of them—a more restrictive use of NSAIDs is recommended.

8.6 Stress Fractures

Stress fractures are uncommon in football, accounting for around 0.5% of all time-loss injuries in high-level football, ¹³ but they are important to diagnose, since some can be serious (such as fractures of the anterior tibia and the femoral neck).

Stress fractures result from repeated submaximal loads, causing fatigue of the bone, and are usually associated with increases in weight-bearing activity such as running and jumping. Younger players are particularly prone to this injury, and more injuries are seen during the preseason preparation period. ¹³ Changes in surface conditions and footwear are thus important factors to consider, as is disordered eating in female players. ¹³

Note: The female athlete triad consists of disordered eating, menstrual dysfunction, and osteoporosis.

8.6.1 Hip and Pelvis

Epidemiology and Diagnostics

Stress fractures are most frequently encountered in the os pubis (typically the inferior ramus), followed by the femoral neck, but they can be located anywhere along the hip and pelvis, including the sacrum and ischium. Recently, pelvic fractures have been shown to account for 6% of all stress fractures in high-level male players. ¹³ Initially, the player can normally walk without any difficulty, but the groin pain gradually worsens over a few weeks to the point where the player also feels pain at rest and while walking.

A stress fracture in the pelvic ring should be suspected if there is severe localized soreness when pressure is applied to the symphysis or other parts of the pelvis, whereas a stress fracture in the femoral neck should be suspected if there is pain with hip joint rotation or when applying longitudinal pressure.

Note: A player with a suspected stress fracture in the femoral neck should immediately unload the hip and be referred for an acute/subacute MRI.

Treatment and Return to Play

Treatment of pelvic stress fractures involves absolute rest from pain-inducing activities (running, jumping, kicking, etc.). Alternative training such as cycling with low resistance and pool exercises is permitted if it can be carried out without pain. In severe cases with pain at rest, the player should be treated very carefully initially. The player should not return to football until the localized tenderness has completely disappeared. If a stress fracture in the femoral neck is suspected, the player should immediately relieve pressure on the affected leg by using crutches until the diagnosis has been radiologically confirmed or excluded, since continued stress can lead to displacement of the fracture.

The treatment of a stress fracture in the femoral neck depends on the location. If the fracture is located superiorly, the player can be treated nonsurgically, with crutches and no weight-bearing initially. If the fracture is located inferiorly, however, there is a high risk of it progressing to a complete fracture with displacement. In this case, osteosynthesis should be performed without delay.

Prognosis

The prognosis after a stress fracture in the pelvis is good. For a stress fracture in the femoral neck of the femur, the prognosis is worse, regardless of the treatment, and setbacks in recovery occur fairly frequently.

8.6.2 Lower leg

Epidemiology and Diagnostics

The tibia and fibula are some of the most vulnerable bones when it comes to developing stress fractures. Fractures are commonly located in the upper half of the tibia and approximately 5 to 10 cm above the lateral malleolus, respectively. In a recent study, tibial fractures accounted for 12% of all stress fractures in high-level male footballers, whereas only 1 of the 51 stress fractures recorded (0.5%) was located in the fibula. ¹³ Tibial fractures can be broken down into anterior and posterior fractures, and this classification often has some etiological and prognostic value. Fibular and posterior tibial stress fractures are usually associated with running, whereas the rarer anterior tibial stress fracture is associated with jumping activities. The diagnosis is often fairly straightforward, since there is typically very distinct localized tenderness around the fracture on physical examination and percussion over the area is very painful.

Treatment and Return to Play

Treatment of stress fractures of the lower leg involves absolute rest from pain-inducing activities, and partial unloading using crutches is often recommended (6–8 weeks for the tibia and approximately 4 weeks for the fibula). Alternative training such as cycling with low resistance and pool exercises is only permitted if it can be carried out without any pain. In severe cases with pain at rest, immobilization in a plaster cast for 3 to 4 weeks might sometimes be required for tibial fractures. Extracorporeal shock wave therapy (ESWT) has been reported to be effective in a small study looking at football players with stress fractures of the tibia and the fifth metatarsal. ¹⁴ Most fractures heal without the need for surgery, but if an anterior tibial stress fracture shows no signs of healing after 4 to 6 months, surgery should be considered. However, there is no consensus as to the recommended surgical method.

Prognosis

The prognosis for fibular and posterior tibial stress fractures is usually good, whereas anterior tibial stress fractures are associated with delayed unions and the development of complete fractures.

Note: Stress fractures of the lower leg should be followed both clinically and radiologically until they have healed to allow for a safe return to football.

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