Sports Medicine

, Volume 24, Issue 2, pp 132–146 | Cite as

Anatomical Factors Associated with Overuse Sports Injuries

  • Lisa S. Krivickas
Injury Clinic


Overuse injuries develop when repetitive stress to bone and musculotendinous structures damages tissue at a greater rate than that at which the body can repair itself. A combination of extrinsic factors, such as training errors and environmental factors, and intrinsic or anatomical factors, such as bony alignment of the extremities, flexibility deficits and ligamentous laxity, predispose athletes to develop overuse injuries. Malalignment of the lower extremity, including excess femoral anteversion, increased Q angle, lateral tibial torsion, tibia vara, genu varum or valgum, subtalar varus and excessive pronation are frequently cited as predisposing to knee extensor mechanism overuse injuries. These and other forms of malalignment have also been implicated in iliotibial band syndrome, medial tibial stress syndrome, lower extremity stress fractures and plantar fasciitis. Muscle inflexibility aggravates and predisposes to the development of a variety of overuse injuries, especially those occurring in children and adolescents, including the traction apophysitises. Flexibility deficits may be improved by an appropriate stretching programme. Unfortunately, lower extremity malalignment is less amenable to intervention. Orthotics are often prescribed to improve lower extremity alignment. However, studies have not shown that orthotics have any effect on knee alignment and, while they can alter subtalar joint alignment, the clinical benefit of this remains unclear. Awareness of anatomical factors that may predispose to overuse injuries allows the clinician to develop individual prehabilitation programmes designed to decrease the risk of overuse injury. In addition, the clinician can advise the athlete on the importance of avoiding extrinsic factors that may also predispose to overuse injury.


