ARTICLE

Modeling Overuse Injuries in Sport as a Mechanical

Fatigue Phenomenon
W. Brent Edwards1,2,3
1
Human Performance Laboratory, Faculty of Kinesiology; 2Biomedical Engineering Graduate Program; 3McCaig
Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Alberta, Canada

EDWARDS, W.B. Modeling overuse injuries in sport as a mechanical fatigue phenomenon. Exerc. Sport Sci. Rev., Vol. 46,
Downloaded from http://journals.lww.com/acsm-essr by BhDMf5ePHKbH4TTImqenVCscuGFl+NVZggpQLqr6TucpYWO3UkTP/RGpyiepKV6otn3BjsqKSBA= on 09/14/2018

No. 4, pp. 224–231, 2018. This paper postulates that overuse injury in sport is a biomechanical event resulting from the mechanical fatigue of
biological tissue. A theoretical foundation and operational framework necessary to model overuse injury as a mechanical fatigue phenomenon is
introduced. Adopting this framework may provide a more mechanistic understanding of overuse injury and inform training and preventive strat-
egies to reduce their occurrence. Key Words: loading magnitude, tissue damage, cumulative damage, Weibull analysis, loading rate

overuse injuries in sport (3,4), including the word “overuse” it-

Key Points self, suggests that these injuries result from a mechanical fatigue
• Overuse injuries result from repetitive loading and cumula- phenomenon. Here, mechanical fatigue refers to the accumula-
tive bouts of activity. tion of tissue damage and progressive loss of stiffness and
• Repetitive loading of biological tissues illustrates damage ac- strength associated with repetitive loading and cumulative
cumulation and failure consistent with a mechanical fatigue bouts of activity. This damage serves as a stimulus for remodel-
process. ing and adaptation (5,6), but without adequate rest and repair,
• Information from mechanical fatigue tests suggest that the continued loading will cause damage accumulation that may
risk of overuse injury should increase much more rapidly
with loading magnitude than loading cycles. eventually lead to failure (i.e., tear, rupture, fracture) (7,8).
• Mechanical fatigue tests also do not support the general no- Despite sharing a common philosophy that overuse injuries
tion that higher loading rates are deleterious to the muscu- in sport result from repetitive loading and cumulative bouts of
loskeletal system. activity, few researchers in this field have incorporated the fun-
• Probabilistic modeling of the mechanical fatigue process damental principles of mechanical fatigue into their applied
may be used to examine the relative risk of injury associated and clinical investigations. This article hypothesizes that over-
with sudden changes in training activity. use injury is ultimately a biomechanical event resulting from
the mechanical fatigue of biological tissue. Thus, any risk factor,
whether intrinsic or extrinsic to the athlete, will contribute to
overuse injury through this dynamic process. The fundamental
principles of mechanical fatigue can be readily applied to over-
INTRODUCTION use injury when one centers their focus of inquiry at the level of
Overuse injuries in sport are thought to have a diverse and the tissue. In this regard, there are several lessons that can be
multifactorial etiology (1,2), but this is true only when overuse learned from mechanical fatigue tests, which may provide a more
injury is defined at the whole-body, or systems, level. Overuse mechanistic understanding of the etiology of overuse injury.
injuries manifest at the tissue level, and previous definitions of This article briefly reviews evidence from ex vivo and in vivo
studies that repetitive loading of biological tissue results in me-
chanical fatigue. The predominant role that loading magnitude
Address for correspondence: W. Brent Edwards, Ph.D., Human Performance Laboratory,
plays in the mechanical fatigue process and its interaction with
Faculty of Kinesiology, University of Calgary, KNB 418, 2500 University Dr. NW, Calgary, loading cycles will subsequently be discussed followed by the
Alberta T2N 1N4, Canada (E-mail: [email protected]). important distinction between cumulative load and cumulative
Accepted for Publication: July 3, 2018. damage, and its implication for injury risk. The stochastic na-
Editor: Paul DeVita, Ph.D.
ture of mechanical fatigue is described, in addition to probabi-
listic analyses that incorporate mechanical fatigue uncertainty
0091-6331/4604/224–231
into injury risk estimations. Finally, the topical debate of load-
Exercise and Sport Sciences Reviews
DOI: 10.1249/JES.0000000000000163 ing rate and its potential role in overuse injury is discussed,
Copyright © 2018 by the American College of Sports Medicine along with the fact that repetitive loading may not only induce

224

Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
damage as a function of loading cycles, but also as a function of
loading duration.

