Saudi Journal of Sports Medicine

: 2019  |  Volume : 19  |  Issue : 1  |  Page : 1--5

Musculoskeletal pain in athletes: A narrative review

Mastour Saeed Alshahrani 
 Department of Medical Rehabilitation, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia

Correspondence Address:
Mastour Saeed Alshahrani
Department of Medical Rehabilitation, College of Applied Medical Sciences, King Khalid University, Abha
Saudi Arabia


Musculoskeletal pain is a major concern in athletes, and its associated disability may contribute to a significant loss of productivity and substantial health-care expenditure. Musculoskeletal pain and disability represent a considerable health burden in the athletic world. Acute musculoskeletal pain generally lasts for a shorter time. The recurrences are frequent. Early intervention and the management of acute pain may reduce the chance of developing it into chronic. Clinical assessment comprising subjective and objective examination is essential to identify the clinical features of severe but rare causes of acute musculoskeletal pain. In most of the clinical conditions, it is difficult to determine the precise cause and management of musculoskeletal pains in the athletic population. Interventions such as manual therapy, electrotherapy modalities, exercises, and active lifestyle maintenance are found to be effective in the management of acute and chronic musculoskeletal pain.

How to cite this article:
Alshahrani MS. Musculoskeletal pain in athletes: A narrative review.Saudi J Sports Med 2019;19:1-5

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Alshahrani MS. Musculoskeletal pain in athletes: A narrative review. Saudi J Sports Med [serial online] 2019 [cited 2020 Jun 4 ];19:1-5
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Musculoskeletal pain and injuries are prevailing in sports where athletes are required to perform at high-intensity activities for more extended periods.[1] In the short term, musculoskeletal pain may significantly impair the athletes' performance, which can lead to unwanted time off from practice and competitive tournaments.[2] Various authors have seen an association between training load, musculoskeletal pain, and performance.[3],[4] These results indicate that an athlete may experience musculoskeletal pain are injured from both too low- and high-training loads.[5]

Electronic sports (E-sports) are gaining the importance in recent days, as they are known as competitive gaming. Hamari and Sjöblom defined this as “sports facilitated by electronic systems by the input by players.”[6] There are only a few data on musculoskeletal pain in E-sports. In a previous study with 65 participants showed that 41 percent of participants reported neck and back pain, similar to athletes from traditional endurance sport.[6],[7] As such, musculoskeletal pain in E-sports may be associated with training load and frequency, as seen in other games.[7]

Musculoskeletal pain arises from the various regions of the body. All the structure's muscles, ligaments, bones, joints, or any soft tissue can contribute to musculoskeletal pain.[8] It can be acute with or without irritability, and sometimes, the pains can progress to chronic in nature.[9] It may be limited to localize to one area, or it can spread to distal regions or distant areas along with the dermatomal or myotomal referral pattern.[10] The common musculoskeletal disorders in athletes include neck pain, upper, and lower back.[10] The conditions such as myalgia pain, tendinitis, tendonitis, sprains, strains, and fractures are also common. Compared to males, females present with more musculoskeletal symptoms, with an estimated prevalence of 62%.[10]


Pains of acute nature usually occur from sprains, strains, fractures, and dislocations, predominantly due to macrotrauma with excitation of nociceptors within the involved tissues.[11] Pains may also occur due to microtrauma injuries, and the symptoms will be seen after a prolonged period of exposure of a tissue to either overuse or misuse. In some athletes, pain may be idiopathic.[11] Muscle pain can be local or referred in the distal direction.[12]


Not all the time, but any athlete can undergo musculoskeletal pains. All structures such as muscles, capsules, nerves, fascia, bones, joints, tendons, and ligaments can result in musculoskeletal pain.[13] Overuse injuries are common and affect 33% of adults.[14] In western society, low back pain is a common work-related condition due to overuse.[14] Musculoskeletal pains also arise due to prolonged immobilization or poor posture.