Overuse Injury Anatomical Factor Plantar Fasciitis Femoral Anteversion Medial Tibial Stress Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978; 6: 40–50PubMedCrossRefGoogle Scholar
  2. 2.
    McKeag DB. Overuse injuries. The concept in 1992. Prim Care 1991; 18(4): 851–65PubMedGoogle Scholar
  3. 3.
    Micheli LJ. The traction apophysitises. Clin Sports Med 1987; 6(2): 389–404PubMedGoogle Scholar
  4. 4.
    Smith AD. Sports medicine musculoskeletal considerations for children and adolescents. In: Nicholas JA, Hershman EB, editors. The lower extremity and spine in sports medicine. St Louis: Mosby, 1995: 1201–27Google Scholar
  5. 5.
    Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Joint Surg Br 1964; 46: 40–5PubMedGoogle Scholar
  6. 6.
    Beighton P, Solomon L, Soskoine CL. Articular mobility in an African population. Ann Rheum Dis 1973; 32: 413–8PubMedCrossRefGoogle Scholar
  7. 7.
    Lysens RJ, Ostyn MS, Auweele YV, et al. The accident-prone and overuse-prone profiles of the young athlete. Am J Sports Med 1989; 17(5): 612–9PubMedCrossRefGoogle Scholar
  8. 8.
    Grahame R, Jenkins JM. Joint hypermobility: asset or liability? A study of joint mobility in ballet dancers. Ann Rheum Dis 1972; 31: 109–11PubMedCrossRefGoogle Scholar
  9. 9.
    Klemp P, Stevens JE, Isaacs S. A hypermobility study in ballet dancers. J Rheumatol 1984; 11: 692–6PubMedGoogle Scholar
  10. 10.
    Diaz MA, Estevez EC, Guijo PS. Joint hyperlaxity and muscuololigamentous lesions: study of a population of homogeneous age, sex and physical exertion. Br J Rheumatol 1993; 32: 120–2CrossRefGoogle Scholar
  11. 11.
    Walsh WM. Patellofemoral joint. In: DeLee JC, Drez D, editors. Orthopaedic sports medicine principles and practice. Philadelphia: W.B. Saunders, 1994: 1163–248Google Scholar
  12. 12.
    James SL. Chondromalacia of the patella in the adolescent. In: Kennedy JC, editor. The injured adolescent knee. Baltimore: Williams and Wilkins, 1979: 205–51Google Scholar
  13. 13.
    Insall J, Falvo KA, Wise DW. Chondromalacia patellae. J Bone Joint Surg Am 1976; 58: 1–8PubMedGoogle Scholar
  14. 14.
    Stroud L, Smith AD, Kruse RW. The relationship between increased femoral anteversion in childhood and patellofemoral pain in adulthood. Orthop Trans 1989; 13(3): 554Google Scholar
  15. 15.
    Turner MS, Smillie IS. The effect of tibial torsion on the pathology of the knee. J Bone Joint Surg Br 1981; 63B: 296–8Google Scholar
  16. 16.
    Buchbinder MR, Napora NJ, Biggs EW. The relationship of abnormal pronation to chondromalacia of the patella in distance runners. J Am Podiatry Assoc 1979; 69: 159–62PubMedGoogle Scholar
  17. 17.
    Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports Phys Ther 1987; 9: 160–5PubMedGoogle Scholar
  18. 18.
    Wiberg G. Roentgenographic and anatomic studies on the femoropatellar joint. Acta Orthop Scand 1941; 12: 319CrossRefGoogle Scholar
  19. 19.
    Kujala UM, Osterman K, Kvist M, et al. Factors predisposing to patellar chondropathy and patellar apicitis in athletes. Int Orthop 1986; 10: 195–200PubMedCrossRefGoogle Scholar
  20. 20.
    Kibler WB. Strength and flexibility findings in anterior knee pain syndrome. Am J Sports Med 1987; 15: 410Google Scholar
  21. 21.
    Smith AD, Stroud L, McQueen C. Flexibility and anterior knee pain in adolescent figure skaters. J Pediatr Orthop 1991; 11: 77–82PubMedCrossRefGoogle Scholar
  22. 22.
    Reider B, Marshall JL, Warren RF. Clinical characteristics of patellar disorders in young athletes. Am J Sports Med 1981; 9(4): 270–3PubMedCrossRefGoogle Scholar
  23. 23.
    Fairbank JCT, Pynsent PB, van Poortvliet JA, et al. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br 1984; 66: 685–93PubMedGoogle Scholar
  24. 24.
    Messier SP, Davis SE, Curl WW, et al. Etiologic factors associated with patellofemoral pain in runners. Med Sci Sports Exerc 1991; 23(9): 1008–15PubMedGoogle Scholar
  25. 25.
    Kujala UM, Kvist M, Osterman K, et al. Factors predisposing army conscripts to knee exertion injuries incurred in a physical training program. Clin Orthop 1986; 210: 203–12PubMedGoogle Scholar
  26. 26.
    Thomee R, Renstrom P, Karlsson J, et al. Patellofemoral pain syndrome in young women, I: a clinical analysis of alignment, pain parameters, common symptoms and functional activity level. Scand J Med Sci Sports 1995; 5: 237–44PubMedCrossRefGoogle Scholar
  27. 27.
    Marks KE, Bentley G. Patella alta and chondromalacia. J Bone Joint Surg Br 1978; 60: 71–3PubMedGoogle Scholar
  28. 28.
    Ferretti A. Epidemiology of jumpers knee. Sports Med 1986; 3: 289–95PubMedCrossRefGoogle Scholar
  29. 29.
    Jones DC, James SL. Overuse injuries of the lower extremity: shin splints, iliotibial band friction syndrome, and exertional compartment syndromes. Clin Sports Med 1987; 6(2): 273–90PubMedGoogle Scholar
  30. 30.
    McCaw ST. Leg length inequality: implications for running injury prevention. Sports Med 1992; 14(6): 422–9PubMedCrossRefGoogle Scholar
  31. 31.
