Overuse Injuries in Females


Overuse injuries result from cumulative trauma or many repetitive minor insults, such that the body does not have adequate time to heal properly. These types of injuries typically occur in low-contact sports that require long training sessions and repetitive loading (e.g., running, jumping, rowing, and swimming) and can lead to loss of playing time, physiologic exhaustion, and pain. Overuse injuries typically present with a gradual onset of pain, masking the true severity of the injury. Yang et al. conducted a study evaluating acute and chronic injuries in professional athletes and reported that male athletes have higher rates of acute injuries than their female counterparts, but female athletes had higher rates of chronic overuse injuries. Previous studies have supported the findings that female athletes have an increased risk of overuse injuries than male athletes. Female rowers reported a significantly greater number of chest overuse injuries and female military recruits reported more stress fractures than male rowers and recruits, respectively. , Magnusson et al. evaluated differences in the adaptability of tendons to loading between females and males and demonstrated that females have an attenuated tendon hypertrophy response to habitual training, a lower tendon collagen synthesis rate following acute exercise, further attenuation of collagen synthesis based on levels of estrogen, and lower mechanical strength in their tendons. Therefore female athletes may be at an increased risk for developing symptoms of tendonitis. The increase in female athletic involvement increases the risk for the development of overuse injuries. Therefore it is important to identify and properly manage these types of injuries in order to allow athletes to return to sport and prevent progression to more serious sequelae.

Achilles Tendon Injuries

Achilles tendon pain is common among athletes and can be related to several conditions including tendinopathy, tendinosis, tendinitis, tenosynovitis, and rupture. Maffulli et al. described tendinopathy as a combination of tendon pain, swelling, and impaired performance, with peritendinitis and tendinosis found on histopathology. Acute tendonitis is defined by the presence of symptoms for less than 2 weeks, while symptoms lasting for more than 6 weeks are classified as chronic tendonitis. The Achilles tendon comprises the distal insertion of the gastrocnemius-soleus musculotendinous unit transmitting loads to the calcaneus in order to plantarflex the foot. There is a relative zone of avascularity approximately 2–6 cm proximal to the tendon insertion, and therefore this area is at greatest risk for degeneration and rupture.

Risk Factors

Achilles tendinopathy is most prevalent in athletes participating in middle- and long-distance running, tennis, volleyball, and soccer, with an incidence rate up to 9% of all top-level runners. , Biomechanical analyses have demonstrated that malalignment within the foot and ankle may predispose to Achilles tendon injuries. Kvist et al. demonstrated that limited mobility of the ankle and subtalar joint may contribute to increased risk of injury. Muscle imbalance and decreased flexibility can lead to a loss of protection of the tendon during increased physical activity and load-bearing exercises.

Presentation/Examination Findings

Patients presenting with Achilles tendon injuries typically recall a change in activity levels that led to either an insidious or a gradual onset of discomfort over the Achilles tendon. The patient usually describes relief of symptoms with rest, but pain returns as soon as the patient resumes activity. Achilles tendon rupture often occurs acutely, with patients describing a “pop”. On physical examination, there is usually a palpable defect over the area of ruptured tendon. Squeezing the calf in the prone position (i.e., Thompson test) does not elicit movement of the foot and can confirm diagnosis of rupture.


Ultrasound is useful in providing information regarding changes of water content within the tendon as well as collagen integrity. Abnormal tendons usually demonstrate a larger tendon diameter with higher levels of water content and collagen discontinuity, and tendon sheath swelling. Although ultrasound is useful, magnetic resonance imaging (MRI) remains the study of choice for diagnosing Achilles tendon injuries ( Fig. 21.1 ).

Fig. 21.1, Magnetic resonance image demonstrating Achilles tendon rupture.


