Weekend warriors are individuals who “engage in [physically] demanding recreational sporting activities on weekends despite minimal physical activity during the [work] week.”^[1] The most common reason cited for this burst of activity on the weekends rather than regular workouts throughout the week is not having enough time to exercise. Consequently, weekend warriors may not be in the best physical shape, and suddenly engaging in intermittent strenuous activity can therefore increase their risk of injury—with certain types of trauma more common to these individuals.

Image courtesy of Wikimedia Commons/Victor Grigas.

Achilles Tendon Rupture

The Achilles tendon is one of the largest tendons in the human body; it is also one of the most frequently injured tendons. The Achilles tendon originates from the gastrocnemius and soleus muscles and attaches to the calcaneal tuberosity.^[2] This tendon powers the foot to push off the ground during such activities as walking and running.^[2]

Sporting activities are the primary cause of Achilles tendon rupture (shown, left leg), and the overall incidence of this injury has been increasing in the last few decades, often in sedentary individuals who occasionally participate in sports.^[3] In general, men are affected more commonly than women, as are middle-aged and obese individuals.^[2,3]

Image courtesy of Wikimedia Commons.

The diagnosis of Achilles tendon rupture is usually made by history and physical examination. Patients often report a feeling of being kicked in the back of the ankle, with or without an audible snap or popping sound. This sensation is usually followed by the inability to bear weight on the injured leg. Often, the clinician feels a palpable gap where the tendon should be.

The Thompson test, also known as the calf squeeze test, is highly sensitive for acute Achilles tendon rupture.^[3] With the patient prone and the injured leg flexed to 90°, the clinician squeezes the calf to observe for plantar flexion of the foot. If the foot does not plantar flex, this test is considered positive for rupture.^[2] If the diagnosis cannot be made by history and physical examination alone, then an imaging study such as ultrasonography or magnetic resonance imaging (MRI) can be used to assess for tendon pathology.

The radiograph (left) does not reveal a fracture or avulsion of the lower extremity and foot; on ultrasonography (right), discontinuity of the Achilles tendon over several centimeters is noted (red line), indicating rupture.

Image courtesy of Wikimedia Commons/Hellerhoff.

Initially, the lower leg on the affected side is splinted in plantar flexion. However, controversy exists regarding the optimal appropriate treatment for Achilles tendon ruptures.^[2,3] Therapeutic options include operative and nonoperative management.

Nonoperative management includes functional bracing/casting. Historically, this treatment has been associated with higher rates of tendon rerupture as well as a decrease in tendon strength when compared to operative management. Newer studies suggest such differences in outcomes between conservative and surgical interventions may not be true.^[3]

Operative management generally includes a procedure in which an incision is made over the ruptured area, and both ends of the tendon are repaired with sutures (shown).^[1,2] This method has been associated with a 1%-4% chance of wound complications.^[1]

Treatment decisions should involve a dialogue between the patient and clinician and take into account factors such as patient compliance and the level of sport participation. High-level athletes may benefit from operative intervention.

Image courtesy of Wikimedia Commons/SSgt Derrick C Goode, US Air Force.

Plantar Fasciitis

Plantar fasciitis is one of the most common sources of inferior heel pain, occurring in up to 10% of the US population^[4,5] and resulting in an estimated 1 million office visits each year.^[4,6] It affects active and sedentary individuals. The cause of this condition may be overload stress at the origin of the plantar fascia. A partial association with heel spurs (shown) has also been observed.^[4,5]

Radiograph of the heel bone in a patient with plantar fasciitis courtesy of Wikimedia Commons/Lucien Monfils.

The diagnosis of plantar fasciitis is generally made on the basis of the history and physical examination findings. Patients often report inferior heel pain, especially upon taking the first few steps in the morning. Frequently, the pain is alleviated by further walking, but it can return after a period of sitting or during exercise. The pain may be so significant at times that patients will often cease exercise activities.

