eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes
Overuse Injury: Treatment & Medication
Updated: Mar 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Relative rest, particularly avoidance of the inciting activity, is a hallmark component of treatment. Using the involved area in nonpainful ways often helps maintain ROM. Total bed rest is virtually never advisable for these patients. Participation in a carefully planned physical therapy program is important for the following reasons:
- Patient education
- Supervised use of the injured part15
- Appropriate use of modalities (eg, transcutaneous electrical nerve stimulation units, similar electrical treatments, ultrasound/phonophoresis, iontophoresis, heat/cold)
- Development of a home exercise program
- Psychosocial benefits related to frequent interaction with an active partner in the treatment regimen
The physical therapy program also offers the patient the chance to see that movement will not lead to ongoing tissue damage, thus preventing significant "sick behaviors" or kinesophobia.
Overuse injury in athletes is commonly caused by ill-fitting equipment (eg, in cycling), overtraining/over-reaching (eg, with regard to triathlons, marathons, etc.), or technique flaws.16,17 Specialized bike-fitting is available, sports psychology is worthwhile in combating overtraining, and sport-specific coaching is often invaluable. Coaches, athletes, and physicians must work together to correct these problems and maintain a healthy musculoskeletal system.
See also the following related Medscape topic:
Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes
Occupational Therapy
Occupational therapists with experience in this field can help to identify workplace modifications. In cases of individuals with disabilities who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Often, simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself confer relief.
Vocational rehabilitation and work-hardening programs are often effective for bringing motivated patients back into the workforce. Integration of this type of program has proven to be effective in the corporate world and has decreased the overall financial impact of overuse injuries in the workplace.
Medical Issues/Complications
Significant medical complications are quite rare with conservative treatment of these disorders. Adverse drug reactions and side effects occur, but they usually resolve with cessation of the medication. Comorbidities, such as diabetes, may be exacerbated by medications, particularly injections of steroids, which may yield elevations in blood glucose levels. Injections and surgical procedures may be accompanied by bleeding or infection. Insufficient treatment may result in chronic pain and disability, depression, and insomnia. These complications may require additional, more complex treatment.
Surgical Intervention
Surgical intervention is undertaken if conservative approaches fail and if the injury is amenable to surgery. In overuse injury, decompression of nerves and repair of lax or failed ligaments are the most common problems that lead to surgery. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.
Consultations
Overuse injuries in athletes are often most effectively treated by a physician with experience in sports medicine and a thorough knowledge of the kinetic chain. Patients with injuries stemming from the performing arts are also often best served by a physician who deals extensively with that population. Consultation with an orthopedist or neurosurgeon is appropriate if conservative measures are unsuccessful.
Medication
Injection of involved structures with combinations of corticosteroids and local anesthetics frequently is quite helpful in persons with overuse injury. Pain relief enables more effective participation in therapy, and it may help to limit the likelihood that the patient will develop a chronic pain syndrome. In most cases, injections should be performed after less invasive measures fail. Rarely, immediate relief of pain may be necessary to allow participation in an athletic or performing arts event, and this can be achieved through injection therapy. Techniques for the injection of specific structures are described in more specific articles in the eMedicine Journal (eg, see the related eMedicine topic Corticosteroid Injections of Joints and Soft Tissues).
Nonsteroidal anti-inflammatory drugs (NSAIDs) are mainstays in the treatment of overuse injuries. However, considerable evidence has been revealed that true inflammation is rarely a component of these disorders, especially tendinopathies. Consequently, the use of simple analgesics has become more prevalent in the treatment of such disorders.
Muscle relaxants, opiates, corticosteroids, tricyclic antidepressants, and sleep medications have a role in the tailored treatment of individuals with overuse injury.
See also the following related eMedicine topic:
Chronic Pain Syndrome
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Used for pain relief and reduction of inflammation.
Cortisone (Cortone)
Reduces inflammation. Decreases inflammation by suppressing migration of PMN leukocytes and reversing increased capillary permeability.
Adult
25-300 mg/d PO/IM divided q12-24h
Pediatric
0.5-0.75 mg/kg/d PO/IM or 20-25 mg/m2/d divided q8h; alternatively, 0.25-0.35 mg/kg/d IM qd or 12.5 mg/m2/d
Co-administration with estrogen may increase levels; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin lesions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, diabetes, and myasthenia gravis
Nonsteroidal anti-inflammatory drugs
Most commonly used for relief of mild to moderate pain. Effects in treatment of pain tend to be patient-specific.
