IB CSL ORTHO

IB CSL ORTHO

OVERUSE SYNDROMES
Dr WY Ip

Ortho

Tue 08-10-02
OVERUSE SYNDROMES

Chronic repetitive injuries

Repetitive stress injuries

Cumulative injuries

Occur when activity > adaptive ability
Related (1) Wk (2) Sports

TYPES

Tendinitis
Bursitis (subacromial bursa)
Chronic m strains (microtear)
Compartment syndromes
Jt overload syndromes (synovitis)
Stress # (bone inj)

WHEN?

Manual/ Domestic/ Cleansing labour
Production line/ check-out chick
Typist
Computer operator

EFFECTS

Tissue fatigue
Pain
Inhibited function (brain inhibits normal movt)
Impaired function

CAUSES

Friction from repetitive activities

Unreasonable repetitive actions

Fast repetitions of movt (eg. typing)

Prolonged contraction of m

Physical deconditioning

¯ Force production in m

Stress at jt

Insufficient truncal + jt stabilisation (eg. back, ab, shoulder girdle m's)

Tissue o'load (® inflam ® m spasm ® adhesion/ fibrosis ® altered NM control ® m imbalance ® cumulative inj ® tissue trauma) = CUMULATIVE INJURY CYCLE

Muscle; Tendon; Synovium; Ligament; Bone; Jt nerve

M weakness \ m work at higher % max voluntary effort (usu do not use all MU in a m)

M imbalance (eg. shoulder: internal rotation > external)

Lack of strength + NM control (eg. play tennis when not properly trained)
Postural stress (eg. do not sit/ stand properly)
Poor technique (eg. ADL)
Pattern o'load
Repetitive movt (eg. repeatedly train bicep but not tricep)
Cumulative trauma

Loss of flexibility

Flexibility: normal extensibility of all ST allowing full ROM; need optimal NM control through entire range; synergistic movt (agonist/ antag/ stabiliser/ neutraliser)
Dynamic functional flexibility: integrated, multi-planar ST extensibility with optimal NM control through full ROM
Proper flexibility: combination of (1) ST extensibility (2) NM control
Suboptimal flexibility (1) Jt surface unevenly loaded (2) Jt alignment altered (3) Faulty static + dynamic posture

UPPER LIMB OVERUSE

Shoulder

Elbow

Wrist

Digits

SITES OF OVERLOAD

Muscle-tendon junction (eg. microtears, heal by fibrosis)

Watershed zone of tendon (¯ BS)

Bone-tendon junction (stress conc) (micro# tissue - focal necrosis - inflam response to attempt to repair - granulation tissue/ scar - degen D )

Bone under XS loading

Synovium

SHOULDER

SUPRASPINATOUS TENDINITIS

Extrinsic compression of supraspinatous tendon by subacromial arch, acromion, acromial ligament and clavicle during overhead activity
Blood supply to supraspinatous tendon from greater tuberosity + from supraspinatous m, resulting in watershed avascular zone
Stress conc at tendon insertion dur to vigorous rotator cuff contraction

SUBACROMIAL BURSITIS

Bursal reaction to extrinsic compression + intrinsic change

ELBOW

BICEPS TENDINITIS

TENNIS ELBOW: common extensor origin

GOLFER'S ELBOW: common flexor origin

WRIST

CARPAL TUNNEL SYNDROME: inflammation of tendon synovium, presses on median nerve (hard roof and hard floor/ carpal bones)

DIGITS

Tenosynovitis

When tendon glides through confined space or retinaculum, there is a layer of tenosynovium
Irritation occurs in repetitive use at a level exceeding normal tolerance
Reactive changes (1) Inflam (2) Repair (3) Scarring/ thickening
Path (1) Tendon microtear (2) Tendon sheath inflam

DE QUERVAIN'S DISEASE: tendon is pinched in its tendon sheath, making the straightening and bending of thumb painful

TRIGGER DIGITS: swollen tendon cannot move through its tendon sheath, so finger stays bent

ALSO

CHRONIC MUSCLE STRAIN (M OVERLOAD SYNDROME)

M ache, loss of function

Microtears within muscle, also microtears in tendon + fascia

Usu muscle-tendon junction

Previous adhesions after m resistance + ¯ arc of motion

Pre-existing m imbalance around jt predisposes to inj

Pain / swelling contribute to neural inhibition

MUSCLE COMPARTMENTAL SYNDROMES

Interference with arterial supply + obstruction of venous outflow
Build-up of intracompartmental pressures (1) Constraint by fascia (2) Hypertrophy of m (3) Fluid accumulation within compartment

JT OVERLOAD SYNDROMES

Reactive synovitis due to (1) Abn load (2) Abn range of excursion (3) Ab level of activities

BONE OVERLOAD SYNDROMES

Stress #

LOWER LIMB OVERUSE

Skin splint

Achilles tendinitis

Tibialis posterior tendinitis

Peroneal tendinitis

PREVENTION & TREATMENT OF OVERUSE SYNDROMES

PREVENTION

Interval rest
Work arrangement
Control speed
Chair + table
Tools + machine operation

TREATMENT

Rest ® (1) Relative rest (2) Modification of activity (3) Avoid further overuse

Conditioning prg for involved body part

Flexibility: ¯ strain at junctions (1) Bone-tendon (2) Tendon-m (3) Bone + jt

Correct m imbalance

m strength + endurance

Relearn proper movt

Physio

Ice, US, laser

Stretching to flexibility + improve general fitness

M strengthening + rebalancing

Ergonomic advice for work + sport (video-tape Pt when using computer + advise proper ht of equipment)
Splintage

Drug

NSAID
Steroid injection (local inflam pt)

Mechanism (1) Glucocorticoid - suppresses inflam (2) Mineralocorticoid - modifies salt + water balance (unwanted effect)

Indications (1) Local inflam prob (2) Known cause/ site of symptoms (3) No infection (3) Proper technique

Comb with other modalities (1) Oral/ local NSAID (2) Physio (3) OT

Site (1) Jt (2) Tenosynovium (3) Bursa (4) Tendon insertion (5) ST tender spot

Adv with LA (1) Proof of correct needle, rapid pain relief (2) Addition vol means wide dispersion (3) No mixing with LA if inject to small jt

Long-acting depot steroids (1) Within tiss for weeks (2) LT effect (2) ¯ Systemic effects

Repeat (1) 1-4 low-dose injection (2) No response? (3) Other Tx (eg. surg)

Post-injection symptoms (1) Short dur pain (2) Infection (3) Facial flushing/ redness

Precautions (1) Mark skin (2) Rest wt-bearing jt + avoid vigorous PA for 1w

Complications (1) Subcut atrophy (too much/ too superficial) (2) Cartilage damage (3) Infection (4) Systemic ( blood sugar in DM, osteoporosis, menstrual irregularity) (5) Tendon rupture (into tendon instead of tendon sheath)

Eg. Tennis elbow: injection beneath periosteum

Surgery

Release operation (eg. carpal tunnel, trigger finger)
Excision of inflamed tissue