Do you or your clients complain of bothersome pain in the shoulder, knee, hip, foot? Perhaps you or your client do not remember any sudden injury leading to the pain? It may be described as a pain that moves around and waxes and wanes.Overuse injuries can often be difficult to diagnose and often go ignored, unlike a sudden traumatic injury, which usually gets attention and an accurate diagnosis rapidly. As many as 33 to 42 percent of athletes will sustain an overuse injury at some point in their careers (Franco et al., 2021). Yet, these injuries are not exclusive to professional or even recreational athletes.
This figure does not include all the individuals who may sustain an overuse injury from the workplace (i.e., carpenters, mason workers, or office workers in the case of carpal tunnel syndrome). Anyone who engages in any sort of activity frequently with repetitive movement patterns is at risk for an overuse injury (O’Neil et al., 2001).
Preventing or correcting specific injuries by body part is talked extensively in section 4 of the Corrective Exercise Specialization.
What is an overuse injury?
Overuse injuries can be simply defined as an injury that is not caused by an acute identifiable event. Generally, they occur from excessive mechanical loading or stress being placed on the tendon, bone, muscle, or ligaments. To elaborate, when we train at the gym, the goal is to place a certain amount of controlled stress on the muscles to stimulate them to improve endurance, increase in size, or strength depending on the training goal/phase.
However, oftentimes we fail to consider that the stresses we place on our muscles from activities (i.e., lifting weights, running, cycling, swimming, or banging a hammer overhead) also stress other tissues such as tendons, ligaments, and bone.
In other words, it is not just the muscle that must recover. Unlike an acute injury which occurs from placing more stress on the tissues than they can handle, an overuse injury occurs when one or more of these tissues fails to recover from controlled stress which is seemingly benign (Aicale et al., 2018).
Common Overuse Injuries
While we have identified many different overuse injuries “jumper’s knee,” “tennis elbow,” “IT band syndrome,” they can be more simply broken down into overuse injury types.
A tendon is a piece of fibrous tissue that anchors skeletal muscle to bone composed of collagen, nerve tissue, and blood vessels. Several terms may seem interchangeable when referring to tendon injuries, however, they mean slightly different things. Tendinopathy is the term that refers to tendon pain without knowledge of the exact cause of it.
Tendinitis refers to definite inflammation of the tendon, while tendinosis refers to the process of the breakdown and misalignment of collagen fibers making up the tendon leading to improper or incomplete healing of the tendon (Bass, 2012). Interestingly, most conditions that are identified as tendonitis are tendinosis (Charnoff et al., 2021).
Common sites for tendinopathies include the ankle, rotator cuff, wrist, elbow, and knee. Achilles and patellar tendinopathy are most common in athletes, while Achilles and wrist tendinopathies are most common in the general population (Xu & Murrell, 2008).
See also: Shoulder Pain Prevention
Bone is in a constant state of remodeling throughout the human lifecycle. Two cell types exist in bone tissue (osteoclasts and osteoblasts). Old bone is removed by osteoclasts and new bone is formed by osteoblasts.
This balance continues as a response to mechanical stress, aging bone tissue, availability of proper nutrients, and hormonal factors. Stress fractures are often the result of an imbalance in this cycle where bone breakdown exceeds new bone formation. Stress fractures account for approximately 20 percent of overuse injuries related to sports and are more common in females than males.
Repetitive and extreme stress placed on the normal bone (common in runners, military personnel, hurdlers, gymnasts, and Olympic lifters) can occur, However, stress fractures can also occur from more normal stresses placed on the bone with impaired formation capability as may be the case in female athletes with low energy availability or individuals with deficiencies in vitamin D and calcium.
Like muscle strains, an abrupt increase in physical activity level or intensity can increase the risk for a stress fracture. Likewise, poor nutrition status from caloric restriction and overtraining by conditioned athletes can lead to a stress fracture. Common sites for stress fractures include the pelvis, tibia, femur, tarsals, and fibula (May & Marappa-Ganeshan, 2022).
Fascia is a connective tissue that covers much of the muscle tissue and functions to separate different compartments of the body. It allows for the sliding of muscles, nerves, and vessels and provides mechanical support by transmitting forces (Bordoni et al., 2020). Inflamed fascia/damage to the facia from overuse can cause quite a bit of pain.
