Mystery Maladies

Getting rid of an overuse injury means getting to the bottom of what’s causing it. Here, athletic trainers show you how they do their detective work.

By Guillermo Metz

Guillermo Metz is an Associate Editor at Training & Conditioning.

Training & Conditioning, 13.2, March 2003,

“Hey, do you have a minute? My elbow’s been bugging me for a couple of weeks. And yesterday, I couldn’t even finish practice.”

You hear it all the time. If it’s not an elbow, it’s an ankle, a knee, a hip, a shoulder. You shake your head, wondering why the athlete waited two weeks before coming to you. Then you get down to business, knowing you’ve just begun a treatment process that could take months to complete.

Athletes at every level, in every sport, are susceptible to overuse injuries. As always, the best medicine is prevention. But you can’t prevent every overuse injury. A well-planned strategy, however, can go a long way to getting athletes back out on the field—and keep them from returning to the training room.

The best way to prevent overuse injuries is by varying the training and stresses imposed on athletes, and building in time for recovery. But that’s easier said than done in an era where there is little if any true downtime for competitive athletes.

“The whole philosophy of sport at the college level has become, ‘We can outwork the other team,’ even though there’s no scientific basis for it,” says Dan Hooker, PhD, PT, SCS, ATC, Coordinator of Athletic Training and Physical Therapy Services at the University of North Carolina.

And, according to Geoff Schaadt, MS, ATC, Director of Athletic Training and Rehabilitation at UCLA, “as things have become more specialized and elite in nature, it’s almost become a situation where those individuals who don’t break down are the ones who are going to become the elite athletes in their sports. That’s helped take a lot of our events to a higher level. But, unfortunately, there are a lot of people who aren’t able to adapt to that level of training.”

That means it’s more important than ever for athletic trainers to be in tune with individual athletes’ capabilities, for athletes to know when they’re heading down the road of doing too much too fast, and for athletic trainers to remind athletes and sport coaches that optimal fitness is possible only when the schedule allows for proper recovery. And the communication should be two-way at all times.

For example, athletic trainers can gain a lot by tapping into sport coaches’ expertise on the demands of their sports. At the University of Connecticut, Ralph Mansell, MEd, ATC, Assistant Athletic Trainer and former Head Athletic Trainer, says his baseball coach has shown the athletic training staff what’s involved with throwing. In lacrosse, the staff also suggested to the sport-coaching and strength staff some exercises to address a rash of ankle injuries and stress fractures.

“We try not to step on anyone’s toes, but when there are areas of concern, we try to point them out,” Mansell says.

Missy Strauch, ATC, CSCS, Head Athletic Trainer at Augsburg College, consults on conditioning plans for coaches who ask her help—and some who don’t. “I may look at their strength programs and say, ‘We had a lot of shoulder injuries last year. I think they came from overuse. And I think you’re doing way too much in a certain category in the weightroom, so let’s fine-tune this.’”

Another tool for detecting athletes in danger of overuse injuries is the preparticipation physical exam. By working with team doctors, athletic trainers can identify athletes who may have some biomechanical imbalance or strength deficiency. Athletic trainers can then address potential problems in what some people refer to as a “prehabilitation” program, beginning treatment before an overuse injury starts to develop.

Most teams already do some sort of basic conditioning tests, and these can help spot a potential injury. But, to be truly effective, Schaadt believes the tests must be sport-specific and biomechanically based. “You have to base your assessment tool on what they’re going to have to do in their sport,” he says.

For example, tests for football athletes would be broken down by position. Thus, a quarterback would have his throwing arm tested for basic strength and flexibility, while a lineman’s test would be focused on leg and hip strength.

Athletic trainers suggest incorporating these tests somewhere in the first two weeks of practice, but not on the first day back. “They may be better off going into practice gently, then being put through the performance tests every few days after that,” says Hooker.

