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Weight Training Injuries: Part 2: Diagnosing and Managing Chronic Conditions

Ronald K. Reeves, MD; Edward R. Laskowski, MD; Jay Smith, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 3 - MARCH 98


This is the second of two articles on weight training injuries. The first, on acute injuries, appeared in February.

In Brief: The repetitive nature of weight training and the often heavy loads involved provide fertile ground for chronic injuries. Common chronic injuries include rotator cuff tendinopathy and stress injuries to the vertebrae, clavicles, and upper extremities. In addition, muscle hypertrophy, poor technique, or overuse can contribute to nerve injuries such as thoracic outlet syndrome or suprascapular neuropathy. Chronic medical conditions that are known to occur in weight trainers include vascular stenosis and weight lifter's cephalgia. Management of chronic problems will vary by condition, but relative rest and correction of poor technique are important for many.

Excessive weight training or the use of improper training techniques—or a combination of both—can lead to chronic injuries in weight trainers. Diagnosing chronic weight training injuries can be a challenge because the connection between patients' symptoms and weight training practices often aren't as obvious as, for example, runners' symptoms and their sport.

However, a familiarity with the spectrum of weight training injuries and an awareness of how improper techniques contribute to specific injuries will help physicians recognize such injuries and treat patients efficiently. It is important for physicians to understand proper technique so that they can instruct their patients accordingly.

Tendon and Ligament Injuries

There are relatively few data on the incidence of overuse injuries in weight lifting. Tendinitis, probably the most common overuse injury seen in weight training, accounts for 3.5% to 12% of weight training injuries (1-3). Chronic excessive stress on a tendon during weight training can overload tissues; using incorrect technique can also cause overuse injuries.

Rotator cuff injury. Several weight training exercises, including the upright row, military press, and use of "pectoral deck" machines, jeopardize the muscles and tendons of the rotator cuff (see "Weight Training Injuries, Part 1: Diagnosing and Managing Acute Conditions," February, page 67). Among the rotator cuff tendons, the supraspinatus tendon is the most frequently involved, probably because of its relative hypoperfusion and location in a potentially narrowed space below the acromion. Though rotator cuff injury is more common in people over age 40, it must be considered when a younger weight lifter or thrower presents with shoulder pain.

Patients may report diffuse aching shoulder pain that sharpens with overhead activity. Frequently, anterior chest and shoulder muscle development is disproportionate to that of the scapular stabilizers. The resultant inability of the periscapular muscles to stabilize the scapula leads to scapulothoracic and glenohumeral dysfunction and dyskinesia, which contributes to inefficient force transfer through the shoulder.

Management is largely nonoperative and entails modalities such as ice massage for pain control, shoulder range-of-motion exercises, stretching (with emphasis on the posterior capsule), and strengthening of the scapular stabilizers, posterior shoulder muscles, and external rotators.

Anterior shoulder instability. Anterior instability of the shoulder can also be chronic during weight training. Several errors of technique can contribute to anterior instability: Behind-the-neck latissimus dorsi pull-downs load the shoulder at the extreme of external rotation; shoulder hyperextension during the bench press produces repetitive shoulder capsule trauma and places excessive traction on the acromioclavicular (AC) joint; and behind-the-neck military presses stress the shoulder capsule, the rotator cuff, and the inferior glenohumeral ligament (4,5).

The patient may report vague symptoms such as a feeling of looseness of the shoulder or transient numbness of the arm. Instability tests, including the apprehension test and the relocation test, should be done. The apprehension test involves passively moving the shoulder toward 90° of external rotation while the arm is abducted to 90°. A feeling of "impending dislocation," not to be confused with posterior shoulder pain caused by rotator cuff injury, signifies anterior instability. Pushing the humeral head posteriorly (the relocation test) will often relieve the symptoms of apprehension, and external rotation may be increased.

Treatment of anterior shoulder instability is still somewhat controversial. Most would advocate aggressive rehabilitation involving scapular stabilization and posterior deltoid and external rotator strengthening to prevent future dislocations. In an overhead-throwing athlete or high- shoulder-demand athlete, however, a case can be made for early evaluation for consideration of surgical repair.