    Andrish JT. The leg. In: DeLee JC, Drez D, editors. Orthopaedic sports medicine principles and practice. Philadelphia: W.B. Saunders, 1994: 1603–31Google Scholar
  32. 32.
    Michael RH, Holder LE. The soleus syndrome: a cause of medial tibial stress syndrome (shin splints). Am J Sports Med 1985; 13(2): 87–94PubMedCrossRefGoogle Scholar
  33. 33.
    Campbell KM, Biggs NL, Blanton PL, et al. Electromyographic investigation of the relative activity among four components of the triceps surae. Am J Phys Med 1973; 52: 30–41PubMedGoogle Scholar
  34. 34.
    Viitasalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983; 11(3): 125–30PubMedCrossRefGoogle Scholar
  35. 35.
    Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20(5): 501–5PubMedGoogle Scholar
  36. 36.
    DeMaio M, Paine R, Mangine R, et al. Plantar fasciitis. Orthopedics 1993; 16: 1153–63PubMedGoogle Scholar
  37. 37.
    Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med 1991; 19(1): 66–71PubMedCrossRefGoogle Scholar
  38. 38.
    Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med 1987; 15: 46–58PubMedCrossRefGoogle Scholar
  39. 39.
    Jones BH, Bovee MW, Harris JM, et al. Intrinsic risk factors for exercise-related injuries among male and female Army trainees. Am J Sports Med 1993; 21: 705–10PubMedCrossRefGoogle Scholar
  40. 40.
    Barrow G, Saha S. Menstrual irregularities and stress fractures in female collegiate female distance runners. Am J Sports Med 1988; 16(3): 209–15PubMedCrossRefGoogle Scholar
  41. 41.
    Protzman R, Griffis C. Stress fractures in men and women undergoing military training. J Bone Joint Surg 1977; 59A: 825Google Scholar
  42. 42.
    Kirchner EM, Lewis RD, O’Connor PJ. Bone mineral density and dietary intake of female college gymnasts. Med Sci Sports Exerc 1995; 27(4): 543–9PubMedGoogle Scholar
  43. 43.
    Slemenda CW, Johnston CC. High intensity activities in young women: site specific bone mass effects among female figure skaters. Bone Miner 1993; 20(2): 125–32PubMedCrossRefGoogle Scholar
  44. 44.
    Rettig AC, Shelbourne KD, McCarrol JR, et al. The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia. Am J Sports Med 1988; 16(3): 250–5PubMedCrossRefGoogle Scholar
  45. 45.
    Cowan DN, Jones BH, Frykman PN, et al. Lower limb morphology and risk of overuse injury among male infantry trainees. Med Sci Sports Exerc 1996; 28(8): 945–52PubMedCrossRefGoogle Scholar
  46. 46.
    McBryde A. Stress fractures of the foot and ankle. In: DeLee JC, Drez D, editors. Orthopaedic sports medicine principles and practice. Philadelphia: W.B. Saunders, 1994: 1970–81Google Scholar
  47. 47.
    Torg JS, Pavlov H, Torg E. Overuse injuries in sport: the foot. Clin Sports Med 1987; 6(2): 291–320PubMedGoogle Scholar
  48. 48.
    Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 1987; 7: 34–8PubMedCrossRefGoogle Scholar
  49. 49.
    Morgan Jr RC, et al. Surgical management of tarsal coalition in adolescent athletes. Foot Ankle 1986; 7(3): 183–93PubMedGoogle Scholar
  50. 50.
    Elkus RA. Tarsal coalition in the young athlete. Am J Sports Med 1986; 14(6): 477–480PubMedCrossRefGoogle Scholar
  51. 51.
    O’Neill DB, Micheli LJ. Tarsal coalition. A follow-up of adolescent athletes. Am J Sports Med 1989: 17(4): 544–9PubMedCrossRefGoogle Scholar
  52. 52.
    Sneyers CJL, Lysens R, Feys H, et al. Influence of malalignment of feet on the plantar pressure pattern in running. Foot Ankle 1995; 16(10): 624–32PubMedGoogle Scholar
  53. 53.
    Clanton TO. Sport shoes, insoles, and orthoses. In: DeLee JC, Drez D, editors. Orthopaedic sports medicine principles and practice. Philadelphia: W.B. Saunders, 1994: 1982–2021Google Scholar
  54. 54.
    Kilmartin TE, Wallace WA. The scientific basis for the use of biomechanical foot orthoses in the treatment of lower limb sports injuries: a review of the literature. Br J Sports Med 1994; 28(3): 180–4PubMedCrossRefGoogle Scholar
  55. 55.
    Smith LS, Clarke TE, Hamill CL. The effects of soft and semirigid orthoses upon rearfoot movement in running. J Am Podiatr Med Assoc 1986; 76: 227–33PubMedGoogle Scholar
  56. 56.
    Kvitne RS, Jobe FW. The diagnosis and treatment of anterior instability in the throwing athlete. Clin Orthop 1993; 291: 107–23PubMedGoogle Scholar
  57. 57.
    Hawkins RJ, Mohtadi N. Rotator cuff problems in athletes. In: DeLee JC, Drez D, editors. Orthopaedic sports medicine principles and practice. Philadelphia: W.B. Saunders, 1994: 623–56Google Scholar
  58. 58.
    Safran MR. Elbow injuries in athletes. Clin Orthop Rel Res 1995; 310: 257–77Google Scholar
  59. 59.
    Indelicato PA, Jobe FW, Kerlan RK, et al. Correctable elbow lesions in professional baseball players. Am J Sports Med 1979; 7: 72–5PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1997

Authors and Affiliations

  • Lisa S. Krivickas
    • 1
  1. 1.Harvard Department of Physical Medicine and RehabilitationSpaulding Rehabilitation HospitalBostonUSA

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