Overuse injuries

If your child or teen has an overuse injury, it will comfort you to know that Children’s Hospital Boston’s Orthopedic Center has a tremendous amount of experience treating these injuries, developing therapies for healing, and conducting research that leads to better care.

What are some common overuse injuries?

Overuse injuries are sports-related injuries that result from repetitive use. Some common types include:

• golf elbow (medial epicondylitis):characterized by inflammation, soreness or pain on the inner (medial) side of the upper arm near the elbow

o   may be caused by a partial tear of the tendon fibers that connect muscle to bone

• jumper's knee (patellar tendonitis): characterized by tenderness right below the knee or upper shin area
  • may occur when the patellar tendon in the knee joint is repeatedly pulled on, especially during jumping activities

• little leaguers' elbow or shoulder: characterized by pain in the elbow or shoulder area, especially after activity
  • may result from repetitive overhead throwing maneuvers that cause damage and inflammation to the growth plates of the bones in the arm (or as a result of a fracture)

• Osgood-Schlatter disease: characterized by painful irritation and swelling on the bump at the upper end (anterior tibial tubercle) of the shin bone
  • can occur when the quadriceps is overused in sports during a child’s growth spurt

• osteochondritis dissecans: characterized by knee or elbow pain and swelling
  • can occur when a piece of the cartilage in the knee or elbow joint separates from the joint surface
  • may run in families or be caused by a metabolic problem

• Sever’s disease (calcaneal apophysitis): characterized by heel pain with limping, especially after running activities
  • results from repetitive running or jumping activities that cause the Achilles tendon to pull on the heel bone

• shin splints: characterized by pain and tenderness over the shin area
  • caused by excessive running, running on hard surfaces and improper shoe wear

• Sinding-Larsen-Johansson disease: characterized by knee pain, especially after jumping activities
  • caused by a fracture of the kneecap due to repetitive extension on the patellar tendon in the knee (the tendon pulls away from the bone)

• spondylolysis: characterized by back pain
  • caused by excessive flexing (flexion) and extension of the low back and is commonly seen in football linemen, gymnasts and ice skater

• swimmer's shoulder (rotator cuff tendinitis and impingement):characterized by shoulder pain in the competitive swimmer

o   caused by the extreme demands of competitive swimming on the shoulder, which is used for locomotion while requiring flexibility and range of motion

• tennis elbow (lateral epicondylitis):characterized by inflammation, soreness or pain on the outer (lateral) side of the upper arm near the elbow

o   may be caused by a partial tear of the tendon fibers that connect muscle to bone

What are overuse injuries, and why do they occur?

Overuse injuries (also called “overstress” or “overtraining” injuries) are microtraumas caused by repetitive stress to bones, growth plates, muscles, tendons or ligaments over a period of time, without a rest that would give the injured area enough time to heal.

Muscles and tendons adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. With an overuse injury the muscle or tendon receives the stress, but never gets a chance to rest.

Are there other reasons that can contribute to kids’ getting overuse injuries?

A prior injury to an area can predispose the area to overuse injuries. Or if a child is simply not conditioned—say, if he’s never played baseball before, and suddenly the coach makes him a pitcher—he can be at risk to sustain an overuse injury.

What are the symptoms of an overuse injury?

Pain and/or inflammation can be symptoms of an overuse injury. The pain from overuse injuries tends to intensify in stages:

• At first, the injury may hurt mildly when the child plays his sport.
• As more trauma occurs, the child will experience constant pain when he’s playing.
• At the end stage, the child has constant pain in that area, even when he’s not playing. At that point, the affected area will have sustained a significant amount of damage.

How is an overuse injury diagnosed?

Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays and MRI (magnetic resonance imaging)—to get detailed images of the injury.

How is an overuse injury treated?

The most important therapy for a mild to moderate overuse injury is simply to rest the injured area—restricting all activities that involve using the injured muscle, tendon, ligament or bone—for a period of weeks or months. Your child’s doctor may also recommend a splint, cast or boot to protect the injured area from further damage.

