Overuse Syndromes EXAM 3

- Peroneal Tendinopathy

- Chronic Exertional Compartment Syndrome

- Bone Stress Injuries (BSI)

What are Key Diagnoses to Discuss when talking about overuse syndromes

- MTSS

- Stress Fracture

What are types of bone stress injuries due to overuse

Peroneal Tendinopathy

Dysfunction to the tendon or tendon sheath as it passes behind the lateral malleolus or at the cuboid (these are avascular areas of the tendon)

Peroneal Tendinopathy

- Often precipitated by prolonged activity such as running or dancing

- Often associated with training error

- Common to have a history of a lateral ankle sprain in the past

- one or both tendons (peroneus longus and/or brevis) displace from behind the retromalleolar groove

- Retinaculum can rupture leading to this condition

How does Peroneal Tendinopathy Subluxation occur

ankle sprain that progressed to chronic ankle instability

history of a prior ankle fracture

What types of injuries can result in Peroneal Tendinopathy Subluxation

Peroneal Tendinopathy Subluxation

Common in sports that involve cutting such as football, basketball, soccer, ice skating, etc.

- Painful active inversion and resisted eversion

- Tenderness to palpation over the peroneal tendons behind the lateral malleolus

- Presence of s/sx consistent with chronic ankle instability

- Swelling to the lateral ankle

- Limited subtalar joint mobility

What are exam findings for Peroneal Tendinopathy

inversion

eversion

Peroneal Tendinopathy = Painful active _____ and resisted ______

- Calm it Down (Activity modification, modalities, taping, orthotics, stretching)

- Build it Back Up (Progressive strengthening, proprioception, return to sport)

- Potential use of a lateral heel wedge

- Immobilized with a cam boot at times

- Manual therapy to the subtalar and/or talocrural joints

- Intrinsic foot strengthening

- Education: training and return to activity

What does physical therapy management of Peroneal Tendinopathy entail

Chronic Exertional Compartment Syndrome (CECS)

- Rare LE diagnosis commonly found in running athletes and marching military members

- Increased compartment pressure resulting in decreased blood flow; also muscle hypertrophy, microtrauma, noncompliant fascia play role

- Reversible increase in LE compartment pressure resulting in pain and neurologic symptoms

Chronic Exertional Compartment Syndrome (CECS) is reversible

What makes Chronic Exertional Compartment Syndrome (CECS) different from acute compartment syndrome

- Severe compartment pain during exercise

- Typically relieved within min-hr of stopping activity

- Accompanied by transient paresthesia, numbness, and potential transient nerve palsy

- May be difficult to pick up at rest

- Point tenderness of compartment

- Perception of tightness in compartment

- Potential atrophy of compartment

What is the clinical presentation of Chronic Exertional Compartment Syndrome (CECS)

Needle manometry

What type of examination tool is used to diagnostically test for Chronic Exertional Compartment Syndrome (CECS)

- Education regarding load management, activity modification

- Gait/running modifications

- Impairment based manual therapy techniques

- Injection

What does non-operative management of Chronic Exertional Compartment Syndrome (CECS) entail

Medial Tibial Stress Syndrome / 'Shin Splints'

- Common injury in athletes/runners that results in posteromedial tibial pain

- Often product of transition in activity (e.g., off season to in season; recreational vs. competitive)

- Traction/friction of periosteum

- BSI/bone density changes

What are the 2 main theories behind the occurrence of Medial Tibial Stress Syndrome / 'Shin Splints'

pain in anterior tibia

What is the Hallmark sign of Medial Tibial Stress Syndrome / 'Shin Splints'

PF

inversion

With Medial Tibial Stress Syndrome / 'Shin Splints', AROM and resistive testing may be painful with _____ and _____

1. Pain after activity

2. Pain before and after activity and not affecting performance

3. Pain before, during and after activity, affecting performance

4. Pain so severe, performance is impossible

What are the 4 stages of Medial Tibial Stress Syndrome Progression

CECS or MTSS

A patient presents with exercise induced pain along the distal 2/3 of the medial tibial border that is provoked by physical activity and reduced with relative rest. The patient describes the pain as cramping and burning over the posterior compartment and numbness/pins and needles in the foot. What is the likely diagnosis for this patient

- Female

- increased weight

- higher navicular drop

- previous running injury

- greater hip ER with hip in flexion

What are risk factors associated with Medial Tibial Stress Syndrome

- Load management

- Relative Rest with carefully designed return to sport (recommended to keep pain < 2/10)

- Weekly load increase of <10% to 30%

- Patient education: load management, expectation of recovery varies from 90 days to up to 9-12 months, shoe wear

- Aerobic conditioning through biking, swimming, etc.

What does the PT management of MTSS entail

Relative Rest with carefully designed return to sport (recommended to keep pain < 2/10)

What is an important consideration for intervention management for MTSS

Bone Stress Injury - Stress Fractures

Microscopic bone injuries that result from repeated bouts of overloading physiological stress with insufficient time to undergo remodeling and adaptation

- Biomechanical factors (including ground reaction force magnitude and rates, segment acceleration/shock, anthro- pometry/alignment, running-gait kinematics)

- Training factors (including duration and frequency of training sessions, and running intensity/speed)

- Muscle strength and endurance

- Training surfaces and terrain

- Shoes and inserts (orthoses and insoles)

Factors modifying the load applied to a bone:

females

lean-weight advantage sports (e.g., combat sports)

lean-weight aesthetics (e.g., gymnastics)

high energy demand

What the risk factors associated with RED-S

- Activity cessation/modification essential (strict, protected WB not required just stop what is causing harm)

- Assistive devices considered (e.g., crutches, walking boot)

- Maintain fitness with load-lessened activity (e.g., aquatics, cycling)

- Strengthening ~1 mo. post

- Progressive running and plyometric activity

What does management for bone stress injuries entail

- achieve pain free gait

- pain relief

- promote bone healing

- maintain aerobic capacity

- promote musculoskeletal fitness

- return to running

- address future risk

What are management goals for patients with bone stress injuries