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    OVERUSE INJURIES- What you need to know.

    Last updated 3 days ago

    By Dr. Robert Nirschl, MD, MS

    Sports injuries are classified as either an overuse or an acute injury. Most sports injuries are a result of overuse and they occur when the body has been pushed too hard, too fast or too long. Pain and swelling are the first indications of overuse injury, and, as is the case for acute injury, “PRICEM” is the rule of thumb for general treatment.

    Protect the injury or it may easily become an acute injury.  Don’t play through the pain. Stop the activity causing discomfort and rest. Put ice on the injured area as soon as possible, but be cautious about direct application that might cause “ice burn”. Compression reduces the swelling. Use an elastic bandage around the injury. Spandex clothing, a neoprene sleeve, or an elastic stocking may serve the same purpose and might also offer some limited measure of support and protection. Elevate the injury above the level of your heart and continue to do so even during sleep.

    It is important to let an overuse injury completely heal before subjecting the injured area to additional stress or abuse. Playing hurt has the same effect as ripping a wound open repeatedly before it can heal. It not only won’t heal, but it may result in a very serious or even irreversible problem. It is also important to reduce the irritative chemical inflammation to aid in the healing process. Compression, ice and elevation are all associated with that component, but medication may be needed as well. Frequently, aspirin or ibuprofen (Motrin, Aleve, Advil, etc.) in therapeutic dosages are effective, but cortisone or some other prescription drug may be necessary. Aspirin at that dosage may cause an upset stomach so buffered aspirin is recommended. Aspirin is not recommended for children because of the risk of Reye’s syndrome. It can also retard blood clotting (helpful to prevent strokes and heart attacks) but should not be taken 10 days in advance of surgery.

    Ice is effective in reducing the pain and swelling in an injured area when inflammation is present. Subsequent treatment with heat will facilitate healing by increasing blood flow to the region for removal of excess liquid and toxins that are a by-product of the injury, as well as enhancing nutrition and oxygenation. It is even possible to create a pumping effect with alternate heat (30 minutes) and cold (5-10 minutes) applications. Massage can also be used to aid circulation to the injured area. But care should be taken not to irritate or abuse the injury, and extreme caution should be used with a mechanical massager.

    The best way to prevent sports injuries is to follow a good warm-up and conditioning program. A regular exercise program with weights and resistance equipment will help structural development that can better withstand the physical stress that will be encountered during sports.  Stretching before and after sports activity will better prepare those muscles and tendons for future use. Some of the more common soft tissue injuries that result from overuse are:

    Sprains: A sprain is an injury to a ligament, a firm band of tissue that supports the joints. Three types of sprains can occur: Grade 1- the ligament is stretched; Grade 2- some of the fibers are torn; Grade 3 – the ligament is totally torn. Sprains are usually the result of twisting trauma, and most commonly occur in the ankle and/or knee joint.

    Strains: A strain is an injury to a muscle-tendon unit. Like sprains, strains can be classified according to severity – stretched, a partial tear, or a complete tear. Strains may occur when muscles lack strength and flexibility. Deficient warm-up or exposure to extreme cold or unusually stressful activity are additional important factors. Strains in the hamstrings and groin adductors (rear and inner muscles of the upper leg) are common, but strains in muscles of the shoulder girdle are becoming recognized as an important contributing factor to shoulder tendinitis as well as primary injury. Strains are always accompanied by weakness.

    Tendinitis/Tendinosis: Tendinosis is a degeneration or injury of a tendon and is generally caused by repetitive trauma. Tendinosis is common in tennis and other sports and repetitive use occupations. Tendinosis, rather than tendinitis, is the correct term as we now know that inflammatory cells are not present in the injured tendons. The most commonly affected tendons are the Achilles, tendon, tendons at the knee (runner’s knee), tendons of the posterior tibial muscles-tendon attachment (shin splints), and tendons of the elbow (tennis elbow) and shoulder (rotator cuff tendinosis). Treatment may include medication for pain control, physical therapy to heal, and control of overuse with counter-force bracing. As a last resort, surgery may be an option. Practicing proper sports techniques will also go a long way in preventing tendinosis.