The final part of prevention is making sure athletes come to you at the earliest sign of trouble. Of course, you don’t want to know about every little soreness, but you want them to recognize when they’re on the road to an overuse injury. Various pain scales have been developed to track overuse injuries, and it may help to post one of these in the locker room. (For a copy of one, see “Getting On the Scale” in the Bonus Editorial section of our Web site,

Unfortunately, even with all your preventative efforts, athletes will still succumb to overuse injuries. They can be the most frustrating, time-consuming injuries you see, which is why it’s critical to have a game plan beforehand. The first step is to treat them no differently than any other injury; the next steps involve putting on your detective hat.

“You begin by treating the injury symptomatically to get rid of the pain,” says Mansell. “Then, it’s a long, slow evaluation process. The history is the most important part: You have to make sure you’re asking the right questions to find out what’s going on, considering both extrinsic and intrinsic factors.”

Common extrinsic factors include training errors, improperly sized or adjusted equipment, environment, poor technique, sports-acquired deficiencies, and extrinsic stresses. Intrinsic factors include malalignment, muscle imbalance, inflexibility, muscle weakness, instability, history of prior injury, and psychological factors.

Kip Smith, MEd, ATC/L, Head Athletic Trainer at Indiana University, hits many of these points by considering the problem from both a subjective and objective view. “Subjectively, we’ll ask them what they’ve been doing in the past that’s brought on their symptoms,” he says. “What are the mechanisms, and what sort of activity causes them pain? Have they done anything different in training?

“Then, objectively, we do a thorough assessment of the injury, where we look at things closely from an anatomical standpoint,” he continues. “We palpate over the area that’s bothering them. We find out if they’ve been injured before and how the injury was treated in the past. We consider different diagnostic tests that may be appropriate to help evaluate them—from manual or clinical tests we can do here to things that may require a physician referral, like x-rays and MRIs, or even advanced biomechanical testing. And then we come up with a plan to correct the problem.”

However you look at the factors that could be at play, often the hardest part is patiently going over the list of possibilities again and again. “What I’ve found is that people, including doctors, will jump to the most recent thing as the culprit,” says Mansell. “If the athlete recently started weight lifting, they’ll say, ‘Aha! That’s the problem!’ But that may not be the problem at all. Maybe it’s leg-length difference or maybe they’ve been running the same path every day. It might be something that’s been going on for a year but that didn’t bother them until now.”

“I’ll look at their particular sport to see if they’ve been doing something repetitive that could have led to the injury,” says Strauch. “I’ll observe them in practice and talk with the coach about the drills they’ve been doing. We also look at things like footwear—maybe they’ve been in a shoe too long and it’s breaking down, or maybe they need to have extra support or orthotics.

“Where it’s a situation of stress fractures, especially with female athletes, I may get into a discussion with the athlete about bone health, and I’ll involve my team physician or orthopedist,” she adds. “We might send the athlete for a workup with the general practitioner to assess if we are dealing with an eating disorder. I would make sure that the physician asked about her diet, found out when her last menstruation was, and so forth.”

Strauch also looks out for other mental and emotional factors. “If I go through and cannot find any physical cause for their pain,” she says, “I’ll talk with them about any underlying issues, like with family or school. I believe that a lot of the illness that we see on campus comes from general stress. I’ve also had athletes who were dealing with issues of suicide, depression, anorexia, drug use, schizophrenia—a whole host of things. I’ll often prompt the physician to look for any factors that the athlete needs to talk about with a counselor or psychologist.”

Mansell feels it’s also important to recruit experts in the treatment process. “We have a doctor here available 24 hours, and we have specialists—for example, someone who’s very good with foot biomechanics,” he says. “Also, we meet as a group every Friday and go over every single athlete we’re working with. That meeting includes our full-time physician, his part-time assistant, the head strength coach, all of our athletic trainers and graduate students. That way, we get a variety of angles and ideas.”

Getting many people involved doesn’t mean trying out a dozen new techniques all at once, though. Because overuse injuries can have so many causes, Schaadt recommends testing one remedy at a time. “Obviously, you’ll have some clear-cut cases where you have to make multiple changes,” he says. “But I was told a long time ago that if you throw all your darts at once, your athlete may get better, but you won’t know why.