MECHANICAL FATIGUE IN BIOLOGICAL TISSUE

Mechanical fatigue is characterized by microstructural dam-
age, or microdamage, in response to cyclic or repetitive loading.
Over time, this microdamage may grow and reach a critical size
(9,10), resulting in complete failure at loading magnitudes
much lower than the material’s monotonic strength (11–13).
The phenomenon of mechanical fatigue has been well de-
scribed in load-bearing biological tissues, either through ex vivo
cadaveric testing (11–13) or in vivo animal studies (14,15).
Microdamage can take many forms depending on the specific
tissue or mode of loading. Cyclic loading of bone, for example,
may illicit linear microcracks approximately 50–100μm in
length, or diffuse clusters of matrix cracks on the order of 1 μm
or less (16). Tendon damage on the other hand presents as
kinked fibers, or localized fiber dissociation and ruptures, de- Figure 1. Theoretical stressed-life plot, or S-N curve, for a material sub-
pending on the degree of fatigue loading (10). jected to cyclic loading. Fatigue life is defined as the number of cycles to fail-
ure Nf at a particular stress magnitude σ.
Mechanical fatigue–induced damage is often, but not neces-
sarily, accompanied by measureable changes in material
properties, such as reductions in modulus or increases in re- into a single, empirical relation. For engineering materials, the
sidual strain. Fung et al. (10), cyclically loaded rat flexor relation between peak stress magnitude σ, and the number of
digitorum longus tendons to low, medium, and high levels cycles to failure Nf is well described by an inverse power law:
of microdamage. Changes in stiffness and hysteresis were
not observed until high levels of microdamage, while tendon Nf ¼ Aσb ð1Þ
strain progressively increased with the level of microdamage.
Burr et al., (17) tested canine femora in four-point cyclic where A is a proportionality constant, and b is the slope of the
bending and observed an almost opposite trend; reductions S-N curve. When cyclically loaded ex vivo, biological materials
in stiffness preceded any observable microdamage, such that illustrate this same exemplar behavior (13); alternatively, loga-
the presence of microcracks was always accompanied by ma- rithmic or exponential decay curves are predictive of fatigue life
terial property degradation, but not the other way around. In (11,12). Although it may be more appropriate to write Eq. 1 in
uniaxial loading, the rate of material property degradation in terms of stress range Δσ (21), i.e., the difference between the
bone was highly influenced by the specific mode of loading (i.e., maximum and minimum stress per cycle, biological tissues in
tension versus compression); however, the total energy dissipated vivo often range between some peak stress magnitude (i.e., ten-
before failure was similar between loading modes (18). sion or compression) and zero, and so here, they may be used in-
Whereas the general pathway from early stage mechanical fa- terchangeably. What is important to recognize is that small
tigue to subsequent pain and overuse injury is understood, spe- changes in σ often will result in large changes in Nf. For the
cific details of this pathway related to the importance of loading magnitudes relevant to running, a 10% reduction in
mechanobiology remain undefined. In bone, it is not known stress generally is associated with a corresponding 100% in-
if the microdamage itself or an excessive remodeling response crease, or more, in the number of cycles to failure (11–13).
is ultimately responsible for stress fracture development. Indeed, If overuse injuries in sport were to result from a mechanical
strong theoretical arguments have been made that bone remod- fatigue phenomenon, then Eq. 1 would suggest that the risk of
eling in response to microdamage accumulation may create lo- injury within a given sport would increase much more rapidly
calized porosity and elevated mechanical stress/strain, which in with loading magnitude than loading cycles (i.e., similar to
turn leads to more microdamage and bone remodeling activ- the theoretical relation illustrated in Figure 2a). Unfortunately,
ity with continued loading (19). Similarly, the extent to the field of exercise and sport science has yet to report the nec-
which tendinopathy is an exclusive degenerative disorder essary data to test this hypothesis; however, convincing evi-
versus an inflammatory mediated response to microdamage dence of a mechanical fatigue-type risk profile has been
accumulation remains a topic of debate (20). But, whether reported for musculoskeletal disorders such as carpal tunnel syn-
biologically mediated or solely due to mechanical degrada- drome, hand-wrist tendinopathy and pain, epicondylitis or ten-
tion, the rate of mechanical fatigue is always a strong func- nis elbow, and lower back disorders. Gallagher and Heberger
tion of loading magnitude. (22) performed a literature review of 12 epidemiological studies
that examined musculoskeletal disorder risk as a function of
THE INFLUENCE OF LOADING MAGNITUDE loading magnitude and loading cycles. They reported evidence
The fatigue life of a material is defined as the number of re- for the presence of a load  cycle interaction in 10 of these
petitive loading cycles it can endure before complete failure. studies. The interactions were such that increased loading cy-
This fatigue behavior often is described by a stress-life plot cles resulted in moderate increases in musculoskeletal disorder
(Fig. 1), or S-N curve, which characterizes the damage nucle- risk for low-magnitude loading tasks, but rapid increases in risk
ation, damage accumulation, and failure processes of a material for high-magnitude loading tasks (Fig. 2b). In other words, it