For an unusually severe overuse injury, treatment options may include:

• Temporary use of crutches or a wheelchair
• physical therapy to stretch and strengthen the injured muscles, ligaments and tendons
• surgery if the injury is recurring, if there’s persistent pain, or if a muscle, tendon or ligament is badly torn

Do a child’s growth plates and growth spurts increase his susceptibility to overuse injuries?

Growth plates do make kids more susceptible to overuse injuries. Growth plates are towards the ends of the bones and are not as ossified as the bones themselves—creating, in essence, an area of weaker bone. And because of that weakness, if a drill or move is pulling on that area over and over, it causes injuries to the growth plates. For example, little leaguer’s shoulder and little leaguer’s elbow are prime examples of growth plate injuries that occur because kids are throwing too much.

During growth spurts kids’ bones and tendons are lengthening and are more prone to overuse injuries. And by continuing to play with trauma to an area, the player will worsen the injury.

While overuse injuries occur equally in boys and girls, adolescent girls have a particular vulnerability. Some—cross-country runners and gymnasts, in particular—can have menstrual dysfunction (amenorrhea), in which they no longer get their periods. This is a situation that can cause osteoporosis (loss of bone density) or osteopenia (a precursor to osteoporosis), and it predisposes the athlete’s bones to sustain stress fractures.

Why is there an increase in overuse injuries in kids these days?

Children in previous generations did a lot of free play instead of organized sports, and didn’t sustain many overuse injuries. With the advent of organized sports—especially those requiring intensive, repetitive drills—the incidence of overuse injuries has increased dramatically.

Youth and adolescent participation in organized sports has grown to about 35 to 40 million kids across the United States. Not surprisingly, the incidence of sports injuries is rising—statistics suggest that 30 to 60 percent of student athletes will have an overuse injury at some point in time. In one Sports Medicine practice at Children’s, for example, at least half of the young patients have an overuse injury.

Aren’t organized sports supposed to be good for kids?

Organized sports are very important and help kids—not just in the sports themselves, but in academics and social situations—and they’re good for children’s overall development and growth. The downside is that “overuse syndrome,” where the kids are subjected to repeating the same drill over and over, causes overuse injuries.

Do overuse injuries impact kids differently from adults?

Adults can certainly sustain overuse injuries, too. But an adult can figure out that swinging the golf club causes his elbow to hurt, whereas a child might not realize that his forearm pain is really his elbow. And even if they understand the cause and effect of their pain, high-achieving sports-oriented kids tend to push themselves—either to please a parent or coach, or because the parent or coach is pushing them.

Do kids heal faster than adults?

Kids do tend to heal faster and better. But, as with all overuse injuries, the key to healing is rest. An injured child needs to stop for a period of time to give the injury time to heal. And even though the healing period is usually shorter for a child than for an adult, it’s hard for a 13-, 12- or 10-year-old to hear that he can’t play his sport for, say, three months—to a child or teen that sounds like an eternity.

What’s the most common sport for developing overuse injuries?

In some of Children’s orthopedic practices, gymnasts are the athletes that sustain the most overuse injuries—mostly young females. Teen and pre-teen gymnasts typically present with osteochondritis dissecans in the elbow and knee, Sever’s disease and spondololisthesis (stress fractures in the back from hyperextending moves).

Gymnastics is very hard on young female bodies. With the popularity of women’s gymnastics in the Olympics, a child who’s seen as having the potential to become an Olympian is too often pushed beyond her body’s capacity by coaches and parents. Other sports that cause undue stress on young female bones are running, basketball and cheerleading.

How can parents and coaches help kids avoid overuse injuries?

Parents and coaches have a great deal of influence—for better or for worse. Parents and coaches should stress moderation in training and should restrain the zeal with which they push youth and teens.

