Overuse injuries: tendinitis,

stress fractures, compartment syndrome,

and shin splints

Robert P. Wilder, MD, FACSM*, Shikha Sethi, MD

Department of Physical Medicine and Rehabilitation, The University of Virginia,

545 Ray C. Hunt Drive, Suite 240, P.O. Box 801004, Charlottesville, VA 22908-1004, USA

Approximately 50% of all sports injuries are secondary to overuse [1]. The

frequency of overuse injuries evaluated in primary care sports medicine clinics is

even greater, reportedly up to twice the frequency of acute injuries [2]. The majority

of injuries evaluated in running injury clinics are related to overuse [3,4], and

approximately half of these involve the lower leg (20%), ankle (15%), and foot

(15%) [5,6].

Overuse injuries result from repetitive microtrauma that leads to local tissue

damage in the form of cellular and extracellular degeneration, and are most likely to

occur when an athlete changes the mode, intensity, or duration of training—

a phenomenon described as the ‘‘principle of transition’’ [7,8]. Physical training

uses prescribed periods of intense activity to induce the desired goal of ‘‘supercompensation’’

or performance improvement. A mismatch between overload and

recovery can lead to breakdown on a cellular, extracellular, or systemic level,

however.At the cellular level, repetitive overload on tissues that fail to adapt to new

or increased demands can lead to tissue breakdown and overuse injury. It is

important to realize that, in theory, this subclinical tissue damage can accumulate

for some time before the person experiences pain and becomes symptomatic. On

the systemic level, rapid increases in training load without adequate recovery may

cause a global ‘‘overtraining syndrome.’’ Strong predictors of overuse musculoskeletal

injury include a previous history of injury as well as walking or running

more than 20 miles per week [9].

Both intrinsic and extrinsic factors contribute to overuse injuries. Intrinsic

factors are biomechanical abnormalities unique to a particular athlete and include

such features as malalignments, muscle imbalance, inflexibility, weakness, and

instability. High arches, for example, have been demonstrated to predispose to a

greater risk of musculoskeletal overuse injury than low arches (‘‘flat feet’’) in

military recruits [10]. Extrinsic (avoidable) factors that commonly contribute to

overload include poor technique, improper equipment, and improper changes in the

duration or frequency of activity. These improper changes in activity duration/

frequency or ‘‘training errors’’ are the most common causes of overuse injuries in

recreational athletes. Vulnerability to extrinsic overload varies with the intrinsic

risk factors of an individual athlete [7].

Sports-acquired deficiencies, categorized as an extrinsic risk factor, actually

represent the product of biomechanical abnormalities and training errors. Because

sports activity can overload an athlete’s musculoskeletal system in predictable

ways, athletic repetition without proper conditioning can propagate muscular

imbalance and flexibility deficits.

Injuries are often related to biomechanical abnormalities removed from the

specific site of injury, underscoring the importance of evaluation of the entire

kinetic chain [11].

Common overuse injuries of the lower leg, ankle, and foot include tendinopathies,

stress fractures, chronic exertional compartment syndrome, and shin

splints.