Area of pain

Participants presenting to the clinic with musculoskeletal pain generally show with 18 separate pain regions.[15] The neck and back are the most common sites followed by knee and hip pains in athletes. The neck and back pain can contribute around 31%, 25% of knee pain, 20% of hip pain, and 15% of shoulder pain.[15]

Type of pain

The type of tissue involved in injury generally exhibits the type of pain. The most common structure at fault is a muscle, and it presents with local dull-aching pain. It is felt either superficial or deep, depending on the location of the muscle. The muscle contributes typically to 50% of pains in athletes, and muscle refers pains distally along the dermatome of myotomal patterns.[15] Neuropathic pain also significantly contributes to musculoskeletal pain. Neuropathic pains usually present with intense and long-lasting pain. Neuropathic pain has high irritability and contributes to 29% of all musculoskeletal pains.[15] Mixed pain patters are uncommon and present both local and referred patterns.[15]


Symptoms vary depending on the type of tissue involved and the injury or friction and the kind of pain (acute or chronic). The presenting symptoms vary from athlete to athlete. Common musculoskeletal symptoms include local or referred pain, fatigue, stiffness or aching pain, twitching in the muscles, sleep disturbances, and the sensation of “burning” in muscles.[15]


Different participants present with varying musculoskeletal signs and symptoms. It has diverse symptoms and causes. Athletes with bone pain usually present with dull, penetrating, or profound.[15] Muscle pain is regularly occurring after a soft-tissue injury, an autoimmune response, infection, tumor, or any decrease in blood supply to the muscle. The muscle pains are associated with cramps and spasms.[15] If it is tendon injury, it is called a strain, and if it is ligament injury, it is called a sprain. These are the most painful when they are stretched or elongated. Some athletes present with fibromyalgia symptoms with multiple areas of pain in muscles, tendons, or ligaments and are challenging to describe the type of pain.[15] Inflammation of joints will lead to pain, swelling, redness, and increased local joint temperature in athletes. The pain intensity does depend on the severity of injury or degeneration. Carpal tunnel or tarsal tunnel syndromes are also common presentations due to nerve compressions. The nerve pain presents as shooting or burning along the course of the nerve.[15]

 Diagnostic Criteria

Assessing the pain intensity and area of involvement and absence of any underlying pathology confirms the diagnosis of musculoskeletal pain. Any signs of inflammation with pain, swelling, increased temperature is the feature of any musculoskeletal injury.[15] The assessment also should focus on excluding serious pathologies such as a tumor, cancer, Paget's disease, infection, and myeloma. Physical therapy assessment should focus on eliminating the signs of systemic illness, lumps, and exquisite tenderness.[16] Radiological imaging is rarely required or indicated, as it shows nothing in specific. Computerized tomography or magnetic resonance imaging has indicated subjects who reveal red flags during the assessment.[16],[17]


Musculoskeletal pain in athletes best managed by concentrating on the overall cause. It will depend on which structure is which is responsible for the presentation and severity of pain such as muscle, tendon, and bone.[18] Different treatment strategies are in place such as heat, cold, manual therapy, change in intensity of workload or training, immobilization, reducing stress, biofeedback, cortisone injections, nonsteroidal anti-inflammatory medications (NSAID's), stretching, massage, strengthening, endurance, aerobic, and conditioning exercises.[18],[19],[20],[21] Athletes with fibromyalgia treated with medications that will focus on increasing the serotonin-norepinephrine levels in the body. Usually, opioids and NSAIDs are prescribed if the pain intensity is high.


The assessment and evidence-based management for the diagnosis play a vital role in rehabilitation. Level of evidence assessing the quality of evidence with ranking and hierarchy are associated with different study designs that have contributed to the evidence base. The level of evidence is summarized in [Table 1].{Table 1}

Available evidence suggests exercise therapy; electrotherapy combined with manual therapy is an effective means of combatting athletes with musculoskeletal pains. Different conditions such as neck pain, back pain, ankle sprains, carpal tunnel syndrome, knee osteoarthritis, and hip osteoarthritis are effectively treated with the use of the holistic approach. Different techniques and outcomes are summarized in [Table 2], and the interventions with their evidence in health-care rehabilitation are illustrated in [Table 3]. The evidence is according to the Australian Acute Musculoskeletal Pain Guidelines Group guidelines.[22]{Table 2}{Table 3}

