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SA Orthopaedic Journal

versión On-line ISSN 2309-8309
versión impresa ISSN 1681-150X

SA orthop. j. vol.9 no.2 Centurion ene. 2010




Management of sports overuse injuries of the lower limb: an evidence-based review of the literature



RP BondI; CH SnyckersII

IMBChB(UCT), Senior Registrar, Department Orthopaedic Surgery, University of Pretoria
IIMBChB(Pret), Dip(PEC)SA, MMed(Ort)(Pret), FC(Ort)SA Consultant, Department Orthopaedic Surgery, University of Pretoria

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This article reviews common lower limb sports overuse injuries relevant to the orthopaedic surgeon. The following conditions are covered:
• Snapping hip syndrome
• Iliotibial band syndrome
• Patellar tendinopathy
• Achilles tendinopathy
• Medial tibial stress syndrome
• Tibial stress fractures
• Chronic compartment syndrome
These conditions can be managed conservatively inmost cases. Adequate rest followed by a graded rehabilitation is extremely important. Intrinsic and extrinsic contributing factors must be sought for and corrected. It is only in the uncommon case of failed conservative treatment that surgical intervention is necessary. For each of the above conditions, the indications for surgery, surgical principles, various surgical procedures and results and complications thereof are analysed and discussed. A meta-analysis of surgical treatment studies with similar methodologies was performed. The majority of studies found were of Level IV evidence with small patient numbers. The recommended outcome measures to assess results of surgical intervention are relief of pain and return to pre-injury level of sporting activity. Surgical treatment often does not result in a cure but an improvement of symptoms. Prospective randomised control trials with adequate patient numbers comparing different surgical treatments are needed.




Sports overuse injuries are common in a modern society of increased sports participation and professionalism. Impressively 50% of sports injuries are due to overuse injuries.1

This article reviews the most common lower limb sports overuse injuries relevant to the orthopaedic surgeon, specifically: snapping hip syndrome, iliotibial band syndrome, patellar tendinopathy, Achilles tendinopathy, medial tibial stress syndrome, tibial stress fractures and chronic compartment syndrome.2

Most of the time, these injuries can be successfully treated conservatively by a multidisciplinary team consisting of a combination of the general practitioner, physiotherapist, biokineticist and sports physician. Surgery is only indicated in uncommon cases of failed conservative treatment. Apart from these infrequent referrals for possible surgical intervention, the orthopaedic surgeon is commonly consulted by general practitioners for opinion on lower limb pathology, which includes sports overuse injuries. In lieu of the above, a broad understanding of the conditions is necessary to manage these patients effectively.

In general, lower limb sports overuse injuries occur when either repetitive friction between two tissue surfaces or tissue overload causes micro trauma. With continuous activity, there is inadequate time for recovery and tissue damage results.2 Predisposing factors to sports overuse injuries are divided into intrinsic and extrinsic factors. Intrinsic factors are very often an athlete's biomechanical abnormalities. The most common extrinsic factors are changes in method, intensity or duration of training.2 In the majority of cases a definitive diagnosis can be made on clinical grounds alone. Conservative treatments should be both supervised and adequate. Relative rest is important and must be followed by a graded rehabilitation programme. The intrinsic and extrinsic contributory factors must be sought for and corrected. There are a multitude of adjuvant treatments that both stimulate healing and improve tissue quality of strength, flexibility and endurance.

The athlete referred for surgery with a lower limb sports overuse injury has often undergone a prolonged and failed conservative treatment programme. At this stage, the athlete is not only frustrated but may also face a potentially career ending injury. Nevertheless, the orthopaedic surgeon must take time to revisit the history, physical examination, special investigations and treatment to confirm the correct diagnosis and ascertain whether conservative treatment has been adequate. It is imperative to know the surgical indications, principles, various techniques, as well as the results and complications. This article reviews the literature on these points for each condition. Data presented is based on articles obtained by a Medline literature search of studies on the surgical treatment of these lower limb sports overuse injuries over the last 10-20 years. A meta-analysis of studies with similar methodologies was performed and when possible, comparisons of the various surgical techniques were made.


Snapping hip syndrome

Snapping hip syndrome (coxa saltans) is a group of conditions characterised clinically by a painful, audible snap occurring during hip flexion and extension.3 It affects mostly the young adult runner, dancer and rower.