Volume 46 • Number 4 • October 2018 Overuse Injuries and Mechanical Fatigue 225

Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Figure 2. A. Theoretical stress-life plot and patterns of fatigue failure risk for different combinations of loading magnitude and loading cycles. B. Averaged
odds ratios for epidemiological studies that examined musculoskeletal disorder risk as a function of loading magnitude and loading cycles (22). [Adapted from
(23). Copyright © 2017 Taylor & Francis Group. Used with permission.]

may be insufficient to examine the main effects of loading and there exists considerable evidence that load-induced tissue
magnitude and loading cycles independently when examining damage serves as a stimulus for biological remodeling (5,6).
injury risk; rather, measurements that account for their It should be clearly stated that the measurement of cumula-
potential interaction may be required. tive damage, and therefore injury risk from a mechanical fatigue
perspective, is not linearly proportional to the measurement of
cumulative load, which often has been defined as the product
DIFFERENCE BETWEEN CUMULATIVE LOAD AND of the number of loading cycles and peak load, or some impulse
CUMULATIVE DAMAGE equivalent (26,27). Although two cycles at loading magnitude
The complex interaction of loading magnitude and loading σ would provide the same cumulative load as one cycle at load-
cycles is inherently captured by cumulative damage models of ing magnitude 2σ, according to the Palmgren-Miner rule, the
mechanical fatigue. The simplest of all cumulative damage damage incurred by these specific loading scenarios would differ
models is the Palmgren-Miner rule, which states that a material by a factor of 2b-1. Therefore, using cumulative load as a proxy
will fail when a specific amount of damage D, as defined by the for injury risk may lead to erroneous conclusions for loading sce-
load-time history and S-N curve, has been accumulated. If a narios that differ in terms of their magnitude and number of cy-
material experiences m different stress cases (i.e., walking, run- cles, even when their cumulative loads are identical.
ning, jumping, etc.), then the fractional damage caused by the To illustrate this concept, data from a previously reported
ith case of peak stress magnitude σi is simply the number of cy- study (28) were used to calculate Achilles tendon force for
cles ni at σi divided by the number of cycles to failure Nfi at ten participants running overground at three different speeds
σi. Thus, according to the Palmgren-Miner rule, failure will (i.e., 2.5, 3.5, and 4.5 m/s). The Achilles tendon impulse per
take place when: step was calculated as the time integral of the Achilles tendon
force curve during stance, and a weighted impulse measure
ni
D ¼ ∑m
i¼1 ¼ 1: ð2Þ was quantified where Achilles tendon force was raised to the
Nfi power of 9 before impulse calculation. This value for b was de-
rived from ex vivo tendon testing data and is described in more
Substituting Eq. 1 into Eq. 2 provides: detail in the following section. The cumulative impulse and cu-
ni mulative weighted impulse were calculated as their respective
D∝∑m ¼ ∑m
i¼1 ni σi :
b
ð3Þ impulse per step measures multiplied by the number of steps
i¼1
σi −b
necessary to run 1 km. Whereas the cumulative impulse de-
Although beyond the topic of this review, there are a number creased with running speed (Fig. 3a), the cumulative weighted
of proposed methods that may be used to reduce a complex impulse increased with running speed (Fig. 3b). In other words,
load-time history with variable stress amplitude into a series of using a traditional measure of cumulative load suggested that
simplified cycle/stress case scenarios that may be used with the running faster might actually decrease the risk of Achilles
Palmgren-Miner rule (24). For the case of a single peak stress tendon injury, although this rather counterintuitive conclusion
magnitude, Eq. 3 may be written as: was not reached when using a weighted impulse measure that
considered the stress-life behavior of tendon.
D∝nσb : ð4Þ
Some individuals will recognize Eq. 4 to be similar to the daily MECHANICAL FATIGUE IS A STOCHASTIC PROCESS
loading stimulus equation proposed by Carter’s group to predict Cumulative damage models like the Palmgren-Miner rule
load-induced tissue adaptation (25). This is not a coincidence rely on equations from S-N curves representing the arithmetic
because Carter based his theory on the Palmgren-Miner rule, mean of sample fatigue behavior derived from one or multiple

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Figure 3. The mean (A) cumulative impulse and (B) weighted cumulative impulse as a function of speed calculated from the time integral of the Achilles ten-
don force curves during the stance phase of running (*P ≤ 0.05). Note that the weighted cumulative impulse has been raised to the power of 1/b to provide
identical units.

