Orthopedics

Overuse Injuries in Pediatric Athletes

Introduction

There are two primary types of injuries that athletes experience: acute and overuse. Acute injuries are those which occur due to a single inciting event. For example, a snowboarder fractures his distal radius when falling on the mountain or a basketball player tears her ACL while making a rapid lateral movement.

In contrast, overuse injuries are those that occur with repetitive and excessive strain of a muscle, tendon, bone, or joint. Inadequate rest does not allow the musculoskeletal system adequate time to adapt to the increased demand. The accumulated micro-traumas ultimately result in a weakened, damaged structure. For example, an inexperienced runner rapidly increases their weekly mileage in preparation for their first marathon, and slowly develops pain in their lower legs, ultimately resulting in medial tibial stress syndrome (i.e. shin splints).

Common overuse injuries 

overuse1.png

Image adapted from DiFiori et. al, 2014. 

 

Epidemiology

  • 60 million children participate in organized athletics annually (1)
  • Annually, over 3.5 million children under the age of 14 are treated for sports injuries (2), and approximately 50% of these injuries are due to overuse (1)
  • Pediatric patients’ bodies are not fully developed, and thus are less resilient to stress (3)
  • Since the year 2000, there has been a greater than 10-fold increase in overuse injuries in the pediatric population (4)
  • Young athletes with overuse injuries are at a higher risk of further injury and permanent limitation (4)

Risk factors for developing overuse injuries

  • Single sport training and year-round training
    • One study identified a 42% increase in overuse injuries in high school players who participated in a sport all year (4 seasons) vs. 3 season participation (1)
  • Common public misconception that specializing in a single sport will lead to improved performance later in life. Research shows that this is not the case (4).
  • Prior overuse injury increases risk for future injury (1)
  • Growth spurts: during these periods of rapid growth, the physes, apophyses, and articular surfaces of bone are less resilient than both mature and  immature bone (1)
  • A history of amenorrhea is a risk factor for stress fractures (1)
  • Poor preconditioning prior to intense training (e.g. refraining from exercise over the summer before starting cross country in the fall) places athletes at risk for overuse injury (1)
  • Individual anatomic factors also play a role, such as joint misalignment or hypermobility (1)
  • There is a linear relationship between hours of sports participation and risk for injury (1)

Treatment of overuse injuries 

  • Rest! The typical recommendation is 3-months rest from the causative activity, NOT simply until the pain subsides
  • Physical therapy may be necessary
    •      Strength training programs targeting supporting muscles and joints
    •      Flexibility training to improve range of motion
  • Analysis of biomechanics to correct improper technique

Prevention of overuse injuries

  • Pre-participation examinations
  • Sports diversification, multi-sport participation
  • Limiting weekly and yearly participation: Less than 5 days of a single sport per week, 1 full day of rest per week, and taking 2-3 months per year off from a single sport (4)
  • Preseason conditioning and cross-training (ex: swimming, biking)
  • Proper sizing and resizing of equipment (ex: shoes, pads, helmets, etc.)
  • Intrasport limitations: An example is the pitch count per game and required rest limitations set by Little League Baseball (2):

overuse2.png

Image adapted Oates and Barlow, 2011.

Burnout and overtraining

Burnout occurs when chronic stress causes a young athlete to cease participation in a sport that was previously enjoyable. There are four stages of burnout (1):

  1. The young athlete is placed in a situation that involves varying demands
  2. The demands are perceived as excessive
  3. The young athlete experiences varying physiological responses
  4. Varying burnout consequences develop

Essentially, the consequence of sport participation transitions from enjoyment to anxiety. This anxiety can be exacerbated by low self-esteem, parental pressure, and single sport training. The stress of participation can lead to loss of sleep, loss of appetite, reduced satisfaction from participation, worse performance, and increased risk of injury.

Burnout/overtraining is a clinical diagnosis, and relies on a thorough history. Treatment is variable, but often involves a combination of rest, behavior change (both parent and youth), mental health consultation, and treatment of any associated illnesses (ex: depression, sleep disturbances, etc.).

overuse3.png

Image adapted from DiFiori et. al, 2014. 

 

Reduce the risk of burnout by following these recommendations (5):

  • Keep workouts interesting, with age-appropriate games and training, to keep practice fun.
  • Take time off from organized or structured sports participation 1 to 2 days per week to allow the body to rest or participate in other activities.
  • Permit longer scheduled breaks from training and competition every 2 to 3 months while focusing on other activities and cross-training to prevent loss of skill or level of conditioning.
  • Focus on wellness and teaching athletes to be in tune with their bodies for cues to slow down or alter their training methods.

 

Position statements and physician guidelines

American Medical Society for Sports Medicine (1)

American Academy of Pediatrics (5)

National Athletic Trainers’ Association (6)

American Orthopaedic Society for Sports Medicine (7)

60 Minutes Sports – The Overuse Epidemic

http://www.cbs.com/shows/60_minutes/video/qGQxegz2_k3iUPSbLMIT__PgrcxUK70T/the-overuse-epidemic/

UCSF Mini Medical School for the Public – Overuse Injuries: How to Solve the Challenging Puzzle

https://www.youtube.com/watch?v=6avzv3Qo1MI

 

References

1. DiFiori JP, Benjamin HJ, Brenner J, Gregory A, Jayanthi N, Landry GL, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med Off J Can Acad Sport Med. 2014 Jan;24(1):3–20.

2. Oates W, Barlow C. Stop Sports Injuries: An Injury Prevention Curriculum for Coaches [Internet]. Nathan Littauer Hospital & Nursing Home; 2011. Available from: http://www.stopsportsinjuries.org/files/coaches_curriculum_toolkit/AOS-1...(nm)%202.8[1].pdf

3. Preventing Overuse Injuries [Internet]. HealthyChildren.org. [cited 2015 Sep 20]. Available from: http://healthychildren.org/English/health-issues/injuries-emergencies/sp...

4. Orthopedics Today. Pediatric overuse injuries increase due to year round, one sport training [Internet]. 2014 [cited 2015 Sep 20]. Available from: http://www.healio.com/orthopedics/pediatrics/news/print/orthopedics-toda...

5. Brenner JS. Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics. 2007 Jun 1;119(6):1242–5.

6. Valovich McLeod TC, Decoster LC, Loud KJ, Micheli LJ, Parker JT, Sandrey MA, et al. National Athletic Trainers’ Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011 Apr;46(2):206–20.

7. Matava M. Overuse Injuries: AOSSM Sports Tips [Internet]. American Orthopaedic Society for Sports Medicine; 2008. Available from: https://www.sportsmed.org/uploadedFiles/Content/Patient/Sports_Tips/ST%2...