Training injuries, custom orthotics and the road to recovery

In the world of sports, we come across two types of injuries: single traumatic events and repetitive strain and stress injuries.

In a single traumatic event injury, the athlete knows exactly what happened and when. The athlete typically experiences pain immediately or very shortly after the incident. In a repetitive strain and stress injury, also known as an overuse injury, the athlete typically reports they are unsure of how or when the condition started, though it has worsened over time. Often, the athlete cannot identify the location of the pain and will indicate pain in a regional distribution or in an area distal to the source of the dysfunction.

Understand overuse injuries

Overuse injuries require proper diagnosis, a thorough understanding of why the injury has occurred and an appropriate management plan. This usually presents a challenge to the practitioner because understanding the root cause of an injury can be multifactorial and may include both intrinsic and extrinsic factors. Extrinsic factors that can contribute to overuse injuries include training errors, training surfaces, inadequate equipment, environmental factors, psychological factors and nutritional deficiencies.

Intrinsic factors that can contribute to overuse injuries include joint dysfunction, muscle imbalances, decreased strength, decreased muscle endurance, gender, body composition, health status and previous history of injury or general medical history. The unique relationships among all risk factors should guide the practitioner’s management of the athlete’s injury and return to sport.¹

Assess and diagnose overuse injuries

Diagnosing overuse injuries involves a focused injury history and investigation into extrinsic factors. A deep dive into possible training errors, surface, equipment and other extrinsic factors often helps identify causative or contributive factors that must be addressed prior to returning the athlete to sport. An athlete’s footwear must be considered when evaluating equipment risk factors. Incorporating flexible custom orthotics into an athlete’s footwear to correct altered biomechanics may be essential or even necessary for full injury resolution. A thorough orthopedic and biomechanical examination of the entire kinetic chain, both above and below the site of pain, should be performed to identify the primary cause of injury. Without a full kinetic assessment, the practitioner will likely miss essential pieces to the diagnostic puzzle.

A study conducted on military recruits found significantly increased risks for training injuries. The study reported a high correlation between rigid, high-arched feet, flexible flat feet, decreased ankle dorsiflexion, increased rear foot inversion, history of ankle sprain and injury.² Incorporating three-arch support custom flexible orthoses into the athlete’s treatment plan can assist the practitioner in resolving these lower limb risk factors and upstream overuse injuries to ultimately provide a faster return to sport.

A systematic approach to injury management

The management of overuse injuries can be broken down systematically. Phase 1 includes activity modification during tissue healing, addressing additional risk factors and biomechanics, and maintaining fitness levels. Phase 2 includes stepwise management for returning an athlete to sport. Activity modification is imperative for athletes to ensure the load and volume of activity do not exceed the rate of tissue healing. The incorporation of three-arch support custom flexible orthotics can be vital for an athlete during the period of activity modification to decrease fatigue and pain in the lower limb, thus allowing the athlete to return to previous training levels faster and with a lower risk for re-injury.

After determining the cause of the injury, the practitioner must address any damaged tissues and joint dysfunction and should be thoughtful of the type of dysfunction present in the soft tissues; often, both the quality and the length relationship of the tissues must be addressed. Once joint dysfunction is identified, manipulative therapy should be utilized along the kinetic chain. Rehabilitation exercises can be considered to restore and maintain proper biomechanics to resolve the current injury and prevent future injuries.

Rehabilitation and return to sport: Criteria and considerations

A rehabilitation program can consist of a combination of activation, strength and endurance exercises, depending on the athlete’s unique needs. A graded rehabilitation program includes a primary focus on regaining active and passive ranges of motion, creating joint stability, strength production as well as speed and agility, and creating power and endurance along with instilling new sport-specific patterns.¹ When managing a lower extremity overuse injury, the practitioner should consider the utilization of custom-fit flexible orthoses. Randomized clinical trials do support using custom orthoses to decrease the incidence of lower extremity musculoskeletal pain within three weeks.³  Additionally, foot orthoses can be used to prevent overuse injuries in the lower extremity.⁴

Many variables can affect a return-to-play decision, including the type of injury, sport, competition level, history of injury and the athlete’s psychological readiness. Coaches, athletes, parents and other individuals may apply external and psychological pressure on the athlete and healthcare team. If an athlete is returned to competition prematurely, they may experience a subsequent re-injury. The practitioner should screen for benchmarks such as full ranges of motion, full strength, the absence of neurologic deficits, the ability to perform sport-specific movements and the athlete’s psychological readiness before considering clearance for competition. A graded return is significant when returning an athlete to a sport. General guidelines for a graded return to sport can include light activity, moderate activity including sport-specific movements without contact, heavy activity including sport-specific movements without contact, heavy sustained activity with contact and finally, competition.

Final thoughts

Whether an athlete’s injury comes from acute trauma or from overuse, the practitioner should consider the benefits of custom flexible orthotics during treatment; these orthotics can assist the athlete in achieving a faster recovery and safer return to competition.

HOLLY WESTBROCK, DC, DACBSP^®, EMT, CSCS, specializes in overuse injuries with associated compensation patterns in elite athletes. She can be contacted at drwestbrock@gmail.com.

References

1. Brukner and Khan’s Clinical Sports Medicine: Injuries. Volume 1, 5th edition. 2017. McGraw-Hill Education: Australia.
2. Molloy JM, et al. Physical training injuries and interventions for military recruits. Med. 2012;177(5):553-558. PubMed. https://pubmed.ncbi.nlm.nih.gov/22645882/. Accessed July 12, 2024.
3. Trotter LC, Pierrynowski MR. The short-term effectiveness of full-contact custom-made foot orthoses and prefabricated shoe inserts on lower-extremity musculoskeletal pain: A randomized clinical trial. Am. Pod. Med. Associ. 2008;98(5):357-363. PubMed. https://pubmed.ncbi.nlm.nih.gov/18820037/. Accessed July 12, 2024.
4. Collins N, et al. Foot orthoses in lower limb overuse conditions: A systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. PubMed. https://pubmed.ncbi.nlm.nih.gov/17371668/. Accessed July 12, 2024.