Skeletal Disorders

Atraumatic osteolysis of the distal clavicle. Cahill (6) was the first to describe a series of weight trainers who developed atraumatic osteolysis of the distal clavicle. Hyperextension of the shoulder during the bench press (ie, dropping the elbows below the body line during the eccentric phase of the press) excessively stresses the AC joint and may contribute to pathogenesis.

Patients describe an insidious aching pain of the AC region that is exacerbated by weight training, overhead activities, and horizontal adduction. The pain may radiate to the deltoid or trapezium and is relieved by prolonged rest. Frequently, patients report that the pain disturbs their sleep.

In patients who have had protracted symptoms, plain radiographs of the shoulder may reveal subchondral osteolysis (figure 1). Early in the course, a bone scan may help to confirm AC joint involvement before changes become apparent on plain radiographs.

[FIGURE 1]

Avoidance of provocative maneuvers, modification of weight training technique, and ice massage constitute the basis of initial treatment. Since the natural history of this disorder is incompletely understood, the role of corticosteroid injections and surgical intervention (such as distal clavicle excision) is not clear. However, AC joint injections may be effective on a limited basis. If symptoms progress or activity modification is impossible, surgical excision of the distal clavicle may be required. Cahill (7) reports that 37 of 40 patients who had surgical excisions returned to weight training and/or competitive weight lifting.

Spondylolysis. Spondylolysis is a stress fracture of the pars interarticularis that is presumed to occur from excessive loads on the posterior lumbar spine, usually during lumbar hyperextension. Improper lumbar hyperextension is often seen during squats, military (deltoid) presses, and bench presses (figure 2). Though data are scarce on the incidence of chronic back pain in weight trainers, it has been shown that 36% of competitive weight lifters have a spondylolytic defect on spine films, compared with 5% of the general population (8). (Spondylolysis has also been associated with gymnastics, wrestling, and the adolescent growth spurt.)

[FIGURE 2]

Generally, patients who have spondylolysis present with chronic unilateral low-grade back pain with exacerbations and radiation to the ipsilateral sacroiliac joint. Lumbar extension and hyperextension usually produce the pain.

On physical examination, patients frequently have tight hamstrings, and the stork test is positive (8). To perform the test, the patient balances on the leg that is on the same side as the lumbar pain, then hyperextends the lumbar spine and rotates the trunk toward the symptomatic side. The test, which unilaterally loads the posterior elements, is positive if the maneuver reproduces the patient's pain. The "Scottie dog" sign on oblique lumbar spine radiographs can confirm the diagnosis, and both the oblique and lateral views can also exclude or confirm spondylolisthesis (figure 3). Bone scans may detect spondylolysis in acute injuries before it is radiographically apparent. Occasionally, single photon emission computed tomography (SPECT) may be needed to more precisely locate the small area of uptake at the lesion.

[FIGURE 3]

The treatment of spondylolysis is controversial. Because these injuries are presumably acute stress fractures, some authors have advocated rigid thoracolumbosacral bracing for all patients who have active lesions on bone scans (9). The intent of bracing is to allow the spondylolytic lesion to heal. Others advocate the avoidance of provocative maneuvers (including weight lifting, lumbar spine extension, and impact-loading exercise), relative rest, and back stabilization exercises (10) that stress flexion rather than extension. Nonunion of a pars defect has not been shown to be a cause of chronic back pain.

Spondylolisthesis. Spondylolisthesis is the anterior subluxation of one vertebral body relative to another. Brady et al (11) found two individuals with spondylolisthesis out of 29 weight trainers who had lumbosacral spine injuries. Congenital cases are the result of bilateral pars elongation, whereas acquired cases are due to bilateral spondylolysis. Slippage of L-5 on S-1 is most common in isthmic spondylolisthesis and is more common in younger people; slippage of L-4 on L-5 is most common in degenerative spondylolisthesis and in older patients.

