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Know Your Options For Treating Overuse Injuries

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Physical Therapist Nate Koch reviews and grades several treatment options for common overuse injuries.

Written by: Nate Koch, PT, ATC

Overuse injuries have been rampant in triathlon since its inception and will continue to do so long into the future. One study in 2003 reported that overuse injuries accounted for 68 percent of preseason and 78 percent of competition season injuries. The term overuse injury can encompass just about any injury in the sport that does not involve a collision. Some examples of overuse injuries are Achilles tendinosis/tendinopathy, plantar fasciosis, anterior knee pain, ITB syndrome and sciatica. The medical terminology that describes the overuse injury and available treatments can be overwhelming.

Recognizing that all injuries and potential treatments cannot be addressed in one article, the most common treatment options for overuse injuries are highlighted below.

Eccentric Exercise: An eccentric muscle contraction occurs when a muscle and its associated tendon have to work while the muscle is being lengthened, such as by doing a negative lift in the gym. A physical therapist or athletic trainer can give you instructions on proper form, resistance and frequency.

Pros: A plethora of high-quality research supports the clinical effectiveness of eccentric exercise over other treatments in the management of tendon injuries. It’s the most low-tech, cheapest and most effective treatment available. It can be done at home in most cases, and instruction by a clinician is covered by insurance.

Cons: Requires a visit to a physical therapist or a certified athletic trainer to receive instruction on technique and proper progression.

Grade: A+

Click the numbers below to see each of the treatment options.

ASTYM: Augmented Soft-Tissue Mobilization is typically performed by a physical therapist, physician or athletic trainer. The clinician must be certified in this technique. Specifically designed solid tools take the place of the clinician’s hands to stimulate healing in abnormal tissue without damaging normal tissue. ASTYM treatment couples the use of these tools with specific exercises designed for each particular injury.

Pros: The treatment provides relatively quick pain relief, which can take between one and 10 visits. Can resume normal exercise immediately after treatment. Covered by insurance. Can be used for prevention, to eliminate weak links and keep old injuries from recurring. Outcome studies provided by the company Performance Dynamics are favorable. Research has shown this treatment does actually change the injured tissue.

Cons: The treatment causes tissue soreness and possibly bruising. You must find a licensed clinician, and more research is needed on humans.

Grade: A

Click the numbers below to see each of the treatment options.

Graston Technique is typically performed by a chiropractor or physical therapist—. The clinician must be certified in this technique. Steel instruments are used to enhance the clinician’s ability to detect adhesions, scar tissue or restrictions in the affected areas. The instruments break up the scar tissue so that it can be absorbed by the body.

Pros: It provides relatively quick pain relief in one to 10 visits. You can resume normal exercise immediately after treatment, it’s covered by insurance and the outcome studies provided by the company, Graston Technique, are favorable.

Cons: The treatment causes tissue soreness and possibly bruising. You must find a licensed clinician. The majority of the research on this technique has been performed by the ASTYM folks, but more research is needed on humans.

Grade: A-

Click the numbers below to see each of the treatment options.

ART: Active Release Technique is typically performed by a chiropractor or physical therapist, who must be certified in this technique. It is a patented soft tissue system/movement-based massage technique. Clinicians use their hands to evaluate the texture, tightness and movement of the soft tissue. Abnormal tissues are treated by combining precisely directed tension with specific patient movements.

Pros: This treatment can provide relatively quick pain relief in 10 or fewer visits. It is non-invasive with no side effects. You can train immediately afterward, and it’s covered by insurance.

Cons: The treatment can be uncomfortable as a result of pressure. Research is limited and frequently has at least one methodological flaw, with most research being case studies and anecdotal reports. Research does not prove a positive change in the injured tissue. Much more research is needed to prove its short and long-term benefits.

Grade: B

Click the numbers below to see each of the treatment options.

