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During training, I suffered a stress fracture. It was madness that I carried on and ran the 800 metres and 1500 metres, but because it’s the Olympics, you run through the pain. You never know if you’ll have another chance at the Olympics, so unless you can’t actually walk you carry on, because you don’t want to be asking yourself, ‘What if?’

Dame Kelly Holmes, MBE, DBE, 800 and 1500 m gold medallist, Athens 2004 Olympic Games

Overuse injuries present three distinct challenges to the clinician—diagnosis, understanding of why the injury occurred and treatment. Diagnosis requires taking a comprehensive history of the onset, nature and site of the pain along with a thorough assessment of potential risk factors, for example training and technique. Careful examination may reveal which anatomical structure is affected. It is often helpful to ask patients to perform the manoeuvre that produces their pain.

The skilled clinician must seek a cause for every overuse injury. The cause may be quite evident, such as a sudden doubling of training quantity, poor footwear or an obvious biomechanical abnormality, or it may be more subtle, such as running on a cambered surface, muscle imbalance or leg length discrepancy. The causes of overuse injuries are usually divided into extrinsic factors, such as training, surfaces, shoes, equipment and environmental conditions, and intrinsic factors, such as age, gender, malalignment, leg length discrepancy, muscle imbalance, muscle weakness, lack of flexibility and body composition. Possible factors in the development of overuse injuries are shown in Table 4.1.

Table 4.1

Overuse injuries: predisposing factors

Treatment of overuse injuries will usually require addressing of the cause as well as specific additional elements such as activity modification, specific exercises to promote tissue repair, soft tissue therapy and pharmacologic agents where appropriate (Chapter 17).


A bone stress injury (BSI) represents the inability of bone to withstand repetitive mechanical loading, which results in structural fatigue and localised bone pain and tenderness. It occurs along a pathology continuum beginning with a stress reaction, which can progress to a stress fracture and ultimately a complete bone fracture.


BSIs ...

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