“So you evaluate as many variables as you can, and you first address the ones that you think are most serious,” Schaadt continues. “If making those changes is not having an effect, then you re-evaluate. You try to find subtler things or things that you missed the first time through. As with any injury, you’re constantly re-evaluating, reassessing, and changing treatment and rehab protocols based on the most recent findings.”

During the treatment process, athletes can usually continue to work out. As with injury prevention, the key is to vary the athlete’s activity while he or she is recovering.

“You have to change their impact cycle and enforce a relative rest period to let their bodies recover,” says Hooker. “I’ll tell the athlete, for example, ‘We’re going to let you work out, but we’re only going to let you work out in the pool.’

“The challenge is that most of the time, overuse injuries don’t hurt so badly that the athlete wants to stop,” he continues. “They have enough pain that they want to talk about it, but they don’t have enough pain that they want to quit. So you find ways that they can continue to train that muscle group without overstressing it.”

Finally, the treatment of overuse injuries differs from that of acute injuries in one significant way: You have to address the factors that caused the injury in the first place. Hopefully, the underlying causes of the overuse injury have become apparent during the course of the treatment, and any mechanical inefficiencies, strength imbalances, training errors, and equipment problems have been corrected. It can be a long and difficult process, but once you fix the root of the problem, you’ve got one less student-athlete with question marks on their chart.

Case Study
Chronic Ankle Sprain
By Lee Burton & Gray Cook
Lee Burton, MS, ATC, CSCS, is Athletic Training Program Director at Averett University. Gray Cook, MSPT, OCS, CSCS, is Clinical Director at Orthopedic and Sports Physical Therapy, in Danville, Va.

A freshman college basketball player reported to the athletic training room after “coming down on someone’s foot and rolling his ankle” during a practice in November. This athlete had a history of poorly managed ankle sprains (four sprains, of roughly grade II severity, in high school).

The athlete was weightbearing, but on evaluation, he had slight swelling, and ligamentous testing revealed laxity and slight pain. He had significant weakness and pain during manual muscle testing for dorsiflexion, inversion, and eversion when compared bilaterally.

The foot, knee, and hip areas were cleared with range of motion, ligamentous, and muscle testing. However, there was tightness in his iliotibial band, which was revealed through the modified Thomas Test. We addressed this with gluteal and tensor fascia latae stretching.

Single-leg stance and squat tests were both performed poorly due to a lack of stability and mobility. The assessment testing indicated that closed-chain dorsiflexion was a limiting factor. If this movement is limited, then the entire kinetic linking system, from the foot to the torso and upper extremities, will be altered and lead to chronic ankle problems.

We assessed the athlete’s closed-chain dorsiflexion by having him kneel on the uninvolved side and place the involved foot on the floor. We then had him lean forward, closed-chain dorsiflexing the involved ankle. The athlete had decreased motion and pain when compared bilaterally. We believe this motion is a common problem area in chronic ankle injuries due to instability in the talocrural joint, causing anterior impingement.

Because he was weightbearing and able to do some closed-chain exercises when we first saw him, we taped the athlete’s ankle and did some stability techniques the very first day by placing a posterior stabilizing force on the medial and lateral malleolus during the closed-chain dorsiflexion movement as described above. The athlete’s motion and pain were tremendously improved during this technique. This movement was performed 10 times; the athlete was then instructed to perform a squat in order to incorporate the improved motion into a functional movement pattern. We then applied tape along the medial and lateral malleolus, pulling them posterior, the same as the stability technique. The athlete’s single-leg stance and functional movements were greatly improved after the stability technique and tape were applied.

At the same time, we treated the athlete’s ankle with a regimen of ice, elevation, and compression, as well as high-volt electrical stim. We continued to see the athlete at least four times a week for the first three weeks. He was held out of practice for two weeks and then started back in slowly.

