Overuse Injuries Symptoms & Causes

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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. Golf elbow 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. Jumper's knee may occur when the patellar tendon in the knee joint is repeatedly pulled on, especially during jumping activities.

Little League elbow or shoulder

Characterized by pain in the elbow or shoulder area, especially after activity. These conditions 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. Osgood-Schlatter disease 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. Osteochondritis dissecans an occur when a piece of the cartilage in the knee or elbow joint separates from the joint surface. This condition 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. Sever's disease 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. Shin splints are caused by excessive running, running on hard surfaces and improper shoe wear.

Sinding-Larsen-Johansson disease

Characterized by knee pain, especially after jumping activities. Sinding-Larsen-Johansson disease is 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. Spondylolysis is 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. Swimmer's shoulder is 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. Tennis elbow 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 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.

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?

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.

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.

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 spondylolisthesis (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 overuse injuries be avoided?

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 5th 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?

Our Sports Medicine Division provides free injury prevention guides for download.

What is Boston Children’s experience in orthopedics?

Boston Children's Orthopedic Center is known for its clinical innovations, research and leadership. Ranked #1 by U.S. News and World Report, the Orthopedic Center provides the most advanced diagnostics and treatments, several of which were pioneered and developed by Boston 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.

Overuse injuries glossary

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•   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.

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- Sandra L. Fenwick, President and CEO

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