 Recent Advances in Treating Musculoskeletal Pain in Sports

Shock-wave therapy

Extracorporeal shock-wave therapy is a noninvasive technique and used in treating chronic musculoskeletal conditions such as tennis elbow and plantar fasciitis.[23] It focuses on the specific internal structure at fault and gives shock waves to the internal structure. Shock-wave technology is previously used to treat patients with kidney stones, and the technique is called lithotripsy. The waves created by shock-wave machines generally produce microtrauma and hyperemia in the involved tissues that promote neovascularization and thereby facilitate healing in the chronic nonhealing tissues.[23]

Eccentric exercises

These types of exercises in rehabilitation, in an aim to restore muscle function at the earliest in terms of time. These are effective and progressed in the albescence of pain in different conditions as chronic tendinopathies.[24],[25],[28],[29] Stergioulas et al. used eccentric exercises along with LASER in subjects with Achilles tendinitis. They reported that outcome measures such as morning stiffness, active dorsiflexion, palpation tenderness, and crepitation significantly improved following intervention.[24] Sayana and Maffulli showed that participants with Achilles tendinopathy who received eccentric exercises along with strengthening exercises for 12 weeks improved in pain and disability scores.[25] Friedmann-Bette et al. reported strength training, along with eccentric overload, showed superior outcomes compared to others in normal athletes.[30]

Platelet-rich plasma therapy

This new technique is developed, aiming to restore soft-tissue injuries using subjects own blood using the centrifugation method.[31] Through a thorough process, they separate the platelets of the injures person's blood, and the platelets are then injected into the injured region. This technique will facilitate the growth factors and promote fibroblasts at the wounded site and thereby facilitate healing at the injured site.[26],[31] Different studies showed improvement in tendon following the application of platelet-rich plasma (PRP) with platelet-alpha granules in tendon regeneration.[27],[32] de Vos et al. examined the effect of PRP injection on chronic Achilles tendinopathy and showed great improvement in pain and activity scores in comparison to control groups.[33] Filardo et al. conducted a study to examine the efficacy of multiple PRP injections for 2 weeks in participants with chronic refractory patellar tendinopathy. There were statistically significant improvements in Tegner, EQ-Visual Analog Scale, and pain level outcome measures after the PRP therapy, which showed the potential benefits of PRP to promote the achievement of satisfactory clinical outcomes in participants with musculoskeletal pains.[34]


This advanced technology used in chronic tendon, ligament, fascial, and joint capsule injuries.[26] This procedure involves injecting hypertonic dextrose or similar solutions to the involved structures to cause entheses and strengthening the structure by collagen laydown and proliferation, thereby strengthening the structure with hypertrophy.[23] Athletes experience pain while performing this technique. Yildiz et al. conducted a study to see the effects of prolotherapy (in recreational athletes with patellofemoral pain syndrome. This study results showed that balance, coordination, and knee functional scores improved significantly compared to the control group after three injections in 21 days.[35] Reeves et al. stated that prolotherapy is the evidence-based regenerative injection therapy efficiently used in sports to accelerate the performance.[36] Rabago et al. proved that prolotherapy, along with alternative medicine, is very effective in dealing with participants with musculoskeletal pains.[26] There is a strong evidence to use prolotherapy in conditions such as osteoarthritis, chronic tendonitis, and low back pain.[26]

 Conclusions and Future Research

Musculoskeletal pain in athletes is short-lived if active management is instituted. The rehabilitation of athletes should focus in decreasing pain and inflammation in the first phase, increase the range, mobility and strength of the athlete in the second phase, enhance aerobic capacity, improve balance and proprioception in the third phase, and should focus in sport-specific drills or functional progression in the last or the fourth phase. The phases of rehabilitation in older ages may be time taking compared younger athletes and Grade 1 injury subjects return to sports earlier compared to Grade 3 injuries athletes. There has been excellent knowledge nowadays in understanding the pathophysiology of injury and inflammation, thereby effective means of strategies in rehabilitation so that the athlete returns to sports at the earliest. Using steroids to combat this problem is of no great importance. Reliable imaging techniques such as computerized tomography and magnetic resonance imaging may guide the clinical therapist to make an adequate diagnosis and see the prognosis in musculoskeletal conditions. Effective therapeutic interventions should aim to facilitate healing and tissue regeneration and thereby improve athletic performance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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