Project: Ghana Emergency Medicine Collaborative
Document Title: Overuse Syndrome
Author(s): Joseph H. Hartmann, DO
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for more information see: http://open.umich.edu/wiki/AttributionPolicy

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Overuse Syndrome
Joseph H. Hartmann, DO
A rose is a rose…
• 
• 
• 
• 
• 
• 

Overuse syndrome
Repetitive stress disorder / injury
Repetitive motion disorder / inj...
What is it?
•  Repetitive activity over a variable course of
time resulting in damage to tissue, usually
muscular or ligam...
Literary Digest,
Wikimedia Commons
Unknown, Wikimedia Commons
Unknown, Wikimedia Commons
Bart, Flickr
Pathophysiology
•  Tissue adaptation can not occur preventing
healing
•  Persistent trauma causes escalating injury
–  Mec...
Clinical Presentation - Hx
•  Begin with PQRST questions
•  More specific detailing of suspected
offending activity
–  Rep...
Clinical Presentation – P.E.
• 
• 
• 
• 

Tenderness
Diminished ROM (active / passive)
Diminished strength
Tissue edema (?...
Laboratory Studies
•  May or may not be indicated
•  General metabolic
–  CBC, comprehensive medical panel with liver
func...
Imaging Studies
•  May or may not be indicated
–  Acute on chronic injury
–  Significant worsening changes (unexplainable)...
Radiographs
•  Bony avulsions
•  Stress fractures
•  Chronic tendonitis
–  Calcification of tendons

•  Myositis ossifican...
Source Undetermined
Source Undetermined
Source Undetermined
Ultrasound
•  Ligament and tendon pathology
–  Opportunity for dynamic examination

•  Higher resolution transducers provi...
Magnetic Resonance Imaging
•  Historically more effective with acute injury
than with more subtle findings associated
with...
Electrodiagnostic Studies
•  EMG - NCT
–  Peripheral nerve compression / injury
•  Location
•  Severity

•  MRI ?
Treatment
• 
• 
• 
• 

Rest
Analgesics
Immobilization (?)
Physical therapy
–  Supervised
•  To more carefully plan tx prog...
Treatment
•  Occupational therapy
–  Tailor physical therapy
–  Identify workplace modifications

•  Sports medicine thera...
Treatment
•  Steroid injections
–  Ligaments and tendons can undergo structural
weakening leading to potential rupture

• ...
Shoulder
•  Impingement syndrome
–  Compression of supraspinatus tendon and
subacromial bursa
–  Pain with abduction (Neer...
National Institute Of Arthritis And Musculoskeletal And Skin Diseases,
Wikimedia Commons
Elbow
•  Epicondylitis
–  Lateral epicondylitis
•  Extensor carpi radialis brevis and longus
•  “tennis elbow”

–  Medial ...
Gray’s Anatomy,
Wikimedia Commons
Wrist and Hand
•  Carpal tunnel syndrome
–  Median nerve entrapment
–  Symptoms typically worse at night
–  Typical sensor...
Gray’s Anatomy, Wikimedia Commons
Wrist and Hand
•  deQuervain’s tenosynovitis
–  Involves abductor pollicus longus and brevis
–  Repetitive gripping / gras...
PhilippN, Wikimedia Commons

Gray’s Anatomy, Wikimedia Commons
Hip
•  Snapping hip syndrome
–  Usually from “iliotibial band snap”
•  Snapping of thick,wide iliotibial tendon over great...
Beth Ohara, Wikimedia Commons
Gray’s Anatomy,
Wikimedia Commons
Knee
•  Patellofemoral pain syndrome
(chondromalacia patella) – “runner’s
knee”
–  Pain posterior to patella / anterior kn...
Kari Stammen, Wikimedia Commons
Medial Tibial Stress Syndrome
• 
• 
• 
• 

“shin splints”
Posteromedial margin of tibia
Dull aching discomfort relieved by...
en:Anatomography, Wikimedia Commons

Gray’s Anatomy,
Wikimedia Commons
Chronic Compartment Syndrome
•  Masquerades as other pain syndromes
•  Aching pain or cramping within 10-30 min
in region ...
Sarte, Wikimedia Commons
Ankle / Foot
•  Achilles tendonitis
–  Heel pain
–  Worse with dorsi-flexion
–  Retrocalcaneal bursa involvement
•  Swelli...
Gray’s Anatomy, Wikimedia Commons
Posterior Tibial Tendonitis
•  Pain over medial ankle
–  Worse with inversion
–  Inability to stand on toes
–  Tenderness ...
Plantar Fasciitis
• 
• 
• 
• 