Diclofenac (Voltaren, Cataflam)
Used to reduce inflammation; inhibits prostaglandin synthesis by decreasing activity of COX enzyme, which, in turn, decreases formation of prostaglandin precursors.
Adult
25 mg PO bid/tid
If well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response obtained or total daily dose of 150-200 mg reached; higher doses generally do not increase effectiveness
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS or to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with pre-existing renal disease or compromised renal perfusion; low WBC counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs
Muscle relaxants
Thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. May have an inhibitory effect on the parasympathetic nervous system.
Cyclobenzaprine (Flexeril)
Acts centrally and reduces motor activity of tonic somatic origins, influencing alpha and gamma motor neurons. Structurally related to TCAs. Skeletal muscle relaxants have modest, short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established. Often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Adult
20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d
Pediatric
Not established
Co-administration with MAOIs and TCAs may increase toxicity; may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced
Documented hypersensitivity; MAOIs within last 14 d
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in angle-closure glaucoma and urinary hesitance
Narcotic analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties, which are beneficial for patients who have sustained injuries.
Hydrocodone and acetaminophen (Vicodin, Vicodin ES, Lorcet-HD, Norcet, Lortab)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn; not to exceed total of 4 g/d acetaminophen
Pediatric
<12 years: 10-15 mg/kg acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Co-administration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; high-altitude cerebral edema or elevated ICP
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tab contains metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Tricyclic antidepressants
Used in the treatment of overuse injury, not for their antidepressant effects but as adjunct pain medications. Act synergistically with narcotic analgesics and appear to alter brainstem pain processing. Their sedating effects also may be used advantageously if the patient's sleep is disrupted.
Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain.
Adult
30-100 mg/d PO hs
Pediatric
Children: 0.1 mg/kg PO hs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses
Phenobarbital may decrease effects; co-administration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances; history of hyperthyroidism or renal or hepatic impairment; avoid using in elderly patients
Anxiolytic agents
Sleep-inducing medications are used in overuse injury when the patient's sleep is disrupted because of discomfort from the injury.
Zolpidem (Ambien)
Structurally dissimilar to benzodiazepine but similar in activity, with exception of having reduced effects on skeletal muscle and seizure threshold.
Adult
10 mg PO hs; not to exceed 10 mg
Pediatric
Not established
Increases toxicity of alcohol and CNS depressants
Documented hypersensitivity; breastfeeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor elderly patients for impaired cognitive or motor performance
More on Overuse Injury |
| Overview: Overuse Injury |
| Differential Diagnoses & Workup: Overuse Injury |
 Treatment & Medication: Overuse Injury |
| Follow-up: Overuse Injury |
| References |
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References
Flick J, Devkota A, Tsuzaki M, et al. Cyclic loading alters biomechanical properties and secretion of PGE2 and NO from tendon explants. Clin Biomech (Bristol, Avon). Jan 2006;21(1):99-106. [Medline].
Arnoczky SP, Lavagnino M, Egerbacher M. The mechanobiological aetiopathogenesis of tendinopathy: is it the over-stimulation or the under-stimulation of tendon cells?. Int J Exp Pathol. Aug 2007;88(4):217-26. [Medline].
Archambault JM, Jelinsky SA, Lake SP, et al. Rat supraspinatus tendon expresses cartilage markers with overuse. J Orthop Res. May 2007;25(5):617-24. [Medline].
Devkota AC, Tsuzaki M, Almekinders LC, et al. Distributing a fixed amount of cyclic loading to tendon explants over longer periods induces greater cellular and mechanical responses. J Orthop Res. Aug 2007;25(8):1078-86. [Medline].
Le P, Solomonow M, Zhou BH, et al. Cyclic load magnitude is a risk factor for a cumulative lower back disorder. J Occup Environ Med. Apr 2007;49(4):375-87. [Medline].
Moore A, Wells R. Effect of cycle time and duty cycle on psychophysically determined acceptable levels in a highly repetitive task. Ergonomics. Jun 10 2005;48(7):859-73.