    Bursitis: Bursitis is an overuse injury that results in the inflammation of bursa and is most common in areas near the elbow, shoulder, knee, heel and hip. Bursa are fluid-filled sacs found in regions where friction occurs. Their main function is to minimize friction between bones and tendons, tendons and ligaments or even bone and bone. The condition is frequently found in association with tendinosis and the bursal inflammation. Players with injury to the knee bursa have excessive swelling due to accumulation of fluids in the bursa over and just below the knee cap. Other common bursitis areas include the shoulder, tip of the elbow, outer hip and under the Achilles tendon. The bursa sometimes must be drained or even removed before proper healing can take place. Cortisone is very effective in reducing the bursal inflammation, but other anti-inflammatory drugs maybe sufficient.

    Contusions: A contusion, or bruise, is an injury to soft tissue or bone in which the skin is not broken. A hard direct blow is the most common cause and a collection of blood (a hematoma) may form beneath the skin in the injured muscles, tendons or bone. Icing or some other form of cold application that will contract the blood capillaries will minimize the damage by preventing accumulation and swelling.


    It takes a long time for most players to admit to themselves that they are not indestructible, and they usually learn the hard way. Loss of flexibility and dehydration of tendons and ligaments with age make aggressive senior players more subject to injury but even the young are vulnerable. Much of this can be avoided by maintaining good strength and flexibility programs, practicing good pre- and post- work out preparation, becoming well informed about injury potential, and by simply using good judgment and control of abuse by using functional counter-force bracing. Following those principles, young people and should be able to continue active sports through their senior years. The enjoyment of that endeavor should result in maintained good health and physical conditioning that will enhance and extend your quality of life.  

    If you have pain or any orthopaedic injury, contact the experts at Nirschl Orthopaedic Center  or Virginia Sportsmedicine Institute in Arlington, Virginia. Schedule an appointment with our orthopaedists today by calling 703-525-2200 or visit our web site.

    No Pain No Gain? How to stay safe and in the game

    Last updated 1 month ago

    Pain is … well, a “pain” for athletes. It can compromise your training routine and keep you out of the sports that you love. If you ignore it or push through it, you can cause more damage and increase the time you will need to recover. We have all heard the “No Pain, No Gain” or the “Pain is Weakness Leaving the Body” adages, but these motivational quotes can give young athletes, or, for that matter, athletes of all ages, the wrong idea. Eventually this can lead to significant injuries that require extended down time to heal.

    So how do you know what is “normal pain” vs. “abnormal pain”? What is unimportant muscle and joint discomfort or an injury waiting to get worse? Here at the Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction we follow the pain phases of our founder, renowned orthopaedic surgeon, Dr. Robert Nirschl.

    These guidelines help athletes, parents, coaches, and trainers to better understand the type and intensity of pain they are dealing with, how to adjust their training routines or when it is time to follow-up with a sports medicine physician.



    Phase 0:  No pain or soreness.

    Phase 1:  Stiffness or mild soreness after activity, usually gone in 24 hours.

    Phase 2:  Stiffness or mild soreness before activity that is relieved by warm-up. Symptoms are not present during activity but return after, lasting up to 48 hours.

    Phase 3: Stiffness or mild soreness before specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity but does not cause athlete to alter activity.

    Phase 4: Pain is similar to but more intense than Phase 3 pain. Phase 4 pain causes athlete to alter performance of the activity. Mild pain may also be noticed with activities of daily living.

    Phase 5: significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living but does not cause a major change in them

    Phase 6: Phase 5 pain that persists even with complete rest. Phase 6 pain disrupts simple activities of daily living and prohibits doing household chores.

