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What is an overuse injury?

As more and more kids play recreational and organized sports, there’s been a rise in the number of overuse injuries seen among children and adolescents. And while it’s still unusual for kids under the age of 8 to develop an overuse injury, the age for team sports and team sports training continues to get younger.

Overuse injuries are sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining.

  • A microtrauma is a small injury that can occur to bone, muscle, tendon, or ligament. Examples are microtears to muscle fibers, stress to the tendon, or bruising of the bone.
  • Pain and/or inflammation of the affected area can be symptoms of an overuse injury.
  • Some overuse injuries are more common in children because of the softness of their growing bones and the tightness of their ligaments and tendons during growth spurts.

Untreated overuse injuries can lead to stress fractures — weak spots or small cracks in the bone.

Many injuries can be prevented with:

  • proper conditioning and training (especially cross-training)
  • sport-appropriate protective gear
  • sport-appropriate equipment

Overuse injuries can heal quickly in children, but they require complete rest of the injured area while it heals.

Overuse Injuries | Diagnosis & Treatments

Diagnosing overuse injuries

At Boston Children’s Hospital, we know that the first step to treating your child is forming an accurate, timely diagnosis.

To diagnose an overuse injury, your child’s orthopedic specialist will take a medical history and perform a physical exam on your child. During the exam, the doctor will move the joint around to pinpoint the area of discomfort.

The doctor will also get x-rays to make sure there isn’t a true fracture. But x-rays can be deceiving, because children can have stress fractures and damage to their growth plates that can’t be seen on x-rays. So occasionally, clinicians will use MRI (magnetic resonance imaging) to get detailed images of the injury and verify that there is — or isn’t — a certain condition.

Treating overuse injuries

Boston Children's Hospital's Orthopedic Center provides patients with comprehensive care — including evaluation, diagnosis, consultation, non-surgical therapies, surgery, and follow-up care.

Initial treatment to stabilize an overuse injury usually includes “R.I.C.E.” (rest, ice, compression, and elevation), as well as medications to help control pain and swelling.

But the most important therapy for the injury is simply to rest it — restricting all activities that involve using the injured muscle, tendon, ligament, or bone — for a period of weeks or months as determined by your child's Sports Medicine specialist. The 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 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

Caring for your child as he heals

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. Most overuse injury patients are able to return to sports and regular activities after several weeks or months of rest and healing time.

During the healing period, it's important for everybody in the family to support the young athlete's resolve to rest the healing area, since he may feel disappointed and even a bit depressed at not being able to play his sport.

Coping and support

At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's — and your own — hospital experience as pleasant as possible. Our Hale Family Center for Families staff will give you all the information you need regarding:

In particular, we understand that you may have a lot of questions when your child is diagnosed with an overuse injury. Will this affect my child long term? When can he return to his sports and activities? Children's can connect you with extensive resources to help you and your family through this stressful time, including:

  • patient education: From the first doctor's appointment to treatment and recovery, our staff will be on hand to walk you through your child's treatment and help answer questions you may have — How long will his recovery take? Will he need home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Children's.
  • parent-to-parent: Want to talk with someone whose child has been treated for an overuse injury? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share with you their experience at Children's.
  • faith-based support: If you're in need of spiritual support, we'll connect you with the Department of Spiritual Care (chaplaincy). Our program includes nearly a dozen clergy — representing Protestant, Jewish, Muslim, Roman Catholic, and other faith traditions — who will listen to you, pray with you, and help you observe your own faith practices during your Children's experience.
  • social work: Our clinical social workers have helped many families in your situation. Your Children's social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to dealing with a child's injury, changing family dynamics, and financial issues.

If you live far from Boston, we can help

As an international pediatric orthopedics center, Children’s treats young patients from all over the world. Global Services assists families residing outside the United States: We facilitate the medical review of patient records; coordinate appointment scheduling; and help families with customs and immigration, transportation, hotel, and housing accommodations.

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.

Frequently asked questions about overuse injuries

If your child or teen has an overuse injury, it will comfort you to know that Boston Children’s Hospital'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 Syndrome: 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 fifth 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.
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.

 

How we care for overuse injuries

You can have peace of mind knowing that the skilled team of experts in Boston Children’s Hospital's Orthopedic Center has treated thousands of children, adolescents, adults, and professional athletes with injuries ranging from the minor to the highly complex. We can provide your child with expert diagnosis, treatment, and care — as well as the benefits of some of the most advanced clinical and scientific research in the world.

The Sports Medicine Division at Boston Children's has provided care to thousands of young athletes and is the health care choice of professional athletes and world-renowned dancers. We are the official orthopedic caregivers for the internationally famous Boston Marathon and the renowned Boston Ballet.

Overuse Injuries | Research & Clinical Trials

For more than a century, orthopedic surgeons and investigators at Boston Children’s Hospital have played a vital role in the field of musculoskeletal research — pioneering treatment approaches and major advances in the care and treatment of trauma to the joint, scoliosis, polio, TB, hip dysplasias, and traumas to the hand and upper extremities.

Our advanced research helps answer the most pressing questions in pediatric orthopedics today — providing the children we treat with the most innovative care available.