experiments. However, owing to the inherent variability in tis- a particular activity, the Pf associated with a specific number of
sue microstructure, two otherwise seemingly identical samples loading cycles can be determined.
will inevitably exhibit scatter in their fatigue behavior. In fact, To quantify ε, data were collected from six university basket-
there is a high probability that a tissue will fail either before or ball players performing maximum vertical jump landings in two
after what is predicted by the S-N curve, and because of the log- footwear conditions while motion capture and force platform
arithmic scale, it may be extremely important to account for data were collected concurrently. The footwear conditions dif-
this variability. fered only in their outsole cushioning material, with a tradi-
The Weibull analysis is a well-known technique used for the tional shoe being 42% stiffer and providing 11% less energy
treatment of scatter observed in the fatigue of materials, based return than an energy return shoe. An inverse dynamics ap-
on a distribution function, which mathematically describes proach was used to quantify intersegmental forces and moments
the “weakest-link-in-the-chain” concept. Briefly, if a series of of the lower extremity, and patellar tendon force F was quanti-
specimens with identical macrostructure are cyclically loaded fied using a musculoskeletal model of the knee that accounted
to failure at stress magnitude σ, their measured fatigue strength for antagonistic coactivation (31). After the calculation of F,
will be expected to vary according to: ε for the patellar tendon during landing was calculated as:
pf ¼ 1− exp½−ðσ=σ*Þm  ð5Þ ε ¼ F=ðAEÞ ð6Þ
where Pf is the probability that the fatigue strength of a given where A and E are the cross-sectional area and elastic modulus
specimen will be less than or equal to σ, and σ* and m are ex- of the patellar tendon, respectively. Tendon dimensions and
perimentally derived constants. The reference stress σ* is a material properties were obtained from the literature (32,33).
measure of the material’s fatigue strength, defined as the σ at Peak patellar tendon strain during landing was on average
which the probability of failure is 63% for a specific number 14% lower in the energy return shoe compared with the tradi-
of loading cycles. The Weibull modulus m defines the degree tional shoe (Fig. 4c).
of scatter observed in fatigue-life measurements, where higher The probability of patellar tendon failure Pf associated with ε
values indicate a lower range of variation. Despite its relative from the maximum vertical jump landings in the two footwear
simplicity, the Weibull distribution performs remarkably well conditions was calculated from Eq. 5. The Pf was examined as a
at describing the Pf for many types of biological materials. function of time in days, assuming a typical basketball player ex-
Considerable work has used the Weibull distribution to ex- perienced 45 jumps per day, based on the average number of
amine the risk of stress fracture development (28–30). Here, a jumps per elite-level game (34). Note that for these calcula-
Weibull analysis will be used to estimate the probability of pa- tions, ε* from Eq. 5 also is a function of time, computed from
tellar tendinopathy, a common overuse injury associated with the fatigue-life data. The Pf increased rapidly and in a nonlinear
repeated bouts of jumping and landing activity. Raw data were fashion as a function of time, demonstrating a greater risk of fail-
first obtained from fatigue tests of human tendon across a range ure for landing in the traditional shoe (Fig. 4d). To compare
of strain magnitudes (12). These data were then fit to Eq. 1 these values with the prevalence of patellar tendinopathy
(Fig. 4a), where peak strain magnitude ε explained 59% of the observed in basketball players, we can look at the Pf associated
variance in Nf with a slope b equal to 9.3. When a Weibull with 1000 cycles of loading, which is just slightly less than
distribution was optimized to the data and normalized to the 1 month of activity, or the approximate length of time it
mean fatigue strength εmean estimated from the S-N curve to takes to induce deleterious structural changes in a rabbit
allow for comparison of data at different absolute strain levels, tendon model (35). The Pf values for 1000 cycles were 14%
m = 6.7 and ε* = 1.076·εmean (Fig. 4b). Using these constants, and 34% for the energy return and traditional shoe, respec-
the equation explained 97% of the variance in experimentally tively. In this particular case, the numbers correspond very well
measured fatigue strength. Therefore, if ε can be calculated for with the prevalence of patellar tendinopathy in basketball

Volume 46 • Number 4 • October 2018 Overuse Injuries and Mechanical Fatigue 227

Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Figure 4. A. S-N curve for human Achilles tendon data from Wren et al. (12) (B) Weibull distribution optimized to the data. Strain axis has been normalized by
the S-N curve trend line. C. Ensemble average curves of patellar tendon strain for basketball players landing in two different shoe conditions after maximal vertical
jumps. D. Ensemble average probability of tendon failure curves associated with landing in two different footwear conditions as a function of time assuming 45
jumps per day.