Nakama LH, King KB, Abrahamsson S, et al. Effect of repetition rate on the formation of microtears in tendon in an in vivo cyclical loading model. J Orthop Res. Sep 2007;25(9):1176-84. [Medline].
Bongers PM, Kremer AM, ter Laak J. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist?: A review of the epidemiological literature. Am J Ind Med. May 2002;41(5):315-42. [Medline].
Melhorn JM. Cumulative trauma disorders and repetitive strain injuries. The future. Clin Orthop. Jun 1998;(351):107-26. [Medline].
Hart DA, Archambault JM, Kydd A, et al. Gender and neurogenic variables in tendon biology and repetitive motion disorders. Clin Orthop. Jun 1998;(351):44-56. [Medline].
Pritchard MH, Pugh N, Wright I, et al. A vascular basis for repetitive strain injury. Rheumatology (Oxford). Jul 1999;38(7):636-9. [Medline].
IJmker S, Huysmans MA, Blatter BM, et al. Should office workers spend fewer hours at their computer? A systematic review of the literature. Occup Environ Med. Apr 2007;64(4):211-22. [Medline].
Andersen JH, Harhoff M, Grimstrup S, et al. Computer mouse use predicts acute pain but not prolonged or chronic pain in the neck and shoulder. Occup Environ Med. Feb 2008;65(2):126-31. [Medline].
Banks KP, Ly JQ, Beall DP, et al. Overuse injuries of the upper extremity in the competitive athlete: magnetic resonance imaging findings associated with repetitive trauma. Curr Probl Diagn Radiol. Jul-Aug 2005;34(4):127-42.
Meltzer KR, Standley PR. Modeled repetitive motion strain and indirect osteopathic manipulative techniques in regulation of human fibroblast proliferation and interleukin secretion. J Am Osteopath Assoc. Dec 2007;107(12):527-36. [Medline]. [Full Text].
Brenner JS,. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. Jun 2007;119(6):1242-5. [Medline].
Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Phys Med Rehabil Clin N Am. Aug 2005;16(3):651-67, vi.
Ireland DC. Australian repetition strain injury phenomenon. Clin Orthop. Jun 1998;(351):63-73. [Medline].
MacEachen E. The demise of repetitive strain injury in sceptical governing rationalities of workplace managers. Sociol Health Illn. May 2005;27(4):490-514.
Szeto GP, Straker LM, O'Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work--2: neck and shoulder kinematics. Man Ther. Nov 2005;10(4):281-91.
Szeto GP, Straker LM, O'Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work--1: neck and shoulder muscle recruitment patterns. Man Ther. Nov 2005;10(4):270-80.
Allan DA. Structure and physiology of joints and their relationship to repetitive strain injuries. Clin Orthop. Jun 1998;(351):32-8. [Medline].
Armstrong AJ, McMahon BT, West SL, et al. Workplace discrimination and cumulative trauma disorders: the national EEOC ADA research project. Work. 2005;25(1):49-56.
Barr AE, Barbe MF, Clark BD. Work-related musculoskeletal disorders of the hand and wrist: epidemiology, pathophysiology, and sensorimotor changes. J Orthop Sports Phys Ther. Oct 2004;34(10):610-27. [Medline].
Bernard BP, ed. Musculoskeletal Disorders and Workplace Factors. Cincinnati, Ohio: National Institute for Occupational Safety and Health; July 1997. [Full Text].
Bonde JP, Mikkelsen S, Andersen JH, et al. Understanding work related musculoskeletal pain: does repetitive work cause stress symptoms?. Occup Environ Med. Jan 2005;62(1):41-8. [Medline].
Bozentka DJ. Cubital tunnel syndrome pathophysiology. Clin Orthop. Jun 1998;(351):90-4. [Medline].
Cailliet R. Foot and Ankle Pain. 3rd ed. Philadelphia, Pa: FA Davis; 1997.
Cailliet R. Knee Pain and Disability. 3rd ed. Philadelphia, Pa: FA Davis; 1992.
Cailliet R. Neck and Arm Pain. 3rd ed. Philadelphia, Pa: FA Davis; 1991.
Cohen RB, Williams GR Jr. Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clin Orthop. Jun 1998;(351):95-101. [Medline].
Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. Nov 2003;181(5):1245-9. [Medline]. [Full Text].
Geraci MC, Brown W. Evidence-based treatment of hip and pelvic injuries in runners. Phys Med Rehabil Clin N Am. Aug 2005;16(3):711-47.
Hadler NM. Coping with arm pain in the workplace. Clin Orthop. Jun 1998;(351):57-62. [Medline].
Hoppenfeld S. Physical Examination of the Spine and Extremities. New York, NY: Appleton-Century-Crofts; 1976.
Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. Sep-Oct 1999;27(5):585-93. [Medline].
Lassen CF, Mikkelsen S, Kryger AI, et al. Elbow and wrist/hand symptoms among 6,943 computer operators: a 1-year follow-up study (the NUDATA study). Am J Ind Med. Nov 2004;46(5):521-33.
Lassen CF, Mikkelsen S, Kryger AI, et al. Risk factors for persistent elbow, forearm and hand pain among computer workers. Scand J Work Environ Health. Apr 2005;31(2):122-31. [Medline].
Lazzarini KM, Troiano RN, Smith RC. Can running cause the appearance of marrow edema on MR images of the foot and ankle?. Radiology. Feb 1997;202(2):540-2. [Medline]. [Full Text].
Maganaris CN, Narici MV, Reeves ND. In vivo human tendon mechanical properties: effect of resistance training in old age. J Musculoskelet Neuronal Interact. Jun 2004;4(2):204-8. [Medline].
Morton JP, Atkinson G, MacLaren DP, et al. Reliability of maximal muscle force and voluntary activation as markers of exercise-induced muscle damage. Eur J Appl Physiol. Aug 2005;94(5-6):541-8.
Novak CB. Upper extremity work-related musculoskeletal disorders: a treatment perspective. J Orthop Sports Phys Ther. Oct 2004;34(10):628-37. [Medline].
Novak CB, Mackinnon SE. Nerve injury in repetitive motion disorders. Clin Orthop. Jun 1998;(351):10-20. [Medline].
Plastaras CT, Rittenberg JD, Rittenberg KE, et al. Comprehensive functional evaluation of the injured runner. Phys Med Rehabil Clin N Am. Aug 2005;16(3):623-49.
Rooks MD, Johnston RB 3rd, Ensor CD, et al. Injury patterns in recreational rock climbers. Am J Sports Med. Nov-Dec 1995;23(6):683-5. [Medline].
Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am. Jul 1995;26(3):547-59. [Medline].
Scheer SJ, Mital A. Ergonomics. Arch Phys Med Rehabil. Mar 1997;78(3 Suppl):S36-45. [Medline].
Shah SN, Miller BS, Kuhn JE. Chronic exertional compartment syndrome. Am J Orthop. Jul 2004;33(7):335-41. [Medline].
Sheon RP. Repetitive strain injury. 1. An overview of the problem and the patients. The Goff Group. Postgrad Med. Oct 1997;102(4):53-6, 62, 68. [Medline].
Sjogaard G, Sogaard K. Muscle injury in repetitive motion disorders. Clin Orthop. Jun 1998;(351):21-31. [Medline].
Szabo RM. Carpal tunnel syndrome as a repetitive motion disorder. Clin Orthop. Jun 1998;(351):78-89. [Medline].
Toledo SD, Nadler SF, Norris RN, et al. Sports and performing arts medicine. 5. Issues relating to musicians. Arch Phys Med Rehabil. Mar 2004;85(3 Suppl 1):S72-4.
Viikari-Juntura E. Risk factors for upper limb disorders. Implications for prevention and treatment. Clin Orthop. Jun 1998;(351):39-43. [Medline].
Werner RA, Franzblau A, Gell N, et al. A longitudinal study of industrial and clerical workers: predictors of upper extremity tendonitis. J Occup Rehabil. Mar 2005;15(1):37-46. [Medline].
Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physician. Sep 1 2005;72(5):811-8. [Medline].
Further Reading
Keywords
repetitive stress disorder, repetition strain injury, cumulative trauma disorder, secondary gain, malingering, worker's compensation fraud, workers compensation fraud, worker's compensation abuse, workers compensation abuse, worker's compensation, workman's comp, overuse injuries, cumulative trauma disorder, repetitive demand injuries, occupational injury