Plantar fasciitis (PF)
PF is a common, yet painful overuse that often causes pain in the heel of the foot. The condition usually occurs due to the repetitive stress of weight-bearing causing repeated microtrauma to the plantar fascia. Most of the time, the condition will resolve with rest, however, it will recur frequently (Buchanan & Kushner, 2020).
Iliotibial Band (IT Band) Syndrome
IT Band syndrome is a common cause of lateral knee pain and most often occurs in runners and cyclists. The IT band is fascia (connective tissue) that runs from the hip down to the knee. It is thought that muscle imbalance, particularly underactive hip abductors, overactive quadriceps, and relative underactivity in the hamstrings, though the exact cause is unknown (Lavine, 2010).
How to Prevent Overuse Injuries
Although the specific cause of an overuse injury may vary based on the type and location, nearly all these injuries can be traced back to placing more stress on the body part than it can recover from. Oftentimes, exercise enthusiasts may feel that more extreme or higher volumes of exercise will bring better results, yet the opposite is usually true. Following these basic strategies can help prevent overuse injuries.
Correct dysfunctional movement patterns
Human movement patterns are influenced by our daily activities which also influence muscle length and firing patterns. However, this relationship between the brain and muscles, even when the person is no longer engaging in the common movement, will continue and the muscles will in a sense, be recruited incorrectly for other movements (Clark et al., 2014).
For instance, sitting for long periods during the day can lead to underactive and often lengthened hip extensors/abductors and overactive and often shortened hip flexors. The hip flexors will continue to be hyperactive about the hip extensors/abductors (glutes) during all movement even when the person is no longer sitting.
This leads to dysfunctional movement patterns, and often, pain from the overuse of body parts not meant to complete the tasks asked of it. Consider an IT professional who sits at a computer for most of the day. Now imagine that same IT professional likes to run recreationally and may even participate in weekend 5Ks or longer runs. Will their running gait be normal?
Correction of underlying dysfunctional movement patterns is critical in the prevention of overuse injuries.
Avoid long periods of low energy availability
The desire to lose weight is a driving force behind many recreational exercisers and sought after by many athletes seeking to get an edge on the competition. However, long periods of low energy availability from chronic dieting can deprive the body of nutrients needed to recover from training. This may be particularly true of female athletes (Rauh et al., 2010).
Warm-ups elevate the heart rate, increase circulation to the muscles, improve flexibility, and should prepare the neuromuscular system for bigger movements coming later in the workout. The Knee Injury Prevention Program (KIPP) warm-up protocol is a good example of a thorough warm-up which includes components of active stretching, strength, plyometrics, agility, and balance drills Herman et al. (2012) determined that the 10-minute KIPP warm up significantly reduced the risk of lower body overuse injuries in young athletes.
Gradually increase physical activity over time
Going all in may sound like just the motivation a client needs to begin an exercise program, however, this approach can overload the body leading to overuse injuries. This is especially true if a client has dysfunctional movement patterns at baseline. Recall that overloading tissues lead to overuse injuries. Rather, a gradual increase in physical activity which stresses the body in a gradual, periodized, and controlled manner is recommended to gain maximal benefit from an exercise program while reducing the risk of injury (O’Neil et al., 2001).
Rest: It is Part of the Program
Sometimes, fitness enthusiasts believe that training hard with no down days will give them better results. However, the muscles, tendons, ligaments, and bones need rest to recover from even the controlled stress of training. Consider taking a day or two during the week for your favorite light outdoor activity like walking, extra stretching, gentle swimming, or yoga to give these tissues some time to recover.
How to Treat Overuse Injuries with Corrective Exercise
Repetitive movements or postural patterns lead to overactivity and shortening in the overused muscle as well as too much stress on the supporting connective tissue. Corrective exercise can be used both to prevent and treat some overuse injuries once they have been identified.
The first step to developing a corrective exercise program is to conduct a series of assessments to determine which muscles are over and underactive and use the findings to develop a plan targeted at inhibiting and lengthening overactive muscles while activating underactive muscles and using integration exercises to solidify the enhanced neuromuscular connection.