About half of patients who have spondylolisthesis are asymptomatic, and the condition is an incidental medical finding. Patients who are symptomatic report lumbar pain that is aggravated by strenuous activity, particularly repetitive flexion-extension or hyperextension of the spine.

The percentage of slippage on x-ray guides the management (figure 4). Symptomatic patients who have slippage of less than 30% can be initially managed conservatively with restriction of vigorous activity, anti-inflammatory drugs or acetaminophen, stretching exercises, and strengthening. Bracing may be helpful for significant muscle spasm, for pain that is unabated despite activity modification, or to allow an acute lysis of the pars interarticularis to heal. In growing adolescents, regular x-ray follow-up is important, and individuals who have rapidly progressing anterior displacement or signs of neurologic compromise should be evaluated for surgical stabilization.

[FIGURE 4]

Osteoarthritis. The prevalence of patellofemoral or tibiofemoral osteoarthritis in former competitive weight lifters has been reported as 31%, vs 14% in competitive runners (10). The same authors also found that patellofemoral arthritis was more prevalent (28%) in weight lifters than in soccer players, runners, and shooters. Suboptimal technique is likely a significant contributing factor for osteoarthritis; for example, squats performed with heavy loads and in which the thighs descend below parallel to the floor place significant load on the thinnest part of the femoral articular cartilage. Repetitive shear force likely takes its toll on the cartilage.

Diagnosis can be made by identifying joint-line tenderness and x-ray evidence of narrowed compartments, tibial plateau ridging, and bony hypertrophy. Standing posteroanterior x-rays in 30° to 45° of flexion are more sensitive in detecting joint space narrowing and osteoarthritic changes. Treatment can include modalities (eg, heat, ice), isolated strengthening and kinetic chain lower-extremity strengthening, orthotic wedges to unload the involved compartment, and activity modification with an emphasis on low-impact to nonimpact aerobic conditioning.

Stress fractures. Typically, stress fractures occur in the lower extremity from repetitive excessive impact loading activities such as running. The demands placed on the upper extremities during weight training may cause similar overload-induced stress fractures. Stress fractures of the ulna (12), humerus (13), sternum (14), and lumbar ring apophysis (15) have been associated with weight training. Patients generally present with chronic, progressive symptoms. As in lower-extremity stress fractures, management involves the restriction of activity for 6 to 8 weeks.

Physical exam findings in stress fractures can include focal or point tenderness and exacerbation of local pain with a vibrating tuning fork placed on the same bone but distant from the site of tenderness. Early x-rays may be negative; later films may reveal subperiosteal elevation ("bumps") or sclerotic margins. A bone scan may be positive before x-ray changes are evident, showing a focal area of increased uptake.

Other chronic bone injuries that have been associated with weight training include olecranon physeal nonunion (16) and bilateral osteochondral flaps in the wrist (17).

Neuropathies

Acute nerve injuries can occur during weight training, but most neuropathies associated with the activity develop over weeks to months from repetitive traction or focal compression. The most common neuropathies associated with weight training include thoracic outlet syndrome, suprascapular neuropathy, scapular winging, musculocutaneous neuropathy, and notalgia paresthetica. Other conditions that have been reported in the literature include ulnar neuritis (18) and lateral plantar nerve entrapment (19).

Thoracic outlet syndrome. There have been no reports of specific sports that cause thoracic outlet syndrome (TOS); however, any upper-limb activity can cause symptoms. Because there is no diagnostic "gold standard," the diagnosis and treatment of TOS are controversial. Some authors claim it is rare and largely overdiagnosed, while others claim it is common and underrecognized (20,21).

The subclavian vessels and the brachial plexus pass through several anatomic spaces at the thoracic outlet (figure 5). In weight lifters, hypertrophy of the scalene muscles can impinge the subclavian vessels and the brachial plexus in the scalene or costoclavicular triangles. Pectoralis minor hypertrophy may impinge the same nerves and vessels in the pectoralis minor space during hyperabduction and external rotation of the shoulder. TOS can be neurogenic and/or vascular.