Imaging studies are usually not helpful, although MRI evaluation may show a thickened plantar fascia with inflammation.

Plantar fasciitis is typically a self-limiting condition,^[4] and most patients eventually improve.^[4,5] In one study, researchers reported that 80% of patients experienced complete resolution of pain/symptoms within 4 years.^[7]

Sonogram depicting thickness of the plantar fascia courtesy of Wikimedia Commons.

Treatment often consists of general measures such as icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and rest.^[4-6] Additional conservative therapies include the use of preformed padded shoe inserts, night splints, and stretching exercises for the calf muscles (shown). Although corticosteroid injections have been shown to provide initial relief, such therapy does not resolve the pain^[7] and it is not recommended as the mainstay of treatment.

Focused extracorporeal shock wave therapy for chronic plantar fasciitis is another treatment option,^[4,8] with a reported success rate of 50%-65%.^[8]

Surgery has not been shown to have an increased benefit compared to conservative management; many patients continue to have pain following operative intervention.^[4]

Image courtesy of Medscape/Vinod K Panchbhavi, MD, FRCS, FACS.

Tennis Elbow

“Tennis elbow” or lateral epicondylitis is one of the most common sources of elbow pain.^[9] Repetitive dorsiflexion of the wrist and supination/pronation movements cause microtears (shown) and collagen breakdown at the origin of the extensor tendons. This overuse injury affects approximately 1%-3% of the US population annually, with men and women impacted equally.^[9,10] Patients are usually older than 40 years and have an occupational and/or recreational history of repetitive activity.

Although lateral epicondylitis can result from playing racquet sports, the term “tennis elbow” is somewhat of a misnomer, as this condition can also be caused by many other sports, including golf (a separate condition from “golfers elbow” [medial epicondylitis]).

C = capitellum; R = radial head.

Image courtesy of Medscape.

The diagnosis of lateral epicondylitis is usually made on a clinical basis. A history of pain on repetitive motion in an occupational or recreational setting is typical. On physical examination, the patient's pain can be reproduced on resisted wrist dorsiflexion or supination with the affected arm extended. There is also tenderness to palpation over the origin of the extensor tendons just distal to the lateral epicondyle (shown). Imaging studies are not usually helpful for the diagnosis.

Image courtesy of Wikimedia Commons and KoS/Yosi I.

Only a few clinical trials have strong supporting evidence for any of the currently available treatment options.^[9] One conservative management option is watchful waiting; a study reported that at 1 year, watchful waiting was comparable to physical therapy but superior to corticosteroid injections. Corticosteroid injections demonstrated improvement at 2-6 weeks of therapy, but there was no benefit after 6 weeks.^[9] NSAIDs may provide temporary relief. Inelastic, nonarticular forearm straps or “tennis elbow braces” provide relief for some patients, but their efficacy has not been proven.^[9]

If conservative treatment fails after 6-12 months, surgery is often recommended. Operative intervention consists of debriding the abnormal tissue at the origin of the extensor carpi radialis brevis tendon or detaching the tendon from its origin altogether. Favorable results have been shown with few adverse effects.^[9]

The image shows a revision debridement for lateral epicondylitis. The fascia covering the origin of the extensor carpi radialis brevis muscle and the extensor carpi radialis longus muscle is fibrotic.

Image courtesy of Medscape.

Ankle Sprain

Ankle sprains are among the most common ankle injuries seen in US emergency departments and primary care offices, with approximately 23,000 ankle sprains occurring each day.^[11] These injuries occur when the foot twists, rolls, or turns beyond its normal range of motions—most often inversion-type injuries of the lateral ankle complex (anterior talofibular, calcaneofibular, and posterior talofibular ligaments).^[12] When excessive force is experienced in the foot during these movements, it can cause stretching and tearing of ligaments in the ankle capsular ligaments.

Patients may report that they hear a “pop,” followed by the presence of swelling and pain. Inability to bear weight on the affected extremity is common.

