What To Expect: In this learn we go deep into overuse injuries defined, causes, prevention, management. 7 minute read.
I recently had a very lengthly conversation with a client about the causes of pain and injury. She felt like her causes aligned more with the typical ones that often get discussed:
1) Moving Incorrectly
2) Being Misaligned
3) Having Poor Posture
4) Having A Muscle that doesn’t “fire”
5) Trauma or a very specific mechanism.
Which I understand the tangibleness of those scenarios. It would make logical sense that maybe those could be the reason for pain. But in our discussion I pointed to the fact that she has ran with the same technique and anatomy for 15+ years and never had these issues so why now? I pointed to the fact that posture is dynamic and never static. We never stay in one posture for any given time and posture is context dependent. Depending on the task and environment. Blaming pain on posture means, “i have not one single clue why you have pain so let me say something.” Muscles are always working. Just because you do not fill it doesn’t mean it doesn’t have an action. I PROMISE YOU, if a muscle did not fire you would have more significant issues and concerns that you would know without a doubt. Anytime there is a traumatic event that results in injury: torn ACL, fractured femur, shoulder dislocation, ankle subluxation, muscle tear, you will 100% remember every single detail of that moment. Where you were, what you are wearing, the temperature, who was there. The body stores these highly emotional events in the Amygdala in the brain. It does this to protect you in the future. So trust me whenI say, if she had tore her hamstring she would know it.
Overuse injuries can happen to any structure in the body.
-BONES
-TENDONS
-MUSCLES/FASCIA
-JOINT
-LIGAMENTS
-BURSA
-NERVES
Here is the tricky part with exercise and movement. The same medicine that heals you always has the ability to hurt you. What I mean by that is this. We use physical stress through load applied to the body to create a desire POSITIVE adaptation or response. We run to run further or faster. We lift weights to lift more weights or get bigger. We stress our recent ACL reconstruction to make it repair more efficiently. These structures mentioned above respond to that physical stress: bones get more dense, muscles get bigger and stronger, tendons get stiffer and thicker.
HOWEVER…
With excessive stress with no appreciation for recovery and other factors, these tissues breakdown faster than they can remodel…. resulting in injury. So we define overuse injuries by saying they occur when the tissue is unable to adapt positively to the demands being placed on it. Why couldn’t it adapt?
1) High Stress
2) Poor Sleep
3) Poor Hydration and Nutrition
4) High Volume and High Intensity Training
5) Under Recovery
6) Prior Injury
7) Muscle Imbalance or Poor Movement Pattern resulting in one area being overloaded.
8) Poor Midline or Trunk Control using in limited extremity stability.
9) Too Much Too Soon
Injury may result from repetitive microtrauma imposed on otherwise healthy tissue or the repeated application of lesser magnitudes of force to pathologic tissue. Either scenario can lead to a sequelae of tissue breakdown.
1) Not enough stress to create positive adaptation. 2) Too much stress and too little recovery. Overuse injury ahead. 3) Adequate stress and adequate recovery.
WHAT CAN YOU DO TO LIMIT OVERUSE INJURIES?
1) UNDERSTAND YOUR TRAINING
Even professional athletes have someone that helps them better understand their overall training volume and intensity. They strategically know when to go 100 or when to go 65. You are not superman or wonder woman. If we do the math you will see the big picture. The number just simply represents how hard you performed.
Day 1: 100
Day 2: 100
Day 3: 100
Day 4: 100
Day 5: 100
Day 6: 100
Day 7: Injury
No Train
ing Day 8-17
versus
Day 1: 75
Day 2: 60
Day 3: 85
Day 4: Rest
Day 5: 80
Day 6: 65
Day 7: 30
Day 8-17: Still Training and progressing towards goals.
Each day is not as intense because it is broken down and layered throughout a given week or training block. The pursuit of a higher level of fitness is a marathon, not a sprint.
2) PRIORITIZE RECOVERY
People often feel that the missing link from their recovery is the magic pill or supplement. The magic cryotherapy chamber and juice cleanse. But let me fill you in on a little secret! Your body is extremely smart and has designed with everything inside to maximize your recovery. You just have to be an ally with yourself and make sure you are getting adequate sleep, drinking water, and eating quality foods that align with your goals. All of which cost you zero extra dollars.
3) LISTEN
Your body keeps the score. But you gotta know how to interpret the score. It’s like having all these wonderful and necessary information but not knowing how exactly to process it and use it for your best interest. When you soreness unmatched to exercise intensity, listen. When you feel pain without mechanical tension or stress being applied, listen. When pain keeps getting worse, listen. When you always feel pain with a certain position, listen. When you are stressed, listen.
THREE MOST COMMON SCENARIOS OVERUSE INJURIES HAPPEN
1) The athlete who attempts to rapidly increase his training load after a period of inactivity or decreased activity. In this situation, the body has an insufficient adaptation period to respond to a higher level of stress and therefore, is not adequately prepared to dissipate repetitive forces. This is where stress fractures and tendonopathies occur.
2) The athlete who attempt to participate at a level which exceeds their individual skill level. In theory, this mismatch of individual skill or fitness level to imposed stress and physical demands can lead to tissue breakdown
3) The athlete who participates at an exceptionally high level all of the time can lead to overuse injury. This group may suffer from excessive micro-trauma over time with insufficient rest, ultimately leading to tissue breakdown. Athletes who continuously participate in sports without rest or who specialize in one sport throughout the year are certainly included in this high risk category.