[FIGURE 5]

TOS should be considered whenever a patient reports vague upper-extremity symptoms. In "classic" neurogenic TOS, patients describe insidious upper-limb pain, ulnar hand paresthesias, and thenar weakness consistent with a lower trunk plexopathy. In the majority of patients who have suspected TOS, the history includes pain, nonspecific numbness in the hands, and subjective weakness. The objective physical examination, electromyography (EMG), and vascular studies are usually normal.

Provocative physical examination tests are used to detect TOS, but their specificity is rather low (22,23). One such test is the Roos hyperabduction/external rotation test, in which the patient opens and closes his or her hands for 1 to 3 minutes with elbows bent and arms abducted to 90° and externally rotated (24). The test is positive if the maneuver reproduces the patient's symptoms. But, again, the specificity of this test is low.

To confirm or rule out arterial compression, the physician should examine the supraclavicular or infraclavicular fossa for a mass or bruit, palpate all distal pulses, and take blood pressure measurements of both arms. Laterally rotating the patient's head and extending it backward may increase the accuracy of tests for arterial compression, as can asking the patient to perform Valsalva's maneuver. EMG can be diagnostic if performed proximal to the areas of compression.

For symptomatic patients who test positive for the provocative maneuvers and for those in whom no definitive abnormality can be identified—and TOS is still suspected—management should focus on muscle strength balance between the anterior and posterior thorax, stretching of the pectoral muscles and the anterior shoulder, and patient education about avoiding provocative positions.

Suprascapular neuropathy. The suprascapular notch, under the transverse scapular ligament, is the most common site for impingement of the suprascapular nerve (figure 6: not shown). Compression of this nerve affects both the supraspinatus and infraspinatus muscles. At this level, the nerve can be traumatized by repetitive shoulder abduction, as in the military press (25,26).

Patients typically present with gradually increasing pain with or without weakness. The weakness may not be apparent to the patient until late in the course when atrophy is noticeable.

The clinical distinction between atrophy from rotator cuff injury and atrophy from suprascapular neuropathy can be difficult, but examining the muscles involved and assessing the degree of atrophy may help differentiate the conditions. Atrophy involving only the supraspinatus muscle could be seen with a supraspinatus tear, but would be unusual for suprascapular neuropathy, which can lead to atrophy in both the supraspinatus and infraspinatus muscles. Isolated infraspinatus atrophy would be unusual for a rotator cuff injury, but could suggest compression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch, perhaps from a ganglion cyst.

Nerve conduction studies of the suprascapular nerve and needle EMG can assist with the diagnosis. Magnetic resonance imaging of the shoulder can confirm the integrity of the rotator cuff tendons and can rule out a neuroma in the suprascapular notch (27).

Treatment involves pain medication, gentle assisted range-of-motion exercises to avoid contracture, and strengthening exercises for surrounding muscles—the rhomboids, latissimus dorsi, trapezius, serratus anterior, and especially the scapular stabilizers. Patients can gradually strengthen the affected muscles when pain is gone and the muscle can be moved against some resistance. An EMG may be helpful to document evidence of reinnervation; if the condition is present, strength training can gradually be initiated in a controlled manner. If nonoperative treatment fails, surgery may be needed.

Scapular winging. Scapular winging is caused by weakness of the serratus anterior muscle from a long thoracic nerve injury, or by weakness of the trapezius muscle from an accessory nerve injury (cranial nerve XI). The injury mechanism is not clear; in many cases, these injuries are idiopathic. No specific exercise has been found to predispose patients to scapular winging, but perhaps the pads on some machines that rest on the shoulders (ie, calf raises, leg presses) could contribute to injury.

Scapular winging from long thoracic nerve palsy is typically more prominent at the inferior medial border of the scapula with shoulder flexion, whereas accessory nerve palsies cause superior medial scapular winging (28).

The diagnosis should include laboratory tests to screen for infectious and inflammatory causes, as well as EMG and nerve conduction studies to establish the level of injury. Treatment consists of relative rest and close follow-up—scapular winging often resolves spontaneously within 3 to 24 months.