There are two types of snapping hip:

1. External snapping is caused by increased tension of the iliotibial band (ITB) and/or its gluteus maximus muscle insertion as they slide anteriorly and posteriorly over the greater trochanter resulting in inflamed, thickened and fibrosed bands. There can be an associated greater trochanteric bursitis.4-7

2. Internal snapping is caused by iliopsoas tendon shifting from lateral to medial with snapping against the pubic bone.8,9

Pain-free snapping should be considered a normal occurrence.9,10 The patient will give no history of trauma. The pain is described as a dull ache but becomes severe with certain movements. With external snapping hip, the snap is felt over the greater trochanter (patients frequently describe a sense that the hip is dislocating, termed pseudosubluxation) while with internal snapping it is over the groin area. The patient is often able to reproduce the snapping during examination.6

Clinically it can be difficult to differentiate internal snapping hip from intra-articular hip pathology causing sounds. Dynamic ultrasound studies, magnetic resonance arthrography and hip arthroscopy can be helpful.11,12


The mainstay of treatment of snapping hip is conservative.3,4,13 Rest and reassurance is often all that is needed. Adjuvant treatment modalities include non-steroidal anti-inflammatory drugs, steroid infiltration and physiotherapy. Importantly the patient must avoid activities that cause snapping.6,14

Surgical intervention is indicated for uncommon, refractory cases, where 3-6 months of conservative treatment has failed.3,4,7,13,14

Surgical treatment of external snapping hip

The important surgical principle is to decrease the tension of the proximal one-third of the ITB complex as it slides over the greater trochanter.6

This can be achieved by:

1. Lengthening of the ITB by Z-plasty. Careful planning of the Z-plasty is needed to obtain maximum length. An Ober's test should be performed intra-operatively to ascertain if lengthening is adequate.4,15,16

2. Release of the ITB and/or gluteus maximus most often by multiple incisions. Intra-operatively one must check if the release is adequate by taking the hip through a provocative range of movement - specifically flexion, adduction and internal/external rotation. Also make sure the tight fibrous bands of fascia lata posteriorly and gluteus maximus anteriorly are released.5,7

3. Excision of posterior half of the ITB. This is most often an open procedure17 but a technically demanding arthroscopic technique has been described.18

Furthermore, an inflamed trochanteric bursa must be excised.5,7,17,18

Postoperatively there are no restrictions in release5,7 or excisional17,18 procedures but partial weight bearing for 2 weeks is needed after Z-plasty lengthening4,15,16 procedures.

A meta-analysis of the results of studies on the different surgical techniques showed that similar, good results were achieved with all techniques. A cure, of no snapping and being pain-free, was achieved in 88% (75-100%) of Z-plasties,4,15,16 85% (73-89%) of multiple releases5,7 and 76% (71-91%) of posterior resections17,18 (Figure 1). There were minimal complications, although some patients reported mild subjective weakness and a limp with lengthening procedures.7



The most common cause of failed surgery was residual bands or recurrent adhesions.5,16 In these patients snapping may have recurred but pain was often significantly less.5,7,15,16 In those with significant pain, a second procedure (a repeat of the initial surgical technique) was found to be curative.5,16

Surgical treatment of internal snapping hip

The important surgical principle is to decrease the tension on the iliopsoas tendon.6

This can be done by:

1. Fractional lengthening of the iliopsoas tendon via either a single incision of the tendinous portion at the musculotendinous junction13,19,20 or multiple partial incisions.3,14 It is most often an open procedure and here care must be taken to avoid injuring the femoral and lateral cutaneous nerves.3,13,14,19,20

2. Full release of the iliopsoas tendon at its insertion on the lesser trochanter. This is most often performed arthroscopically.10,11,21 Postoperatively patients mobilise as pain allows.3,10,11,21 Return to sports activity is usually at 3 months.11,13

Open fractional lengthening procedures3,13,14,19,20 gave a cure, of having no snapping and being pain-free, in 74% (56-89%) of cases. Multiple incision release procedures3,14produced better results than single incision releases:13,19,20 75% (70-78%) versus 65% (56-89%) cure rates (Figure 2). Complications reported were sensory nerve injury in 9-50 % of cases and hip flexor weakness occurring in 4-45% of patients.3,13,14,19,20 If snapping did recur, there was often a significant reduction in pain.3,13,14,19,20 Recurrence of snapping can be due to inadequate tendon lengthening and excessive scarring with adhesions.21