Involves plantar aponeurosis
Plantar heel and / or mid-foot pain
Passively dorsi-flex toes ...
Wikimedia Commons
Lucien Monfils, Wikimedia Commons
Davius, Wikimedia Commons
Finally
•  Lengthy recovery times
–  4 – 6 weeks common
–  6 months possible

•  Return to pre-injury activities
–  Comple...
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GEMC- Overuse Syndrome- Resident Training

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This is a lecture by Dr. Joseph Hartmann from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Overuse Syndrome- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Overuse Syndrome Author(s): Joseph H. Hartmann, DO License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that 2 your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Overuse Syndrome Joseph H. Hartmann, DO
  4. 4. A rose is a rose… •  •  •  •  •  •  Overuse syndrome Repetitive stress disorder / injury Repetitive motion disorder / injury Repetitive strain disorder / injury Cumulative trauma disorder Musculoskeletal disorder
  5. 5. What is it? •  Repetitive activity over a variable course of time resulting in damage to tissue, usually muscular or ligamentous / tendinous (nerve entrapment also included). •  Repetitive activities –  Occupational –  Recreational (sport-related) –  Habitual (Nintendo thumb, Nintendinits, gamer’s thumb, PlayStation thumb)
  6. 6. Literary Digest, Wikimedia Commons
  7. 7. Unknown, Wikimedia Commons
  8. 8. Unknown, Wikimedia Commons
  9. 9. Bart, Flickr
  10. 10. Pathophysiology •  Tissue adaptation can not occur preventing healing •  Persistent trauma causes escalating injury –  Mechanical effects –  Biochemical effects •  Free radicals, prostaglandins, proinflammatory interleukins –  ? Genetic effects
  11. 11. Clinical Presentation - Hx •  Begin with PQRST questions •  More specific detailing of suspected offending activity –  Repetitive activity (mechanism) –  Technique employed •  Limbs malpositioned from neutral position –  Equipment used / worn
  12. 12. Clinical Presentation – P.E. •  •  •  •  Tenderness Diminished ROM (active / passive) Diminished strength Tissue edema (?) –  Swelling of bursae, synovial sheaths •  Evidence of musculoskeletal compensation •  Classically recognized presentations
  13. 13. Laboratory Studies •  May or may not be indicated •  General metabolic –  CBC, comprehensive medical panel with liver function testing, TSH •  Rheumatologic –  ESR, CRP, ANA, RPR
  14. 14. Imaging Studies •  May or may not be indicated –  Acute on chronic injury –  Significant worsening changes (unexplainable) –  Mechanism of injury questioned
  15. 15. Radiographs •  Bony avulsions •  Stress fractures •  Chronic tendonitis –  Calcification of tendons •  Myositis ossificans •  Bone scan / CT –  Stress fractures
  16. 16. Source Undetermined
  17. 17. Source Undetermined
  18. 18. Source Undetermined
  19. 19. Ultrasound •  Ligament and tendon pathology –  Opportunity for dynamic examination •  Higher resolution transducers provide higher spatial resolution rivaling MRI •  Procedural and professional costs are 20% that of comparable MRI study
  20. 20. Magnetic Resonance Imaging •  Historically more effective with acute injury than with more subtle findings associated with chronic injury •  Newer generation units, increasing experience, use of gandolinium enhancement with fat saturation (identifies inflammation) has provided excellent soft-tissue resolution
  21. 21. Electrodiagnostic Studies •  EMG - NCT –  Peripheral nerve compression / injury •  Location •  Severity •  MRI ?
  22. 22. Treatment •  •  •  •  Rest Analgesics Immobilization (?) Physical therapy –  Supervised •  To more carefully plan tx program •  Use of modalities •  Patient education –  Home exercise program
  23. 23. Treatment •  Occupational therapy –  Tailor physical therapy –  Identify workplace modifications •  Sports medicine therapy –  Sport specific physical therapy –  More knowledgably address •  Training issues •  Technique flaws •  Ill-fitting equipment