    Phase 7: Phase 6 pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity.

    If an exercise or activity causes Phase 3 pain or greater, this should be considered indications of injury. You need to modify or adjust the activity if possible or stop the activity completely, check with your therapists or doctor, and work in a “pain free” range.

    Some ideas are as follows:

    a.      Decrease the length of time of the exercise/activity and/or

    b.     Decrease the intensity at which you are performing the activity

    c.      Decrease the speed you are performing the exercise/activity

    d.     Alter the technique of the activity

    If you are unable to find a “pain free” way to complete your exercise, it is a good indication that there is an underlying injury that needs addressing. It is important that you follow up with a sports medicine physician to get an accurate diagnosis. A physical therapist will design a program to get you back to your full work out without further damage.

    Remember “No Pain, No Gain” can sometimes put you on the sidelines for a very long time. Listen to what your body is telling you and take the proper actions to keep you healthy and strong. The pain phases may be a helpful guide. If you are unsure check with your doctor.

    Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. In addition Virginia Sportsmedicine Institute physical therapy has been rated one of the top sports medicine clinics in the area. If you have an orthopaedic injury, schedule an appointment with one of our doctors today by calling our Arlington, VA location at (703) 525-2200. Visit our websites at and to learn more about our services. For more info on orthopaedic issues visit our blog at

    The Importance of Core Strengthening for Pitchers

    Last updated 1 month ago

    The importance of the baseball player’s arm is often the main focus for their preseason and offseason work-out programs.  Often the core of the player is ignored and often neglected.  The strength of the legs and core can often lead to increased power in the correctly conditioned athlete.  If the core of the player is weak, the arm is often placed in increased tension and usually trails behind the body during the throwing motion, leading to increased strain on the shoulder girdle, namely the rotator cuff musculature.  Several studies have shown an increase in strain on the anterior, or front, structures of both the shoulder (capsule and rotator cuff) and elbow (ulnar collateral ligament). Weakened core can often be attributed to an increase in arm injuries in the younger athlete.  Focus on stability, balance, and strength of the lower half of the body should be a main focus for baseball players, in addition to proper conditioning of the throwing arm.

    While strength and conditioning of the arm is also of great importance, large parts of the athlete preseason workouts should be devoted to increasing the strength and balance of the core.  The core consists of many different muscle groups that all must work in concert in order to generate the most power under a well-balanced motion during the throwing process.  Attention should be paid to the gluteus, quadriceps, hamstrings, abdominal, and lower back muscle groups during preseason conditioning.  Several workout protocols can be found and followed in order to strengthen the muscles properly.  Several exercises that can be done in order to maximize your results are as follows: single leg lunges (with and without weights), squats, leg extensions, leg curls, oblique crunches, hyperextensions (for lower back), balance and stability exercises for the push off leg.  These exercises plus many different others will aid you in becoming stronger and generate more power through the throwing motion.  Not only can a stronger core increase your velocity but more importantly it will also greatly decrease the stress and strain on your arm, thus decreasing the chances of an arm injury during the season.

     If you have an orthopaedic injury, contact the experts at Nirschl Orthopaedic Center in Arlington, Virginia. Schedule an appointment with an orthopaedic surgeon today by calling 703-525-2200 or visit our web site.


    Avoid Injuries -Proper Breaking in and Care of your New Orthotics

    Last updated 1 month ago

    If your orthopedic doctor informs you that you have an improper foot alignment or another kind of abnormality, he or she might recommend orthotics. Orthopedic doctors also recommend these devices for those who have low back pain, knee pain, plantar fasciitis, and shin pain. Custom-made orthotics are specially designed to correct your foot problems in order to restore proper function and alleviate discomfort. When you receive your orthotics, follow your orthopedic doctor’s advice carefully. Your orthotics may take a little getting used to.