players, which ranges from 12% to 32% (36,37). However, the reduce fatigue life relative to a loading profile with no impact,
model in its current form is too simplistic for long-term injury even though samples from both groups were loaded to the same
prediction, where remodeling and adaptation are likely to peak stress. Similarly, seminal work in this area, which manipu-
play a key role in the fatigue failure process. The strength of lated loading rate through different sinusoidal frequencies, has
the model lies in its utility to examine the relative risk of in- consistently demonstrated that the fatigue life of bone and ten-
jury associated with sudden changes in training activity, don actually increases with loading frequency (40,41). These
which for this shoe example ranged from 2.7 to 2.1, depending findings cannot be explained by the viscoelastic response of bi-
on the number of days. ological tissue, because changes in loading rate must reach or-
ders of magnitude in order to observe an appreciable change
LOADING CYCLES VERSUS LOADING DURATION in material properties – changes well beyond what would be ex-
Until now, this article has focused solely on mechanical fa- pected for different physiological movement patterns (41,42).
tigue and damage accumulation in regards to stress or strain As previously mentioned, repetitive loads in vivo typically
magnitude and their interdependence with loading cycles. Of range between zero-tension or zero-compression, and this
course, increased loading rate has frequently been implicated means that a nonzero mean stress exists. Consequently, damage
in the etiology of overuse injuries, at least in runners (38). may accumulate as a function of loading duration (i.e., creep, or
These studies relied on data from surrogate measures of tissue time-dependent damage), loading cycles (i.e., fatigue, or cycle-
loading such as the vertical ground reaction force (vGRF) or dependent damage), or both. Figure 5 illustrates the number of
peak tibial acceleration. But what effect might loading rate ac- cycles and time to failure as a function of peak stress for bone
tually have on the mechanical fatigue of biological tissue? Cy- samples loaded in zero-compression at either 3 or 9 Hz. In gen-
clically loading bovine cortical bone samples using vGRF-like eral, samples loaded at 9 Hz survived more cycles of loading, but
waveforms in running suggested that the loading rates associ- no difference between frequencies was observed as a function of
ated with impact have little influence on the mechanical fa- time (39). Zioupos et al. (40) demonstrated this same phenom-
tigue behavior of bone when compared to loading magnitude enon for human and bovine bone loaded in zero-tension. In
(39). The presence of an impact and higher initial loading rate other words, fatigue loading can be considered a “continually
in a vGRF profile characteristic of rearfoot running did not interrupted creep test,” where the frequency of loading has no

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Figure 5. A. Cycles to failure and (B) time to failure as a function of stress magnitude for bovine cortical bone samples cyclically loaded at 3 and 9 Hz. Samples
loaded at 9 Hz illustrated a longer fatigue life, although no differences in time to failure was observed. [Adapted from (39). Copyright © 2018 The American
Society of Mechanical Engineers. Used with permission.]

other effect than to influence the impulse and thus the damage prevalence rates in athletes (28,29). The primary limitation of
accumulated per cycle, but the total damage as a function of these models was that repair and adaptation parameters were
time remains the same. These results relate explicitly to bone- not subject-specific and as such they are unlikely to provide im-
fatigue; damage in tendon will demonstrate both time- and proved discriminatory power when assessing injury risk between
cycle- dependency, though the spread in loading frequency is individuals. Indeed, the greatest challenge moving forward with