PRP: Platelet-rich plasma injections are performed by a physician only. This procedure requires injecting some of the athlete’s own blood directly into the injured tissue. The plasma portion of the blood contains platelets, which release protein growth factors responsible for initiating the body’s healing process. The goal is to restore injured tissue to its normal state, not reduce inflammation.

Pros: While more research is necessary, the current research is encouraging, showing positive change in the injured tissue. It can be done in a physician’s office setting. The injury can improve after one injection, and there is minimal risk for complication.

Cons: Research is limited, and the procedure is not typically covered by insurance. It’s an expensive treatment that must be performed by a physician. Only light exercise is recommended. There can be injection site soreness. Complete healing can take four to six months and may require several injections.

Grade: B

Click the numbers below to see each of the treatment options.

IONTO: Iontophoresis is a localized medication in a patch form delivered directly to the injury location via electrical stimulation. This procedure is typically performed by a physician or physical therapist.

Pros: There are fewer side effects than with oral medication and cortisone injection. It’s typically covered by insurance. It’s a painless procedure that may provide pain relief within the first five sessions.

Cons: The pain relief is only short-term. The research has shown varied and inconsistent results. The treatment does not result in a positive change in tissue.

Grade: C+

Click the numbers below to see each of the treatment options.

LLLT: Low Level Laser Therapy is sometimes referred to as cold laser therapy. It uses low-level lasers or light-emitting diodes to stimulate or inhibit cellular function. The exact mechanism is unknown, and it is theorized that the laser light can penetrate deep into the injured tissue. It’s typically performed by a chiropractor or physical therapist.

Pros: There is no pain or discomfort with delivery of this treatment, and it only takes between two and six minutes.

Cons: Research is limited and is typically done by manufacturers. There is limited agreement among clinicians on the most efficacious dosage and parameter choices. The results are varied and inconsistent. It is typically not covered by insurance.

Grade: C

Click the numbers below to see each of the treatment options.

NSAIDs, or Non-Steroidal Anti-Inflammatory Drugs. You can get NSAIDs over the counter or as a prescription from a physician. Some examples are aspirin, ibuprofen and Aleve.

Pros: They provide quick pain relief and are easily available.

Cons: They provide only short-term pain relief. Some side effects are gastrointestinal distress, increased incidence of hyponatremia in endurance athletes, myocardial infarction and bleeding. They do not result in a positive change in tissue.

Grade: C-

Click the numbers below to see each of the treatment options.

Cortisone Injections are performed by a licensed physician and involve an injection of cortisone directly into the injured tissue. It’s usually mixed with a numbing agent like lidocaine. It’s used to suppress inflammation. The physician may use fluoroscopy (X-ray-guided technology) or a diagnostic ultrasound to determine the best location for the injection.

Pros: It provides quick pain relief and is covered by insurance in most cases.

Cons: The relief is short-term. It comes with a recommendation of time off from training. The side effects are potential fascia/tendon rupture and skin irritations. While it may decrease inflammation, it does not result in a positive change in tissue. Plus, it can be an expensive procedure.

Grade: D

This should be a last resort before looking into surgical options. Definitely consider PRP before taking this step.

Before deciding on a treatment option, it is best to consult a sports medicine clinician. Furthermore, in order to optimize your treatment choice, it is crucial that a biomechanical assessment be performed by a licensed physical therapist to determine the underlying cause of injury. Remember that these treatment tools are only as good as the hands that wield them. Most of these injuries are preventable, fixable and require a team approach to most effectively recover.

My experience treating endurance athletes leads me to recommend ASTYM and eccentric exercise as the most effective treatments of overuse injuries from those discussed above. While ASTYM and Graston are very similar, I give a slight edge to ASTYM since it was developed by a physician and physical therapist, and they continue to advance the research. ASTYM is taught more as a treatment process or philosophy. Our athletes and clinicians prefer an active treatment approach that allows continued training, focuses on normal tissue healing and is backed by research.

Nate Koch is a physical therapist and certified athletic trainer. He owns Endurance Rehabilitation in Scottsdale, Ariz.