  24. 24. Treatment •  Steroid injections –  Ligaments and tendons can undergo structural weakening leading to potential rupture •  Surgery –  Failed conservative management •  Nerve decompression •  Ligament repair (laxity) –  Dismal outcomes if performed for subjective pain relief without objective findings
  25. 25. Shoulder •  Impingement syndrome –  Compression of supraspinatus tendon and subacromial bursa –  Pain with abduction (Neer maneuver) and flexion / internal rotation (Hawkins maneuver) –  Subacromial tenderness –  Normal ROM –  Normal strength
  26. 26. National Institute Of Arthritis And Musculoskeletal And Skin Diseases, Wikimedia Commons
  27. 27. Elbow •  Epicondylitis –  Lateral epicondylitis •  Extensor carpi radialis brevis and longus •  “tennis elbow” –  Medial epicondylitis •  Flexor carpi radialis •  “golfer’s elbow” –  Pain with strong gripping –  Decreased grip strength –  Normal ROM
  28. 28. Gray’s Anatomy, Wikimedia Commons
  29. 29. Wrist and Hand •  Carpal tunnel syndrome –  Median nerve entrapment –  Symptoms typically worse at night –  Typical sensory distribution –  Flattening of thenar eminence –  Thumb adduction weakness –  Hoffman-Tinel test – tapping –  Phalen maneuver - flexion
  30. 30. Gray’s Anatomy, Wikimedia Commons
  31. 31. Wrist and Hand •  deQuervain’s tenosynovitis –  Involves abductor pollicus longus and brevis –  Repetitive gripping / grasping motions –  Local tenderness over radial styloid region –  Pain with resisted thumb extension/abduction –  Pain with passive ulnar deviation with thumb adducted in palm – Finkelstein maneuver
  32. 32. PhilippN, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons
  33. 33. Hip •  Snapping hip syndrome –  Usually from “iliotibial band snap” •  Snapping of thick,wide iliotibial tendon over greater trochanter with hip extension –  Snapping sensation –  Audible “pop” –  Commonly seen in runners –  May cause a trochanter bursitis
  34. 34. Beth Ohara, Wikimedia Commons
  35. 35. Gray’s Anatomy, Wikimedia Commons
  36. 36. Knee •  Patellofemoral pain syndrome (chondromalacia patella) – “runner’s knee” –  Pain posterior to patella / anterior knee –  Pain with compression of patella or with resisted knee extension –  Repetitive irritation – increased lateral forces on patella –  More commonly seen in women (anatomy)
  37. 37. Kari Stammen, Wikimedia Commons
  38. 38. Medial Tibial Stress Syndrome •  •  •  •  “shin splints” Posteromedial margin of tibia Dull aching discomfort relieved by rest Progresses to worsening discomfort not relieved by rest •  ? Hyposthesia over fourth toe •  r/o stress fx – “female athlete triad”
  39. 39. en:Anatomography, Wikimedia Commons Gray’s Anatomy, Wikimedia Commons
  40. 40. Chronic Compartment Syndrome •  Masquerades as other pain syndromes •  Aching pain or cramping within 10-30 min in region of particular compartment •  Exaggeration of normal exercise response –  Increased blood flow = increased muscle volume = decreased blood flow = compartment pressures above 20 mmHg •  Return to normal function between episodes •  Non-urgent fasciotomy (?)
  41. 41. Sarte, Wikimedia Commons
  42. 42. Ankle / Foot •  Achilles tendonitis –  Heel pain –  Worse with dorsi-flexion –  Retrocalcaneal bursa involvement •  Swelling, erythema, warmth
  43. 43. Gray’s Anatomy, Wikimedia Commons
  44. 44. Posterior Tibial Tendonitis •  Pain over medial ankle –  Worse with inversion –  Inability to stand on toes –  Tenderness over tendon sheath –  Often pronated flat foot found = overly-inverted •  Tarsal Tunnel Syndrome –  Nerve entrapment of posterior tibial nerve
  45. 45. Plantar Fasciitis •  •  •  •  Involves plantar aponeurosis Plantar heel and / or mid-foot pain Passively dorsi-flex toes and palpate sole Bilateral presentation 1/3 of patients
  46. 46. Wikimedia Commons
  47. 47. Lucien Monfils, Wikimedia Commons
  48. 48. Davius, Wikimedia Commons
  49. 49. Finally •  Lengthy recovery times –  4 – 6 weeks common –  6 months possible •  Return to pre-injury activities –  Complete resolution on pain –  Full range of motion –  At least 90% recovered strength •  Prevention –  Education –  Modification

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