much greater as a function of cycles than time (41). In other models of overuse injury is the appropriate representation of
words, it seems that musculoskeletal tissues are better able to subject-specific remodeling and adaptation behavior.
tolerate loads when applied over shorter time durations, specif- An accurate prediction of cumulative damage requires both
ically because less damage is accumulated at a given stress level. an accurate estimation of tissue stress/strain and the number
So why have so many studies in the running literature re- of loading cycles. In regards to the latter, the emergence of wire-
ported an association between individuals who experience high less sensor technology to track physical activity has great po-
rates of loading and those with prevalent or incident overuse in- tential; data from inertial measurement units (IMUs) can
jury (38)? It is important to note that not all studies have re- directly monitor loading exposure with a high degree of accu-
ported this association (43,44); in fact, some studies suggest racy. However, barring the development of wireless sensors
that increased loading rate has a protective effect (45,46). I sus- capable of direct tissue stress/strain measurement, the infor-
pect much of this discrepancy arises from the complex rela- mation provided by current IMUs is unlikely to have a sub-
tion between external transducer measurement (e.g., force stantial impact in the field of injury risk surveillance, unless
platform and accelerometer) and tissue-level stress/strain the objective is to identify hazardous training patterns within
(30,47). Stress and strain are not only dependent on applied a particular athlete. The optimal approach will likely require
load, but also on tissue size, geometry, material properties, and bringing athletes into the laboratory for a series of calibration
how the applied load is transferred to the tissue locally through trials, where both sophisticated subject-specific computational
forces and moments (48,49). I speculate that the positive rela- modeling approaches and data from IMUs can be used to gen-
tion between loading rate and injury observed in previous stud- erate a surrogate model (51), which may subsequently be used
ies is real, but that increased loading rates are associated with to estimate tissue stress/strain in a more ecologically valid envi-
lower-extremity mechanics that also increase stress and strain ronment outside of the laboratory.
magnitudes. Increased cadence, for example, would be expected
to lower both loading rates at impact (50) and loading magni- CONCLUSIONS
tudes throughout stance (27,29). This article argues that overuse injury is ultimately a biome-
chanical event resulting from the mechanical fatigue of biolog-
LIMITATIONS AND FUTURE DIRECTIONS ical tissue and Figure 6 provides a conceptive framework
This article has focused on the damaging effects that repeti- summarizing this hypothesis. Both ex vivo cadaveric and in vivo
tive loading and cumulative bouts of activity may have on mus- animal studies of biological tissues illustrate damage accumula-
culoskeletal tissues, with no regard to the repair and adaptation tion and stress-life behavior that is exponentially related to
responses that play an important role in the fatigue failure pro- stress magnitude. There is no reason to believe that human
cess. These natural defense mechanisms may improve fatigue re- tissues behave any differently when loaded in vivo as sug-
sistance at a particular stress level (i.e., a shift in the S-N curve gested by epidemiological data of musculoskeletal disorders
up and to the right) and reduce the stress magnitude associated such as low back pain and carpal tunnel syndrome. Attempts
with a particular activity. Previous work has incorporated repair to characterize material property degradation in response to
and adaptation into predictive models of stress fracture, and repetitive loading in vivo should recognize that the relation
these were necessary to provide risk estimations inline with between damage accumulation and material property