It is very important, especially in the case of tendinopathy, to focus on the eccentric portion of the activation exercises. It may be helpful to count with your client during the eccentric portion to ensure a 4/2/2 (4 seconds eccentric, 2 seconds isometric, and 2 seconds concentric) tempo (Woodley et al., 2007). Check out this sample client.
Client Complaint - Anterior (front) knee pain
Table 1: Assessment
|Overhead Squat Assessment (OHSA)||Knee moves inward, excessive forward lean|
|Heel Elevated OHSA||Excessive forward lean improves|
|Single-leg Squat Assessment||Knee moves inward|
Table 2: Likely Muscle Imbalances (note this list is not all inclusive)
|Overactive Muscles||Underactive Muscles|
Table 3: Corrective Exercise Plan
|SMR (Foam Rolling)||Static Stretches||Activation Exercises||Integration Exercises|
2 Sets of 12 Repetitions
Resisted Dorsiflexion Clamshells
Resisted Hip Abduction Ball Bridge
2 Sets of 12 Repetitions
Ball Squats with Resistance Band Around Knees
(Clark et al., 2014)
New exercisers, non-exercisers, and professional athletes can sustain an overuse injury. Corrective exercise programs can be a great addition to a regular training program, or an excellent place to start when beginning an exercise program for the first time.
Ensuring proper movement patterns, thorough warm-ups, optimal nutrition, and solid recovery strategies can go a long way towards preventing and helping to treat most common overuse injuries.
Aicale, R., Tarantino, D., & Maffulli, N. (2018). Overuse injuries in sport: a comprehensive overview. Journal of Orthopaedic Surgery and Research, 13(1). https://doi.org/10.1186/s13018-018-1017-5
Bass, E. (2012). Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. International Journal of Therapeutic Massage & Bodywork, 5(1), 14–17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312643/#:~:text=Tendinosis%20is%20a%20degeneration%20of
Bordoni, B., Mahabadi, N., & Varacallo, M. (2020). Anatomy, Fascia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493232/
Buchanan, B. K., & Kushner, D. (2020). Plantar Fasciitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431073/
Charnoff, J., Ponnarasu, S., & Naqvi, U. (2021). Tendinosis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448174/
Clark, M. A., Lucett, S., & Sutton, B. (2014). NASM essentials of corrective exercise training. Burlington Jones & Bartlett.
Franco, M. F., Madaleno, F. O., de Paula, T. M. N., Ferreira, T. V., Pinto, R. Z., & Resende, R. A. (2021). Prevalence of overuse injuries in athletes from individual and team sports: A systematic review with meta-analysis and GRADE recommendations. Brazilian Journal of Physical Therapy, 25(5), 500–513. https://doi.org/10.1016/j.bjpt.2021.04.013
Herman, K., Barton, C., Malliaras, P., & Morrissey, D. (2012). The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Medicine, 10(1). https://doi.org/10.1186/1741-7015-10-75
Lavine, R. (2010). Iliotibial band friction syndrome. Current Reviews in Musculoskeletal Medicine, 3(1-4), 18–22. https://doi.org/10.1007/s12178-010-9061-8
May, T., & Marappa-Ganeshan, R. (2022). Stress Fractures. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554538/#:~:text=They%20often%20occur%20when%20the
O’Neil, B. A., Forsythe, M. E., & Stanish, W. D. (2001). Chronic occupational repetitive strain injury. Canadian Family Physician, 47, 311–316. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2016244/
Rauh, M. J., Nichols, J. F., & Barrack, M. T. (2010). Relationships Among Injury and Disordered Eating, Menstrual Dysfunction, and Low Bone Mineral Density in High School Athletes: A Prospective Study. Journal of Athletic Training, 45(3), 243–252. https://doi.org/10.4085/1062-6050-45.3.243
Woodley, B. L., Newsham-West, R. J., Baxter, G. D., Kjaer, M., & Koehle, M. S. (2007). Chronic tendinopathy: effectiveness of eccentric exercise * COMMENTARY 1 * COMMENTARY 2. British Journal of Sports Medicine, 41(4), 188–198. https://doi.org/10.1136/bjsm.2006.029769
Xu, Y., & Murrell, G. A. C. (2008). The Basic Science of Tendinopathy. Clinical Orthopaedics and Related Research, 466(7), 1528–1538. https://doi.org/10.1007/s11999-008-0286-4