Boston Children’s research shows that too much high-impact training can lead to stress fractures in pre-teen and teen girls

Today’s kids are urged to participate in sports at younger and younger ages and at greater levels of intensity. While weight-bearing activity is generally thought to increase bone density, a Children's study found that for preadolescent and adolescent girls, too much high-impact activity can lead to stress fractures.

If stress fractures are detected too late in children and adolescent athletes, they pose a risk of true fracture, deformity or growth disturbance requiring surgical treatment, say the researchers, led by Alison Field, ScD, of Children's Division of Adolescent/Young Adult Medicine, and Mininder S. Kocher, MD, MPH, associate director of Sports Medicine at Children's.

Their study, published online on April 4, 2011, by the Archives of Pediatric and Adolescent Medicine, followed 6,831 girls aged 9 to 15 participating in the large national Growing Up Today study, co-founded by Field. During the seven years after enrollment, 4 percent of the girls developed a stress fracture. The most significant predictors were high-impact activities — particularly running, basketball, cheerleading, and gymnastics.

"This is the first study to look prospectively at causes of stress fracture among a general sample of adolescent girls," says Field, who is also affiliated with Brigham and Women's Hospital. "Most research has been on specialized groups, such as army recruits or college athletes, making it difficult to figure out if the results apply to average adolescents. Our study was large enough to look at the risk associated not only with hours per week of activity, but also hours per week in a variety of activities."

When researchers adjusted for other risk factors (age, later onset of menstruation, and family history of osteoporosis and low bone density), the association between high-impact sports and fractures only strengthened. Girls engaging in eight or more hours of high-impact activity per week were twice as likely to have a stress fracture as those engaged in such activity for four hours or fewer.

"We are seeing stress fractures more frequently in our pediatric and adolescent athletes," says Kocher, senior author on the report. "This likely reflects increased intensity and volume of youth sports. Kids are often playing on multiple teams, including town and travel teams, and participating in high-intensity showcases and tournaments. It's not uncommon to see young athletes participating in more than 20 hours of sports per week."

Each hour of high-impact activity per week increased fracture risk by about 8 percent. Basketball, cheerleading/gymnastics and running were independent predictors.

"The youth athlete is specializing in a single sport at a younger age," says Kocher. "This does not allow for cross-training or relative rest, as the athlete is constantly doing the same pattern of movement and impact. Small injuries are being made in the bone with greater cumulative frequency than the body can handle."

The key to the treatment of stress fractures is early recognition, Kocher adds. If recognized early, most stress fractures will heal fully with activity restriction. "Kids should not play through pain," he says. "'No pain-No gain' is not an appropriate adage for the young athlete."

The study was supported by the Department of Orthopedic Surgery at Boston Children's Hospital and the National Institutes of Health.

Sports Medicine Research Laboratory

The Sports Medicine Research Laboratory, led by principal investigator Martha M. Murray, MD, focuses on sports medicine injuries, including those of the ACL (anterior cruciate ligament), knee meniscus, and articular cartilage.

In conjunction with our collaborators, we are studying these problems on multiple levels: gene, protein, cell, tissue, and organism.

The lab’s research includes projects in:

  • molecular orthopedics
  • platelet optimization and characterization
  • tissue engineering
  • joint imaging
  • biomechanics of injury repair
  • histology and immunohistochemistry
  • device design and development
  • injury prevention
  • outcomes research

The Orthopedic Center conducts research into:

  • the mechanisms of sports injuries
  • the techniques of rehabilitation and treatment
  • the physiology of exercise and conditioning

Ongoing research includes the study of:

  • knee injuries
  • running injuries
  • injuries to pre-adolescent children
  • the psychological impact of sports and sports injuries
  • the treatment and prevention of injuries to dancers

Sports Medicine director Lyle J. Micheli, MD, is one of the world's leading authorities on sports care. Micheli has treated world-renowned dancers and professional athletes, and is the author of hundreds of published clinical studies and scholarly review articles and books.

Innovations for tendon and ligament treatment

Platelet-rich plasma. For tendon repair, as with tennis elbow, the Orthopedic Center is now incorporating the latest in tendon regeneration — the application of platelet-rich plasma (PRP). This treatment has been popular in Europe — and now in the United States — for stimulating tissue regeneration in difficult-to-heal areas such as tendons (including Achilles, elbow and patella) that don’t respond to physical therapy or to limits on activity.

There are normally many healing growth factors in our platelets. The process involves isolating these growth factors in the patient’s blood platelets, and then injecting them into the affected areas under ultrasound guidance. This special procedure is performed by Children’s Pierre d'Hemecourt, MD.

Physeal sparing. A series of innovative, age-specific reconstruction techniques for treating the ACL injuries of growing children has been developed by Children’s orthopedic surgeon and director of the Division of Sports Medicine Lyle Micheli, MD. These are classified as physeal sparing procedures — that is, they spare the child’s growth plates (physes) from disruption that would occur in traditional ACL reconstructive surgery.

These physeal sparing treatment techniques are customized to the growing child’s age: pre-pubescent, adolescent, or older adolescent. Originally developed as a temporary procedure until a child reached skeletal maturity, follow-up studies have found that five years after their surgeries, 95 percent of children who’d had physeal sparing procedures were doing so well that they didn’t need ACL reconstructive surgery, after all.

Overuse Injuries | Programs & Services