Volume 46 • Number 4 • October 2018 Overuse Injuries and Mechanical Fatigue 229

Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 work is needed to elucidate the mechanism by which increased
loading rates at impact are associated with overuse injury.
Mechanical fatigue principles would suggest that future areas
of research should focus on a potential relation between ex-
ternal loading rate at impact and tissue stress/strain magni-
tude and loading duration throughout stance.

SUMMARY
Although current definitions of overuse injury in the field of
exercise and sport science are consistent with a fatigue failure
process, few studies have incorporated the fundamental princi-
ples of mechanical fatigue into their investigations of overuse
injury. The information outlined in this article provides a theo-
retical foundation and operational framework necessary to
model overuse injuries in sport as a mechanical fatigue phenom-
enon. In doing so, future work may provide a more mechanistic
understanding of these injuries as well as training programs and
preventive strategies to minimize their occurrence.
Figure 6. Conceptual framework for the potential role of mechanical
fatigue in overuse injury. Load applied to tissue results in stress/strain,
which in combination with loading cycles/duration causes damage forma- Acknowledgments
tion that is highly dependent on loading magnitude. Damage formation
This work was funded in part by the Natural Sciences and Engineering Research
contributes to the total damage in the tissue, resulting in material property
Council of Canada (Grant Nos. NSERC; RGPIN 01029–2015 and RTI
degradation and increased stress/strain. When total damage (D) is less than
00013–2016). Special thanks to Tishya A. L. Wren, Ph.D., for providing access
some critical damage (Dc), a stochastic parameter, this damage induces tissue
to raw data from tendon fatigue experiments, and to Darren J. Stefanyshyn, Ph.D.,
remodeling/adaptation. Damage induced tissue remodeling/adaptation may
and John W. Wannop, Ph.D., for providing motion analysis data of basketball
be positive, resulting in damage removal and improved tissue integrity (e.g.,
players performing jump landings.
material properties, geometry, size), or negative, resulting in diminished tis-
sue integrity. This feedback loop continues until D becomes greater than
Dc, leading to overuse injury.
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