Overuse injuries occur due to repetitive loading without adequate rest to allow for adaptation of musculoskeletal structures. In adults, overuse injuries commonly affect muscles and tendons. These are often the result of being “under prepared” for the activity, training or from a spike in training loads i.e. doing too much too soon.
Children and adolescents can sustain all the same injuries adults do, such as fractures, dislocations, tendon injuries, ligament sprains and ruptures. However, due to normal growth and development, overuse injuries can also affect areas of bone growth instead of muscles and tendons. Overuse injuries are 3-6 times more common than acute injuries in adolescent athletes. (Cassel et al, 2019)
Children and adolescents can experience a unique kind of overuse injury that occurs during this growth and development phase: apophysis injuries. An apophysis is a normal developmental outgrowth of bone. An apophysis is found where tendons and ligaments attach to bone. The apophysis is subject to tensile forces due to the pull that occurs when muscles contract. The apophysis is most susceptible to injury during periods of rapid growth, generally between the ages of 10-14 years in girls and 12-16 years in boys, although it can be affected outside these age ranges. Apophysis injuries can also be acute and traumatic, or due to overuse.
Avulsion fractures are an acute injury to the apophysis that occur as a result of sudden, rapid and forceful muscle contractions. Repetitive overuse can also lead to avulsion fractures. Common sites of injury include the pelvis and groin. (Vandervliet et al, 2007) Apophysitis is a term used to describe overuse injuries. Overuse injuries to the apophysis occur in response to repetitive loading during periods of skeletal growth, typically as a result of sports-related tasks such as running, jumping and throwing. The most common sites of apophysitis are the pelvis, knee, heel and elbow. Adolescent athletes are also susceptible to bone stress injuries. Stress fractures or bone stress are a type of overuse injury that occurs to bone caused by repeated pressure or tension.
Common Overuse Injuries in Children and Adolescents
Osgood-Schlatter Disease (OSD) affects the front of the knee where the tendon of the patella inserts onto the tibial tuberosity. It typically causes pain with jumping, running and kicking. OSD is remarkably prevalent, affecting 1 in 10 adolescents and as many as 1 in 5 in certain sports. It has typically been described as a “self-limiting” condition that settles with a “wait and see” approach, however, recent evidence suggests that pain and symptoms can persist for many years after diagnosis. (Cairns et al, 2018)
Sever’s Disease affects the heel and is caused by painful inflammation of the heel’s apophysis. It is a common cause of heel pain in children and adolescents and can occur in one or both feet. Overuse via repeated loading from running and jumping causes stress through the calcaneal apophysis. Symptoms can include pain in one or both heels, limping, walking on tip toes, and difficulty running and jumping.
Spondylolysis is a common cause of back pain in young athletes. It is a stress injury thought to be secondary to repetitive hyperextension of the spine. Activities such as gymnastics, soccer and bowling in cricket are known to put increased demand on the spine. Adolescents with spondylolysis will present with sports-related back pain that is exacerbated by extension of the lumbar spine. Pain may also be present during rest and activities of daily living. (Cassas and Cassettari-Wayhs, 2006)
Proposed risk factors for overuse injuries in children and adolescents include variations in growth and development, previous level of conditioning, muscle strength and flexibility, biomechanics and anatomic alignment and previous injury. High training volumes and intensity are also strongly linked to an increased risk of overuse injury in sport, especially with less time in the sport.
It is important to note that not all overuse injuries in adolescents are low risk. High risk overuse injuries are those that can result in significant loss of playing time, function, and threaten future sports participation. Stress fractures are a specific type of high risk injury Physiotherapists screen for. Common sites include the spine, femoral neck, patella, anterior tibia (shin), medical malleolus, navicular and fifth metatarsal. Most stress fractures will heal well if recognised early and treated appropriately. However, for stress fractures that fail to heal and cause persistent symptoms, surgical treatment may be required. (DiFiori et al, 2014)
Treatment and Prevention of Injuries
It is important to treat overuse injuries appropriately to prevent recurrence and enable optimal participation. Generally speaking, continuing with sports participation is usually not harmful, however, it may make the pain worse. After a thorough Physiotherapy assessment, a plan is developed where training can usually be modified to ensure the enjoyment of sports participation continues. Strategies such as training load reduction during periods of rapid growth have been proposed.
Symptomatic overuse injuries are usually treated with a combination of relative rest where the symptomatic area is allowed to rest from repeated bouts of loading, followed by targeted rehabilitation strategies including physical conditioning, correction of movement faults that may predispose to injury, strengthening, proprioception and flexibility exercises. (Arnold et al, 2017) During a period of relative rest, athletes should undertake supervised exercise programs focussing on sports specific skills while avoiding aggravating activities.
Strategies focussed on prevention are also beneficial, particularly following recovery from an overuse injury. Long term follow-up with a sports specific injury prevention exercise program can help to prevent recurrence of overuse injuries. (Longo et al, 2016) Monitoring of acute on chronic training load, preseason conditioning programs, neuromuscular training programs and sports specific skill development can also reduce the risk of injury. (DiFiori et al, 2014)
How can physiotherapy help?
Physiotherapists are trained to diagnose sports injuries by undertaking a comprehensive clinical history and assessment, as well as identifying risk factors, causes and contributing factors to injury. A clinical examination to determine the exact cause of symptoms, such as potential movements contributing to pain and injury are assessed.
Physiotherapists can address factors such as pain, joint stiffness, muscle weakness or tightness, training workload, strength, conditioning, flexibility, balance, sports specific skills and movements, and equipment to design a comprehensive rehabilitation program. Your physiotherapist will also work closely with your doctor and coaches to ensure the best possible management, determine the need for X-Rays or MRI, and plan a successful return to pain-free sport.
Arnold et al. Overuse Physeal injuries in youth athletes: risk factors, prevention and treatment strategies. Sports Health, 2017; 9(2): 139-147.
Cairns et al. Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport and Exercise Medicine, 2018.
Cassas and Cassettari-Wayhs. Childhood and adolescent sports-related overuse injuries. American Family Physician, 2006; 73(6):1014-1022.
Cassel et al. Orthopaedic Injury Profiles in Adolescent Elite Athletes: A Retrospective Analysis From A Sports Medicine Department. Frontiers in Physiology, 2019; 10; 544.
DiFiori et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine. Clinical Journal of Sports Medicine, 2014; 24:3-20.
Longo et al. Apophyseal injuries in children’s and youth sports. British Medical Bulletin, 2016; 120:139-159.
Vandervliet et al. Sports-related acute and chronic avulsion injuries in children and adolescents with special emphasis on tennis. British Journal of Sports Medicine, 2007; 47:827-831.