During the treatment period we continued to work to improve the athlete’s closed-chain dorsiflexion through the stability technique and functional movements (squat, lunge, leg press) during the next few exercise sessions. We slowly weaned the athlete off the taping technique as we progressed with the functional movements and stability exercises.

When we repeated the functional movement and stability testing, as performed initially, after a couple weeks of therapeutic exercise, these tests were greatly improved. To maintain the closed-chain dorsiflexion and stability in the involved ankle in order to prevent the recurrence of ankle sprains, the athlete’s maintenance program included squats, in-line lunges, jumping rope, and various agility movements.

Case Study
Wrestling Back Pain
By Missy Strauch
Missy Strauch, ATC, CSCS, is Head Athletic Trainer at Augsburg College.

In September, a 20-year-old male college wrestler presented to the athletic training room prior to the start of wrestling practice complaining of low back pain at the L4 to L5 level. The mechanism of injury was unknown. This athlete reported having a water skiing incident the previous summer and continuing to work a construction job for the rest of the summer.

At the initial training room evaluation this athlete complained of vague mid to low back pain (T-10 to L5 levels), and showed negative straight-leg raise, negative Fabers test, and no myotome weakness or neurological symptoms. He reported most of his pain at approximately 40 to 50 degrees of standing trunk flexion. Trunk extension did not seem to create pain. The athlete is a very active and fit individual with good muscle tone. However, due to his back pain he was unable to train at the level of conditioning required for his sport.

Initial treatment consisted of ice, stretches, massage, electric stim and ultrasound, and abdominal and paraspinal strengthening. The team family practice physician, suspecting paraspinal strain, prescribed muscle energy techniques for neutral group left dysfunction, but this and adjustments by the team chiropractor failed to resolve the pain. X-rays showed no pars defects.

The athlete was prescribed anti-inflammatory medication, and his family-practice physician (who saw him because of the athlete’s insurance restrictions) ordered oblique views of the lumbar spine, which revealed bilateral spondylolysis at the L5 level. He recommended two months of restricted activity with possible referral for surgical fusion or bracing. This was not acceptable to the athlete.

I requested a physical therapy referral be written for core stabilization training. This was granted and, in January, the athlete started a regimen of physical therapy that continued to April.

The initial evaluation by the physical therapist found that forward trunk flexion continued to duplicate pain, and trunk extension, side bending, and rotation left also duplicated pain but to a lesser degree. Additional findings: reflexes normal, right hip flexor stronger than left, causing low back pain, no palpable “step-off” deformity, and hypertonicity marked tenderness over lumbar muscle group. The Sorenson test was only held for six seconds.

The treatment plan consisted of progressive strengthening, stretches, functional retraining, and manual therapy twice a week in the clinic. He was also instructed to continue with a similar program daily at home. After 18 visits, the athlete perceived significant improvements. Objectively, good core stabilization with advanced exercises, Sorenson test at 190 seconds, and lumber AROM were within normal limits.

The athlete reported to fall wrestling camp (one year after the initial complaint) stating that he still had some low back soreness. His summer regimen included only very mild manual labor, but he also stated that he was not very disciplined with daily back stabilization exercises. He was able to successfully strength train over the summer and reported a significant decrease in pain with wrestling activity. However, the pain was still there.

The athlete was then sent to see a physical therapist assistant trained as a certified Pilates instructor, who found that the athlete lacked flexibility in his hamstrings and upper thoracic muscle region. She also noted a lack of strength in his core muscles.

Other evaluation revealed that the hamstrings and adductors are weak in a shortened position, which contributes to the overuse of the iliopsoas, external rotators, and the rectus abdominis. With these weaknesses, he was unable to utilize his transverse abdominis (primary core muscle) effectively. The lack of transverse abdominis strength contributes to the overuse of the iliopsoas and erector spinae muscles. This information and further evaluation led us to believe that this athlete’s lumbar pain may not be coming from the diagnosed spondylolysis, but perhaps from the abnormal amount of stress put on the anterior lumbar spine at the origin of the psoas muscle.