Coaches should themselves learn and use proper training techniques and avoid too many repetitive drills, since the overwhelming reason for overuse injuries is overuse—repeating movements too much, resulting in microtraumas. Coaches should also teach proper motion techniques for such activities such as throwing or running.

Physical education departments should make sure that the surfaces of a playground, track or field are in good shape, and that proper equipment, footwear and protective gear are used for each sport.

Our specialists advise:

• warming up and stretching before practice
• resting at least one day a week
• cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to not get as many overuse injuries as ones who just specialize in one sport.
• training in an age-appropriate way: In most cases, kids younger than 5^th grade should play sports for two seasons, rather than three.
• alternating exercises during practice: For instance, in tennis, don’t do 100 forehands followed by 100 backhands. Change it up from forehand to backhand. Not only are you less likely to experience an injury—studies have also shown that over the long term, muscle memory actually improves if you vary the drills.

Are there other guidelines and resources for injury prevention and safer training?

The American Academy of Orthopaedic Surgeons (AAOS) has issued guidelines for helping to prevent sports injuries. The AAOS recommends that athletes:

• Use proper equipment. Replace athletic shoes as they wear out. Wear comfortable, loose-fitting clothes that are light enough to release body heat. When exercising in cold weather, dress in removable layers.
• Warm up. Warm up to prepare to exercise, even before stretching. Run in place for a few minutes, breathe slowly and deeply, or gently rehearse the motions of the exercise to follow. Warming up increases heart and blood flow rates and loosens up muscles, tendons, ligaments and joints.
• Stretch. Begin stretches slowly and carefully until reaching a point of muscle tension. Hold each stretch for 10 to 20 seconds, then slowly and carefully release it. Inhale before each stretch and exhale as you release. Do each stretch only once. Never stretch to the point of pain, always maintain control, and never bounce on a muscle that is fully stretched.
• Take enough time. Move through the full range of motion with each repetition. Breathe regularly to help lower blood pressure and increase blood supply to the brain.
• Drink water. Drink enough water to prevent dehydration, heat exhaustion and heat stroke. Drink one pint of water 15 minutes before exercising and another pint after cool-down. Drink water every 20 minutes or so while exercising.
• Cool down. Make cooling down the final phase of an exercise routine. It should take twice as long as warming-up. Slow down motion and lessen intensity for at least 10 minutes before stopping completely. This phase of a safe exercise program should conclude when skin is dry and cooled down.
• Rest. Schedule regular days off from exercise and rest when tired. Fatigue, soreness and pain are good reasons to not exercise.

Who at Children’s will be caring for my child if he develops an overuse injury?

Members of our orthopedic team will provide expert care and support for your child. Our staff includes 10 primary care sports medicine specialists, 24 orthopedic surgeons, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers.

What is the Orthopedic Center at Children’s doing to encourage injury prevention and safer training?

With Children’s goal of dramatically reducing overuse injuries in youth sports, members of our team often travel to local and regional schools, youth groups and sports clubs to teach leg strengthening and other techniques. We also conduct frequent safe training programs and clinics for coaches. Call 617-355-3501 for details.

FAQs

Q: What are overuse injuries?
A: Overuse injuries (also called “overstress” or “overtraining” injuries) are microtraumas caused by repetitive stress to a certain area over a period of time, without a rest that would give the injured area enough time to heal.

Q: How does an overuse injury happen?
A: Muscles and tendons adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. With an overuse injury the muscle or tendon receives the stress, but never gets a chance to rest.

Q: What are the signs and symptoms of an overuse injury?
A: Pain and/or inflammation can be symptoms of an overuse injury. The pain from overuse injuries tends to intensify in stages—from occasional and mild to constant and severe.

Q: What should we do before we see the doctor for a diagnosis?

A: If you suspect that your child has an overuse injury, home care before your child gets to the doctor should include:

• rest:Make sure he doesn’t exert in any way that involves the injured area; he can use crutches or a cane, if it helps.
• ice:Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
• compression:Wrap a bandage or soft brace (from the drugstore) around his injury.
• elevation:If the injury involves his leg, he should remain seated or reclining, with his knee elevated as much as possible. If the injury involves his arm, he should elevate the arm to a level above his heart.