Initial management of Achilles tendinopathy includes activity modification, physical therapy, and antiinflammatory medications. Niesen-Vertommen et al. reported that eccentric training was superior to concentric training in reducing pain in chronic Achilles tendinopathy. Deep friction massage accompanied by stretching is utilized to restore elasticity and reduce muscle-tendon strain. It has been reported that 24%–45% of patients with Achilles tendon injuries fail conservative management, ultimately requiring surgical intervention. , Surgical treatments include open versus percutaneous Achilles tenotomy for tendinopathy and tendon repair for rupture ( Fig. 21.2A–C ). Testa et al. evaluated 52 male and female elite middle- and long-distance runners with Achilles tendinopathy and reported good functional outcomes following percutaneous longitudinal tenotomies. Postoperatively, patients are often immobilized for 2 weeks and then transitioned to a CAM (controlled ankle motion) boot where they may begin ankle range of motion. Patients are often non-weight-bearing for as long as 6–8 weeks following repair.

Fig. 21.2, (A) Acute Achilles tendon rupture. (B) Achilles tendon repair of proximal and distal ends utilizing the Krackow technique with FiberWire suture. (C) Repaired Achilles tendon.

Patellar Tendinopathy/Tendonitis

Patellar tendinopathy, also referred to as “jumpers knee”, is common in athletes involved in repetitive jumping, climbing, kicking, or running as a result of excessive pain over the patella tendon. Repetitive motion of the extensor mechanism results in focal degeneration leading to fraying and microtearing of the tendon. ,

Risk Factors

Patellar tendon injuries typically affect athletes involved in sports including basketball, volleyball, football, soccer, high/long jump, tennis, and running. Torstensen et al. demonstrated that elite athletes are more often affected than recreational athletes. Van der Worp et al. conducted a meta-analysis reviewing risk factors for developing patellar tendinitis. The authors found that body mass index, waist-to-hip ratio, leg-length difference, arch height of foot, quadriceps/hamstring flexibility, quadriceps strength, and vertical jump all influence loading of the patellar tendon. In addition, several factors related to training can contribute to the development of patellar tendinopathy/tendinitis, including quick acceleration, deceleration, stopping, and cutting actions.

Presentation/Examination Findings

Athletes typically present with an insidious onset of pain that is related to the frequency and intensity of their training. Initially, pain presents as a dull ache on the anterior aspect of the knee just inferior to the patella. Patients often state that the pain is worse when walking or running upstairs and downstairs. The key finding is tenderness to palpation over the patellar tendon, which is usually worse in extension.


Ultrasound and MRI are imaging modalities often utilized to confirm the diagnosis of patellar tendinopathy. Ultrasound can identify decreased echogenicity and irregularities within the tendinous envelope. MRI can also demonstrate areas of higher signal intensity in the affected regions of the tendon.


Nonoperative intervention is the first line of treatment in patients with patellar tendinitis. Activity modification, antiinflammatory medication, and physical therapy are initially recommended. Rest is important in the early phases of recovery. Rehabilitation progresses from controlled exercises without load, to eccentric and concentric load, and finally to return to sports. Other methods to reduce the load on the tendon include orthotics, braces, and straps. The Cho-Pat strap is commonly utilized to support the tibial attachment of the patellar tendon. Most athletes will be successfully treated with conservative measures alone.

Patellar tendon surgery is typically reserved for patients who have failed at least 6 months of conservative therapy. Surgical interventions include drilling of the inferior pole of the patella, resection of the tibial attachment of the patellar tendon, repair of defects, tenotomy/tenoplasty, percutaneous needling, and excision of the inferior pole of the patella with repair. Ferretti et al. reported excellent results in 70% of male and female amateur and professional athletes with a mean age of 27 years treated with longitudinal splitting of the tendon and drilling of the inferior pole of the patella. Cucurulo et al. evaluated arthroscopic procedures in the treatment of patellar tendonitis in athletes, which involved controlled shaving of retrotendinous tissue and excision of damaged tendon. This study demonstrated good results in motivated athletes and reported equivalent outcomes in both open and arthroscopic techniques.

Rotator Cuff Tendonitis

Rotator cuff tendonitis is often used as a general term for athletes experiencing shoulder pain without a full-thickness rotator cuff tear or another identifiable cause for the pain. Rotator cuff tendonitis can often lead to tendinosis (i.e., degeneration of the tendon) and tear. The rotator cuff is composed of four muscles, namely, supraspinatus, infraspinatus, teres minor, and subscapularis, with all arising from the scapula. These four muscles combine to provide dynamic stability to the glenohumeral joint.

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