After four Pilates sessions, the athlete reported an increase in flexibility, improved core strength, and, most importantly, little to no low back pain. He continues to strength train with Pilates techniques and is having a successful wrestling season this winter.

Case Study
Hidden Fractures
By Russell Zelko, Michelle LaForte, and Ian McLeod

Russell Zelko, MD, PC, is an orthopedic consultant to Cornell University,
Michelle LaForte, ATC, MAEd, is a former Assistant Athletic Trainer at Cornell, and Ian McLeod, ATC, MEd, is an Assistant Athletic Trainer at Arizona State University.

Four weeks into the season of her junior year, a 20-year-old female collegiate field hockey player had complaints of general weakness and an inability to perform at her maximal level. She especially felt weak in both legs and complained of a low-grade aching discomfort in both thighs and in the right knee. This discomfort began two weeks prior to the initial evaluation and had slowly progressed. Several weeks prior to the evaluation, the athlete had significantly increased her level of activity for preseason conditioning.

The athlete stated that during the summer she ran 45 minutes on a rubberized track three to four times a week. Formal field hockey practice then began and involved approximately two hours of constant running, 29 practices in 31 days, with 27 of those having occurred on artificial turf and two on grass. She did not engage in additional conditioning outside of practice. She had been a vegetarian for two years and denied ever having any menstrual irregularities.

The initial assessment by the athletic trainer revealed full range of motion and no obvious strength loss in her arms or legs. The athletic training staff suspected possible dehydration and fatigue from overuse and possible heat-related illness because temperatures had been above normal during the previous week and the athlete had not increased her fluid intake. The athlete was advised to decrease her activity and increase her fluid and electrolyte intake.

Ten days later, her thigh discomfort had increased and become more localized to the proximal mid-thighs. She also developed visible, unilateral muscle twitching of the right quadriceps every few hours lasting approximately five seconds at a time. The weakness and aching in her right quadriceps region had become more pronounced and constant. She said it felt like a chronic muscle pull. The muscle twitching gradually became more frequent and lasted for longer periods, especially after prolonged activity.

On re-evaluation, there was pain with combined hip movements of passive flexion, abduction, and external rotation. Later that evening, the team physician elicited a positive fulcrum test, a positive hop test, and focal thigh tenderness. The most persistent and unusual observation, however, was the repetitive muscle twitching of the right quadriceps muscle. The twitching occurred directly over the area in which the athlete experienced most of her pain.

Radiographs of the right hip and femur performed the following day (approximately three weeks after the onset of symptoms) revealed a small focal area of fine fuzzy periosteal elevation along the medial cortex of the proximal femoral shaft. A Technetium-99 bone scan performed the same day showed increased uptake in the focal area seen on the x-ray and also disclosed an area of increased uptake in the medial cortex of the mid-shaft of the opposite (left) femur. These studies confirmed not only unilateral but bilateral acute femoral stress fractures.

Although still rare, fractures of the femur are becoming increasingly common. This is the first case we are aware of with muscle twitching as a primary presenting symptom. If associated with muscular weakness and atrophy, muscle twitching can signify motor neuron disease, but may also be seen in diseases that affect the gray matter of the spinal cord. Widespread twitching also may occur with dehydration. In our case, the muscle twitching represented increased muscle irritability due to an underlying painful stimulus (occult stress fracture).

Treatment at that point included restriction from all running with walking limited to necessary daily activities only. The muscle twitching subsided approximately 10 days following activity restrictions. After two weeks of relative rest, aquatic therapy and work on a stationary bike were started three times weekly to maintain cardiovascular conditioning and to improve musculoskeletal strength and flexibility.

Radiographs performed three weeks later revealed increased healing callus formation and consolidation of both areas. Repeat fulcrum test caused less pain. The athlete noted that the symptoms and her limp initially increased even with activity restriction, but by the third week of restricted activities, they began to subside. Seven weeks after this point, she started into spring lacrosse, but continued to have low-grade discomfort during the entire season. After the end of the season, when she was able to cut back on activities further, her symptoms slowly receded, and she is now symptom-free.