Q: How is an overuse injury usually diagnosed?
A: Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays and MRI (magnetic resonance imaging)—to get detailed images of the injury.

Q: How does Children’s treat overuse injuries?
A: The most important therapy for a mild to moderate overuse injury is simply to rest the injured area—restricting all activities that involve using the injured muscle, tendon, ligament or bone—for a period of weeks or months. Your child’s doctor may also recommend a splint, cast or boot to protect the injured area from further damage.

Q: Will my child be OK?

A: Most overuse injury patients are able to return to sports and regular activities after several weeks or months of rest and healing time. Your child’s doctor will give you guidance about how long your child’s overuse injury should be rested in order for it to heal.

During the healing period, it’s important to support the young athlete’s resolve to rest the injured area, since he may feel disappointed and frustrated at not being able to play his sport.

Q: How long will it take for my child to recover from an overuse injury?
A: Children usually heal faster and better than adults. Your child should heal from an overuse injury in a period of weeks or months, depending on the severity of the injury.

Q: If my child has been injured playing sports, should he go back to sports?

A:If your child’s doctor has cleared him to go back to sports, the many benefits and life lessons he’ll gain from playing greatly outweigh the risks of injury. These benefits include:

• physical fitness
• teamwork, competitive prowess, accomplishment
• improved body composition—less risk of obesity
• reduced risk of heart disease and diabetes
• stronger immune system
• academic fitness—kids who play sports often academically outperform kids who don’t
• emotional and psychological fitness—improved self-esteem, self-concept, self-confidence, empowerment and perception of competence

Q: Can kids’ bodies be more physically suited to certain sports than others?

A: There are intrinsic reasons—such as their bony alignment—that can predispose kids to be more or less suited to a given sport. A prime example is hockey goalies: there are little kids who “toe-walk” and sit like a “W” because their hips are built that way. Those kids are built to be hockey goalies because they can get into the goalie position.

Other kids walk “like Charlie Chaplin” because their hips are built the opposite way, with a twist in the femur. These kids shouldn’t be hockey goalies because their hips just can’t go into that position. If they try to play goalie, they can end up causing damage.

Q: What is Children’s experience in orthopedics?

A: At Children’s Orthopedic Center we’re known for our clinical innovations, research and leadership. Ranked among the top three in orthopedics for 2012 -13 by U.S.News & World Report, we provide the most advanced diagnostics and treatments, several of which were pioneered and developed by Children’s researchers and clinicians—including platelet-rich plasma (PRP) treatment for tendon repair and physeal-sparing ACL procedures for children whose growth plates are still open.

Causes

As more and more kids play recreational and organized sports, there’s been a rise in the number of overuse injuries (microtraumas to bones, tendons, ligaments or muscles) seen among children and adolescents, largely from repetitively using the same parts of the body, usually by overtraining.

Signs and symptoms

Pain and/or inflammation can be symptoms of an overuse injury. The pain from overuse injuries tends to intensify in stages: A first, the injury may hurt a child mildly when he plays his sport. As more trauma occurs, the child will experience constant pain when he’s playing. At the end stage, the child will have constant pain in that area, even when he’s not playing. At that point, the affected area will have sustained a significant amount of damage.

When to seek medical advice

A younger child who has an overuse injury may not be able to express where his discomfort is coming from. And a determined teen may try to play through pain. Consult your child’s doctor if you notice that:

• your child is, or seems to be, in pain
• an area of his arm or leg is swollen
• walking and/or bending his knee is difficult

Questions to ask your doctor

• What has happened to my child, and why?
• Is this a serious injury? Will it do any permanent damage?
• What tests will you perform to diagnose my child?
• What actions might you take after you reach a diagnosis?
• Are there alternative therapies?
• Will my child be OK if he has an overuse injury?
• Will there be restrictions on my child’s activities? If so, for how long?
• What should we do at home?
• How can we help him understand that he needs to rest the injury?

