Overuse Injuries



Q: I’ve read that overuse injuries are on the rise in children and teens. What are they and why are they increasing?


A: Overuse injuries are different from sports injuries caused by a single, sudden twist, fall or collision. They develop gradually due to repetitive stress on developing body parts and can cause stress fractures, injury to soft tissue (muscles, tendons and ligaments), or bone deformities.  Once rare in pediatric patients, they account today for the majority of injuries seen in young athletes, particularly in teens. The increase seems to be due to several reasons. 


Sports programs appear to be more intense and with longer practice times than in years past. The pressure to specialize in one or two sports can affect young athletes as they enter puberty, leading to a growing risk in overuse injuries. The more they specialize, the fewer the benefits from cross training they get from a variety of physical activities. 


Rapid growth during puberty makes some body parts more vulnerable to injury from repetitive stress. The bones, muscles, tendons, ligaments and joints are not fully developed until the end of puberty – typically at around age 15 for girls and 17 for boys.


As adolescents grow taller, the bones lengthen faster than the surrounding muscles, tendons and ligaments – resulting in a decrease in flexibility. This decrease leads to an increased risk of muscle strains and ligament sprains, as well as increased stress where these structures attach to bone. 


The growth plates located at the ends of bones and other growing areas of bones where tendons attach are often the weakest link in an adolescent’s system. An injury that would cause a ligament sprain or muscle strain in adults will often result in a fracture or other injury to the bone’s growth plate in adolescents. Because injury or pain in these “growth sites” can lead to permanent injury, persistent pain around joints should never be ignored or dismissed as “growing pains.” 



Q: Is it OK for children who have not yet reached puberty to participate on a team that has daily practices of at least an hour, and several hours of games on weekends? 


A: While children are at lower risk of overuse injuries before puberty, it is still a concern with an intensive practice and game schedule. In addition, I would make sure that the sport does not require so much time that it reduces your child’s ability to take part in other experiences that comprise a well-rounded lifestyle, such as school, friends, family and unstructured time. 


To decide if a more intensive sports program is right for your child, consider if the coaching is age appropriate, if the emphasis is on fun and skill development and, most importantly, if your child enjoys the experience. If you can say yes to all these questions and have no other concerns, it is fine to participate. 



Q: How can I tell if my child may be developing an overuse injury?


A: With overuse injuries, progression is the key warning sign. Generally, overuse injuries go through four stages. In the first, the child may have soreness lasting several hours after an activity. In the second stage, there is soreness or pain toward the end of the activity and afterward lasting until the next morning. In the third stage, there is soreness or pain as the activity begins, continuing into the next day. Finally, in the last stage, there is soreness and pain all of the time with regular routine activities.


Children and teens often experience some discomfort with athletic activity. Some aches and pain can be expected. Kids’ bones and muscles are growing, and their level of physical activity may increase with a sudden, intense interest in sports. Still, a child’s complaints always deserve careful attention. A child who develops a symptom that persists or that affects his or her athletic performance should be examined by a physician with expertise in pediatric and adolescent sports medicine. A child should never be allowed or expected to “work through the pain.”


Signs that warrant a visit to a sports medicine specialist would include significant swelling or deformities to arms or legs, or severe pain that prevents a child from using an arm or leg. In addition, any pain – even a minor ache – that goes on for three weeks or more should be evaluated by a doctor.


One of the most serious overuse injuries that doctors now see more frequently is a stress fracture in the lower back. While most adults suffer back pain at some point, this is not a normal symptom for children or teens. If your son or daughter complains of persistent back pain, have him or her evaluated by a doctor.


Sally S. Harris, M.D., MPH, a board-certified pediatrician and pediatric and adolescent sports medicine specialist at the Palo Alto Medical Foundation in Palo Alto, provided this month’s medical responses. Advice is not intended to take the place of an exam or diagnosis by a physician.




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