MANAGING OVERUSE INJURIES
Managing overuse injuries will look different based on many different factors: type of activity that predisposed overuse injury, experience, pathology, structure and body region involved, demand of return activity, and beyond. An elite powerlifter with achilles tendonopathy will have a different rehab than the 35 year old who developed achilles tendonopathy because they started running for the first time since high school. Each person has different neurological efficiency and musculature development. The powerlifters baseline is much higher when we think of the years of stress and adaptation applied to the achilles tendon over time. Likewise, a runner will use his achilles tendon in a much different capacity than powerlifter would. We need to consider getting back to energy storage exercises for the runner and not so much energy storage but just an overall healthier tendon matrix with added stiffness for force transfer. The powerlifter will have much more compressive force at the achilles tendon because of the ankle dorsiflexion range compared to that of a runner. There are so many different factors to consider.
STEP 1: Discuss stress, sleep, nutrition, and hydration. If a client or athlete has those bases covered then we can move on. If not, address this FIRST because those are the closest thing we will ever have to a magic pill. DO NOT UNDERESTIMATE the power of good sleep.
STEP 2: Determine if motor control limitations or poor movement patterns contribute to overuse pathology. If so, address this FIRST. If someone can not adequately stabilize their femur in the frontal plane during a squat and you’re doing all the exercises in the world to improve IT Band Syndrome, it will continue to come back because one of the underlying causes has not been addressed.
STEP 3: Educating the athlete on programming and tracking variables of workload using distance, volume, intensity, RPE, HR, and more. Maturing as an active adult or athlete in any setting is understanding the concept of OVERTRAINING versus UNDER RECOVERING. Consider the development of a blister vs. the development of a callus on your body. A blister occurs most usually due to a stimulus of friction and heat which is too much for your body to handle all at once, this is an injury not an adaptation (think developing a blister on your foot after going for a really long in the middle of summer wearing new shoes). On the flip side if we were to gradually introduce the new shoes and hiking, instead of all at once, our body would instead develop calluses, not blisters. We gave our body just enough of a stimulus that it was able to adapt to it, but didn’t completely overload it so much so that we got hurt.
This is the difference between you getting stronger week to week on a solid program vs. you getting injured because all you ever do when you go to the gym is full send an RPE 11 effort. Smart training and proper programming set you up to be successful in your recovery endeavors. There’s no amount of recovery tricks you will be able to pull to outrun a program that is just downright beating you into the ground every single training session.
STEP 4: Understand that rest is the last resort. When we rest we just further exacerbate the potential for an overuse injury to occur again. When we decrease any and all stress to these tissues with the goal of returning to those activities at the same intensity without understand capacity; the issue does not get solved. Instead we MODIFY or REGRESS the activity. For simplicity we will use patellar tendonopathy for a Crossfit athlete as a real life scenario.
MODIFY VARIATION: If front squats are causing excessive pain can we offload the knee joint by performing more of a back squat OR belt squat?
MODIFY RANGE OF MOTION: More range means more demand. If the pain is provoked at the bottom near maximal knee flexion can we use a box or medicine ball to restrict that range?
STANCE or MECHANICS: This is where having a good eye and understand movement really helps. Tactile or verbal cueing can really make a drastic impact on symptom management. Placing a foam roller in front of the knee to limit anterior knee translation to require more of a hip dominant squat. Going into a more narrow or wide stance to decrease stress applied to the hip joint (if the hip is the overuse area). When you continue to accumulate volume in the same exact pattern over time, sometimes breaking the mold of repetition can be a really good thing.
WEIGHT: That easy. We can reduce the same stress that caused the overuse injury by working with less weight. Not only does this work from a numbers perspective but it also allows you to focus on coordination and movement pattern refinement. Think of it as a makeover to your activity or movement. This is where monitoring RPE is HUGE for tracking progress over time time during a rehab progression. We can self limit by capping your RPE which gives you the flexibility to work with higher numbers given your target RPE is not surpassed. Consider yourself lucky if you can still even perform that particular irritating movement with an overuse injury. With the right progression you will be back to your normal training loads.
TEMPO: Different tissue types will respond to different contract types and speeds. If the overuse injury is a muscle we know we likely want to avoid slow eccentrics and rapid concentric muscle actions. If the pathology is in a tendon we know we want to begin with submaxmimal isometircs with low load and long duration to rebuild tendon capacity.
Do you have an overuse injury like the ones listed below?
Anterior Knee Pain: Patellafemoral Pain, Patellar Tendonopathy, Jumper’s Knee, Runner’s Knee
Foot and Ankle Pain: Achilles Tendonopathy, Plantar Fasciitis, Stress Fracture
Elbow Pain: Golfers Elbow, Tennis Elbow, Triceps Tendonopathy
Shoulder Pain: Shoulder Impingement or Rotator Cuff Tendonopathy, Bursitis
Hip Pain: Hip Impingement, Glute Med Tendonoapthy, Hamstring Tendonopathy,
Lower Leg: Shin Splints, Calf Strain, Tibialis Anterior/Posterior Tendonoapthy
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