Who’s at risk

• children who play team sports that involve repetitive training drills—like soccer, basketball and football
• kids who pitch in Little League
• female gymnasts, runners and cheerleaders
• children who have had a prior injury to a given area
• children who are not conditioned yet are suddenly thrust into a rigorous sport

Complications

If an overuse injury is not treated and the injury continues to worsen, a stress fracture can result. Complications after proper treatment for an overuse injury are uncommon, but can occur. These can include:

• nerve damage (rarely)
• vulnerability of the area to re-injury
• superficial wound infection
• scarring

For teens

Many teens who have overuse injuries are not only high-performing, determined athletes, but also high-performing, determined students. If you approach your rest and healing period with that same spirit of determination, you should be back to sports and your active lifestyle within a few weeks or months, depending on how severe your injury was in the first place.

The most important thing you can do to get back into the game is to give your injured area a total rest. But even though you know the importance of rest and recovery, you still could find this to be a tough time. If you feel frustrated, depressed or angry during this important time, speak to your doctor, parent or counselor—they’re all on your team, and they all want to help.

For parents

If your teen is like many young athletes who have an overuse injury, he’s not only a high-performing, determined athlete—he’s also a high-performing, determined student. Encourage him to approach his rest and recovery period with the same spirit of determination that he applies to other areas of his life. With patience and perseverance, he’ll probably be back to sports and his active lifestyle within a few weeks or months.

Even though you and your teen know the importance of resting his overuse injury, you both might experience his healing period as a difficult time. Parents who identify with their children’s success can feel frustrated or depressed along with their children, so speak to your doctor or counselor if you need help.

Prevention

Our orthopedic specialists advise young athletes to:

• warm up and stretch before practice
• rest at least one day a week
• cross-train/alternate sports: It’s usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend not to get as many overuse injuries as those who just specialize in one sport.
• train in an age-appropriate way: In most cases, kids younger than 5^th grade should play sports for two seasons, rather than three.
• alternate exercises during practice: For instance, in tennis, don’t do 100 forehands followed by 100 backhands. Change it up from forehand to backhand. Not only are you less likely to experience an injury—studies have also shown that over the long term, muscle memory actually improves if you vary the drills.

Overuse injuries glossary

• brace: a custom-made protection worn around an area while it heals
• cartilage: a smooth, rubbery tissue that cushions the bones at the joint, and allows the joint to move easily without pain
• diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
• extension and flexion: the acts of straightening (extending) and bending (flexing) a knee, elbow or other joint
• growth plate (physis): cartilage at either end of a bone from which growth occurs
• ligament: elastic band of tissue connecting bone to bone
• microtrauma: a small injury to the body, such as microtears to muscle fibers, stress to the tendon, bruising of the bone; can occur to bone, muscle, tendon or ligament. If not allowed rest in order to heal, accumulated microtraumas can lead to overuse injuries.
• MRI (magnetic resonance imaging): produces detailed images of organs and structures within the body; shows the amount of damage from an overuse injury
• non-surgical (non-operative) treatments: alternatives to surgery; most treatments for overuse injury are non-surgical
• orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
• orthopedist/orthopedic surgeon: a physician concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
• osteopenia: less bone mineral density than normal, a precursor to osteoporosis
• osteoporosis: loss of bone density
• overuse injuries: sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining; can occur to muscle, tendon, ligament or bone
• physis, physes: medical name for the growth plate(s) at both ends of a bone that is not yet skeletally mature; the source of bone growth
• physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
• skeletally immature: the bones of the skeleton have not yet fully grown, as with pre-pubescent or early-adolescent children
• tendon: a band of tough, inelastic fibrous tissue that connects a muscle with its bony attachment
• tibia: shin bone

See our complete glossary of orthopedic terms.