Musculocutaneous neuropathies. In a report (29) of three patients who had musculocutaneous neuropathies, all occurred in the patients' dominant arm and spared the coracobrachialis muscle. The patients' symptoms were precipitated by repetitive biceps curls. Symptoms included biceps muscle pain and weakness. Theoretically, symptoms are caused by impingement of the musculocutaneous nerve from coracobrachialis muscle hypertrophy. Because the symptoms of C-5 or C-6 cervical radiculopathy, brachial plexopathy, and biceps muscle rupture are similar, EMG may be required to establish the diagnosis.

Management is nonoperative, consisting of activity restriction. The three patients described above regained biceps and brachialis muscle function within 3 months (29).

Notalgia paresthetica. Notalgia paresthetica is thought to be caused by a lesion of a thoracic dorsal primary ramus. It's not known if this condition is seen in weight trainers; the injury mechanism is essentially unknown. Patients typically report chronic pain and sensory symptoms that are frequently described as intense itching in an area 4 to 10 cm in diameter over the thoracic paraspinal muscles at the inferomedial scapula.

Capsaicin can help alleviate symptoms (30). It acts by depleting the local C fiber store of neuropeptides, which are the principal substance responsible for transmitting pain and itching.

Chronic Medical Conditions

Vascular stenosis. Though uncommon, vascular stenoses may result from repetitive trauma to a blood vessel. Several cases of external iliac artery stenosis in the region of the inguinal ligament have been reported in bicyclists (31). Khaira et al (32) reported on a young bodybuilder who had a similar injury. They hypothesized that the injury resulted from repetitive hip flexion during leg press and squat exercises. Symptoms may include anterior thigh pain. The diagnosis may require vascular studies; treatment in bicyclists has involved vessel grafting.

Weight lifter's cephalgia. Weight lifters headache is generally sudden in onset and occurs during active lifting (33-35). In many cases, the weight training exercise being performed at the time of headache onset was the bench press. The pain is described as burning or boring in quality and localized to the posterior head and neck. Though onset is abrupt, the headache may persist for several days to weeks, gradually resolving. No clear cause has been identified; the presumed mechanism is ligament or soft-tissue injury.

Initial management consists of avoidance of weight training, cervical range-of-motion exercises and stretches, and pain medication. After a patient's pain resolves, training technique should be reviewed to eliminate incorrect technique.

Weight lifter's heart. Physiologic stress on the cardiovascular system during weight training changes the myocardial architecture in "weight lifter's heart (36)." The intraventricular septum thickens relative to the ventricular free wall (37). The condition may be inaccurately diagnosed as hypertrophic obstructive cardiomyopathy (HOCM); however, the ratios of intraventicular septum thickness to body surface area and of ventricular free wall thickness to body surface area are the same in weight trainers and controls (37). In patients who have HOCM, these ratios are significantly greater than in controls.

Hernias. Though hernias are commonly mentioned in association with weight training, and popular weight lifting magazines have many advertisements for hernia repairs, no incidence or prevalence studies have been completed.

Know What to Expect

Becoming aware of the host of chronic conditions that can arise during weight training will help physicians make more efficient use of the time they spend with the next weight trainer who walks through the door with, for example, vague upper-extremity symptoms or a sore shoulder. Questioning patients about their weight lifting practices and making them aware of incorrect technique can help them get back to their fitness routines faster and enable them to work out pain free.

References

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Dr Reeves is chief resident, Dr Laskowski is a consultant, and Dr Smith is a senior associate consultant in the department of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minnesota. Dr Laskowski is codirector and Dr Smith is a staff physician at the Mayo Sports Medicine Center, and Dr Laskowski is an associate professor and Dr Smith is an assistant professor at Mayo Medical School in Rochester. Address correspondence to Edward R. Laskowski, MD, Mayo Sports Medicine Center, 200 First St SW, Rochester, MN 55905; e-mail to [email protected].


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