    We use Foot Management Orthotics in our clinic, they are fabricated using the highest quality material. The body or shell of the orthotics generally lasts 5 or more years depending on the patient's weight and activity. If orthotics need to be cleaned, this is best done by gently wiping the top surface with mild soap and water. Avoid immersing your orthotics. If they get wet, remove them from your shoes and let them air dry. If your orthotics need repair or the top cover replaced, please contact our office.

    Due to the wide variety of footwear used and activities performed, and for convenience, you may want to have more than one pair of orthotics. Your scans will be saved for 5 years. If you are interested in a second pair please inquire with your insurance provider.



    Your new orthotics have been custom fabricated to your unique foot with a digital laser scan and are designed to provide maximum comfort and appropriate biomechanical control to address your specific needs. Initially your body will need time to adjust to this new "foot posture". It is very important that you follow the recommended break-in program to prevent any unnecessary discomfort or injury. Overuse of the orthotics during the break-in period may result in foot/arch discomfort or blisters, as well as ankle, knee, hip or back pain. If these symptoms occur, reduce or suspend use as described in the break-in instructions. Be sure your shoes are in good condition and not broken down. Shoes that are excessively worn will significantly diminish the effectiveness of the device. It is recommended that new orthotics be installed in new shoes.



    Full Length Designs: Remove any existing sock liners or shoe inserts from your shoes. Some shoes have sock liners that are glued in. These may need to be removed to provide enough space for your new orthotics. If they are too large to fit into your shoes this may cause wrinkling of the top cover. If this occurs, take the sock liners from your shoes and, after lining up the heels, carefully trace the toe box shape and trim your orthotics with scissors. Be careful not to cut too much off. The orthotics should lie flat on the bottom of the shoe with minimal "rocking". Place the orthotics in the shoes with the orthotics as far back into the heel cup as possible. When putting on the shoe, be sure the orthotic remains completely at the back of the heel counter. Once in the shoes, the orthotics should feel fairly natural to your feet. They should provide contact over the entire bottom of your feet. It is normal to feel the orthotics slightly more or differently in one foot than in the other for the first few weeks. Orthotics also have unique properties where you will feel different pressure points and may require additional break-in time in these areas, even if you have previously worn orthotics.



    Your new orthotics will take some time to get used to. It is recommended that you wear them in only one pair of shoes during the break-in period. It is best to BREAK-IN ORTHOTICS with a new pair of shoes that have NOT been broken down or stretched out. Properly fitting footwear is essential for the orthotic to work correctly. Start by wearing them for no more than two hours the first day, and increase wear time by one hour each day after that. It may take from three to four weeks before you can wear them comfortably all day. Avoid running or other intense activities with the orthotics until your feet have had an opportunity to adjust to the new foot posture and you can wear them 8 hours a day. For runners, it is possible that some irritation may also develop in the arch, usually just behind the big toe. If you feel a "hotness" developing in this area take the orthotics out before a blister is formed. Lubricating this area may be helpful until the skin becomes toughened up. If you experience discomfort in your feet, ankles, knees or back while wearing your new orthotics, take them out of your shoes and reduce the wear time by one hour each day until the discomfort disappears. Resume the normal break-in procedure, increasing wear time by an hour per day. If after 3-4 weeks, you are still having difficulty adjusting to the orthotics, contact our office for instructions. Your orthotics may need to be adjusted. Do not attempt to adjust the orthotics yourself. Be patient, the results will be long lasting.


    Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. Schedule an appointment with an orthopedic doctor today by calling our Arlington, VA location at (703) 525-2200. You could also visit our website to learn more about orthotics and other orthopedic services


    Preventing Injury & Enhanced Performance for Baseball Players-Dr. Robert Nirschl

    Last updated 2 months ago

    Nirschl Orthopaedic Center renowned surgeon Dr. Robert NIrschl discusses injury prevention and performance enhancement for baseball players. This is the second video in a series on Sports Tips and Injury Prevention. For more information and videos check out our web page at

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