Diseasification of Exercise aka Overuse Injury, pt. 3 of 3

written by Robert Truax, DO

I dislike the term overuse.

Merriam-Webster dictionary defines exercise . . .

Noun: regular or repeated use of a faculty or organ

Verb: to use repeatedly in order to strengthen or develop

From an exercise physiological perspective, exercise is only exercise if the body is engaged in some form of exertion and the exertion is repeated so as to improve overall performance.

So, exercise is the use of muscles over and over again.

The most common diagnosis of a musculoskeletal (MSK) problem is overuse injury . . . and injury is disease.

To put this in a syllogism . . .

Exercise is use, over and over again to exertion. In other words, overuse.

Overuse is a disease.

Therefore, exercise is a disease.

Do you see the problem?

There's no objective criteria for an overuse injury.

A non-traumatic shoulder pain or hip pain is often diagnosed as an overuse injury. Yet, the term overuse is so non-specific that you don’t know what it actually is.

This makes it ripe for misunderstanding. And what do many people, including some physicians, understand overuse to mean?

Regrettably, exercise.

“I stand too much.” “I walk too much.”  “I run too much.”

Unfortunately, if a person has pain that seems to get worse with activity, it might seem logical to blame that activity as the cause.

BUT, another logical reason is that the activity is revealing an imbalance or weakness in some area of your musculoskeletal system, leading to muscle fatigue and consequently, pain.

 

Blaiming the Activity

When you blame the activity as the cause of a problem, the logical solution would seem to be to stop the activity.

This may stop the pain but does it really fix the problem?

If a car is pulling to the left, will it drive straight if it stays in the garage, undriven, for 4-6 weeks?

A 34-year-old came to me for left hip pain that made it difficult for her to play soccer.

When she saw me, she had already been evaluated by a sports medicine physician (who was also a team physician for a professional sports team) who did not find any reason for the pain.

“He told me that I was probably too old to keep playing soccer,” was the report from this patient.

A sports medicine physician said this!

To my unsurprise, this athletic woman's hip pain didn't improve and she still continued to play soccer and refused to follow-up with that physician.

Athletes don’t typically stop; they play through the pain.

What did I do when she saw me?

Rather than thinking that her soccer playing and age were causing the pain, I chose to think that playing soccer was revealing her muscle imbalance and that age was not a factor.

I looked for muscle imbalances, treated those imbalances and she had less pain when she left.

At her 3-week follow-up, she was 90% better and had no limitations playing soccer. 

Then there was the 32-year-old marathoner who limped in on Monday morning with right ankle pain after doing a 10-mile run on Saturday.

She didn't twist her ankle or fall; it just started bothering her Sunday morning. My exam revealed an inflamed right tibialis posterior. Her diagnosis was tibialis posterior tendonitis.

This is typically considered an overuse injury and on the surface it makes sense – she just ran 10 miles!

Does something not seem right about that conclusion though? 

This is where you play Sherlock Holmes.

Think about it. Before you read my answer, write down what you believe the significance of each of these factors to be:

• 32-year-old
• female
• marathoner
• right ankle pain
• limping
• didn't twist or fall
• didn't bother her during or after race
• pain began next morning
• inflamed right tibialis posterior
• tibialis posterior tendonitis is diagnosis

 What do you think? 

How would a musculoskeletal specialist think through this issue?

 

 

 

 

 

 

 

 

No, the article didn't stop abruptly.

I want you to have your own answer before I tell you mine. 

 

 

 

 

 

 

 

My turn:

She is a seasoned runner, so the distance was familiar to her body.

Also, did she only run 10 miles on her right ankle?

If the distance was the cause of this tendonitis then why is her left ankle fine?

What if the 10-mile run revealed an imbalance in her musculoskeletal system. An imbalance that only just started or just started to reveal itself?

I noticed that her right leg was slightly shorter than her left and her right quadratus lumborum was tighter than her left. This would definitely create a running imbalance which then overloaded her right tibialis posterior.

So, I corrected this and she walked out still in pain but no longer limping.

Two days later, she left a message that she ran 5 miles pain-free that day.

Did she have tendonitis? Yes, my physical exam showed that.

BUT, I chose not to blame the running and instead, looked for the reason that her normal running regimen resulted in dysfunction, and as a consequence, the body was able to resolve the inflammation without pills or diet change.

I have many patients who come to me saying, “I stopped running/lifting/etc for 6/8/12 weeks and still have the problem.”

So many people stop doing things and don’t get better.

The over-diagnosis of overuse needs to stop. 

 

Overdiagnosis of Overuse Explained

Why is overuse overdiagnosed?

You have fifteen minutes with a patient to hear their problem, then treat.

GO.

Which is easier?

• Blame the activity for causing the pain, or
• look for subtle imbalances and learn manual therapy strategies that may require more than fifteen minutes to help which means you’re late for other patients.

You know the answer.

And that is where you have an opportunity to be the one person who listened and helped.

You have the time, patience, scope, and desire to look for those imbalances and to help the body come back to balance.

All you need is the know-how.

You can learn how in Mentor Connect and our four Skills Courses: Assessments, Breath, Positional Release and Muscle Energy.

 

Touchpoints

• Avoid suggesting to a client that they stop doing an activity you think is the cause of their pain.
• Don’t tell clients you don’t believe in overuse injuries and to do whatever they want.
• Both of these statements presume the ability to manage that diagnosis. 
• Find and address soft tissue imbalances with the intention to make whatever activity they are doing or want to do more efficient and balanced.
• In my experience, an active client is likely experiencing pain not because of the activity, but because of muscle imbalances.
• Have confidence that your massage can play a role in balancing their muscles. If you know basic strategies taught in our Courses, you'll begin to see improvement in clients with overuse misdiagnoses.
• Be prepared that when you start seeing the impact of your treatments on these cases, any frustration with the current state of medicine will feel justified and you will be pleased to learn that you are part of the solution.
• Also consider your own overuse aches and pains. Perhaps your fitness regimen needs to be enhanced so that your overall health and fitness can absorb the demands of massaging. Or perhaps you have imbalances or are working in imbalanced ways that can be corrected.