Arthroscopic treatment of internal snapping hip is most often a full release procedure10,11,21 but a fractional lengthening procedure10 has also been studied. It must be noted that there is a 75% (57-83%) incidence of associated intra-articular hip pathology in internal snapping hip patients, most often anterosuperior labral tears and femoral acetabular impingement.10,11,21 The few small case series11,21 (n = 6 and 7 respectively) on arthroscopic release have shown promising results with 100% cure rates (Figure 2). The intra-articular hip pathology can be addressed at the same time and sensory nerve injury complications are avoided. However, a concern is that full release procedures resulted in hip flexor weakness in 54% (0-100%) of patients.11,21

With an open release of the iliopsoas tendon it might be beneficial to assess for treatable intra-articular hip pathology either by a pre-operative MRI arthrogram11 or alternatively a hip arthroscopy at the time of surgery.6,10,11,21 If arthroscopic release of the iliopsoas tendon is the preferred treatment, it should be considered to perform fractional lengthening rather than full release procedures in order to avoid the complication of hip flexion weakness.

The majority of studies on external snapping hip (n = 5-44)4,5,7,15-18 and internal snapping hip (n = 6-92)3,10,11,13,14,1921 to date have been case series with small sample sizes. Randomised controlled trials comparing the various surgical techniques are required. A significant problem is the lack of study patient numbers as conservative treatment is mostly successful.


Iliotibial band syndrome

Iliotibial band syndrome (ITBS) is a common cause of lateral knee pain in athletes participating in sports with repetitive knee flexion. It is particularly prevalent in long-distance runners, cyclists and football players.22

It results from excessive lateral to medial compression of fatty, connective tissues between the posterior iliotibial band (ITB) and the lateral femoral epicondyle at an impingement zone of 30º flexion.23,24 The resultant inflamed tissues may form a pathological adventitial bursa. An alternative theory is that this 'bursa' is actually an out-pouching of synovium from the lateral synovial recess in the suprapatellar pouch.22,25,26

Extrinsic predisposing factors include increase in training intensity, downhill running and running in same direction on a track. Common intrinsic factors are weak hip abductors, varus deformities of the leg and heel as well as forefoot supination.22,27

The diagnosis is made on clinical grounds. The athlete complains of lateral knee pain coming on after a specific duration of exercise or distance run, usually not before 3 km. The pain is then progressive. An Ober's test is often positive. Noble's compression test (pressure applied to the lateral femoral epicondyle while passively extending the knee causes familiar pain at 30º) is usually confirmatory. Importantly, the hip abductors should be assessed for weakness.28,29


Conservative treatment is mostly successful.28,30,31 A rest period of 4-6 weeks, with graded return to sporting activity, is imperative. Physiotherapy is often beneficial. If recurrent, the entire lower limb kinetic chain must be analysed and abnormalities addressed. Excessive supination is corrected with lateral heel wedges.22,28,29,31

Surgery is warranted in the uncommon situation (1-6% of patients) in which symptoms do not improve after 6-12 months of conservative treatment.22,23,29

Surgical treatment

The important surgical principles are:

1. Decrease impingement of the tighter posterior fibres of the ITB on the lateral femoral epicondyle.22,28

2. The pathological tissue underlying the ITB needs to be excised.25,27

In a meta-analysis of studies of the various surgical techniques, the following procedures gave similar excellent (no pain with activity) to good (significantly less pain with activity) results in 95% or more of cases operated:

• incision of the posterior fibres of the ITB27,32,33

• excision of either a triangle29 or ellipse33 of the posterior fibres of ITB

• Z-plasty lengthening of the distal ITB31

• arthroscopic resection of the lateral synovium.25

Less success was achieved in procedures done under local anaesthetic,27 standalone open bursectomies23 and percutaneous releases33 with excellent to good results obtained in 85%, 82% and 25% of cases respectively. Routine knee arthroscopy does not add to the treatment of ITBS, unless there is associated intra-articular pathology.23,31,33

Procedures generally have low morbidity and quick recovery, with weight-bearing postoperatively as pain allows and usually return to sport at 4-6 weeks.22,25


Tendinopathies of the lower limb

Patella and Achilles tendinopathies are common tendinopathies of the lower limb in the athlete.

Tendinopathy refers to overuse injuries of tendons presenting with pain, swelling and functional limitation, as well as the histopathological entities of paratendinitis and tendinosis. Tendinosis describes lipoid degeneration of the tendon with associated in-growth of disorganised vascular and neural elements (neoneurovascularisation).34 The latter is thought to be the primary pain generator in tendinopathies.34-37 Paratendinitis is a precursor to tendinosis38 and refers to the pathology or imaging proven presence of inflammation and