Image of a grade 2 ankle sprain courtesy of Wikimedia Commons/Boldie.

The diagnosis of an ankle sprain is made on the basis of the history and physical examination findings. These injuries are generally classified into three grades, as follows^[12,13]:

• Grade 1 sprain: Mild stretching/damage to the ligament fibers; there is little to no functional loss and no joint instability.
• Grade 2 sprain (shown): Partial tearing of the ligament(s), which can cause laxity of the ankle on physical examination; there is moderate to severe swelling and ecchymosis, with moderate functional loss and mild to moderate joint instability.
• Grade 3 sprain: Complete rupture of the ligament(s), resulting in instability of the ankle; there is immediate, severe swelling, ecchymosis, an inability to bear weight, and moderate to severe joint instability.

Radiography is used to rule out bony pathology such as an ankle fracture, which can have a clinical presentation that is similar to an ankle sprain.

Image courtesy of Wikimedia Commons/Dr Harry Gouvas.

A grade 1 sprain can be treated conservatively with rest, icing, compression, and elevation (RICE).^[12,13]

A grade 2 sprain (shown) can be treated with RICE and the use of a walking boot or splint for 2-3 weeks. Additional time thereafter should be allowed for healing to occur. Eventually, after resting the ankle and conservative treatment, physical rehabilitation can help patients to recover range of motion, with the goal of returning patients to their preinjury level of activity. NSAIDs are effective for pain control and helping to minimize inflammation.^[12,13]

A grade 3 sprain may result in permanent instability regardless of treatment.

Surgery may be necessary for some cases of ankle sprain.^[12,13] There are many techniques and procedures to correct chronic ankle instability and sprains, with varying outcomes. In general, an incision is made over the affected ligament(s), with suture repair to the ligament(s).

It is not uncommon for a patient who has suffered an ankle sprain to experience additional ankle sprains in the future. Therefore, preventative measures such as wearing appropriate footwear, identifying signs of fatigue, and being mindful of walking/running surfaces are important to avoid recurrences.

Image of an ankle stirrup splint courtesy of Wikimedia Commons and Bruce Blaus, Blausen gallery 2014, Wikiversity Journal of Medicine.

Shin Splints

“Shin splints” or medial tibial stress syndrome (MTSS) refers to pain along the tibia (shown), a condition that is common in runners, dancers, and military recruits. It is also often seen in athletes who have changed or recently intensified their training routine.^[14]

Risk factors that predispose individuals to shin splints include running, playing sports on hard surfaces, uneven terrain, pes planus, high arches, and military training.^[14]

Image courtesy of Wikimedia Commons/Anatomography.

MTSS is diagnosed on a clinical basis. Obtain a detailed history and perform a thorough physical examination. Symptoms/signs include tenderness, soreness, and pain along the anterior tibia. Mild swelling may be present. Initially, these symptoms/signs may resolve when the inciting physical activity ceases. Eventually, however, the pain may become continuous.

Radiography may be helpful in the evaluation of severe cases, as there can be other causes of tibial pain (eg, stress fractures).

The left radiograph (A) is the initial film in a patient who presented with lower leg pain. The follow-up right radiograph (B) reveals local periosteal reaction, which may indicate shin splints or stress fractures. Bone marrow abnormalities on high-resolution axial MRI may aid in distinguishing between these types of tibial stress injuries.^[15]

Image courtesy of Mammoto T, Hirano A, Tomaru Y, et al.^[15] Sports Med Arthrosc Rehabil Ther Technol. 2012;4(1):16. [Open source.] PMID: 22574840, PMCID: PMC3411460.

Treatment consists of conservative management, such as resting (ie, avoidance of the activities that cause the pain), icing the affected area (shown), and using over-the-counter pain relievers and/or NSAIDs.

Preventive measures may include the use of arch supports, wearing sport-appropriate shoes, and cross-training.

Image courtesy of Wikimedia Commons/US Navy Mass Communication Specialist 2nd Class Jhi L Scott.