Understanding Pediatric Overuse Injuries: Prevention and Management

Making up to 50% of sports medicine visits, overuse injuries are common in pediatric populations. Overuse injuries have physical and mental health complications for young athletes, including pain, lost time from their sport, frequent medical visits, and anxiety over poor performance. These complications can also lead to attrition from sport and exercise. Seventy percent of youth discontinue their organized sport by 13 years of age, some of which may be due to overuse, overtraining, and burnout. Thus, it is important for athletes, parents, coaches, and health care providers to maintain vigilance in looking for the signs and symptoms of overuse in young athletes.Overuse injuries are caused by repetitive, submaximal stress on a particular body area without sufficient rest. They differ from acute injuries in etiology, symptoms, and timing. Acute injuries present suddenly, typically with a known event, and are associated with acute findings, such as swelling, redness, warmth, or bruising. Overuse injuries have a vague or slow onset but often some other link to athletic participation, such as a change in intensity/time of the activity, a new activity, limited rest periods, or inadequate equipment or playing surfaces.Risk factors for overuse injuries can be classified as intrinsic and extrinsic. Intrinsic factors are those unique and inherent to the individual. Extrinsic factors are external and more malleable. Intrinsic factors include growth spurts and developmental considerations; biomechanical factors, such as alignment issues; metabolic concerns, such as nutrition status, including low energy availability, low calcium/vitamin D, and obesity; behavioral factors, such as sleep and appropriate technique; prior injury; fitness level; and psychosocial factors, such as life stress and athletic identity (ie, how much of the athlete’s sense of self is invested in being an athlete). Extrinsic factors include training issues, such as excessive volume or intensity and inadequate rest and recovery. Some sports offer significant opportunities for repetition, leading to potential overload, such as baseball (ie, pitching) and running.Sports specialization is an extrinsic risk factor for overuse injuries. Sport specialization involves participating in one sport to the exclusion of all others, often for most (if not all) months of the year without rest. High levels of specialization increase the likelihood of an overuse injury. Sports that favor early specialization include gymnastics, ice skating, and dance.Athletes often complain of a gradual onset of pain that presents with activity. Over time, the pain may persist during nonactivity times as well. Athletes may also complain of intermittent swelling and of decreased function in their sport (eg, decreased speed, force, accuracy, agility). This chronic pain and its effect on their daily and athletic lives can also cause mental health disturbances, including anxiety and depression. A change in athletic performance can also put their athletic identity at risk.With those considerations in mind, the clinical evaluation of an athlete with a potential overuse injury should begin with a good history. It is helpful to obtain details about the pain location, duration, onset, and timing; associated symptoms; aggravators; ameliorators; and previously tried therapies. Other important details include the athlete’s training load, both school related and league related; recent training changes; and individual overuse risk factors.The physical examination should include vital signs, particularly temperature and body mass index (helpful for weight-bearing joints); a general musculoskeletal examination, including motion, strength, sensation, and palpation; a composite joint examination, evaluating all joint components, including all relevant muscles/tendons and ligaments; and bodily locations that cause pain radiation, such as a hip concern causing knee pain.Imaging is not always necessary for overuse injuries. Consider x-rays for an unexplained or severe deformity or pain or for loss of function or motion. Consider also ordering x-rays of the contralateral side if there is a potential anatomical variant.Overuse injuries may be more or less likely, depending on the age, sport, and risk factors of the athlete.Apophysitides make up a large group of overuse injuries. These injuries are due to traction causing irritation of an apophysis, a growth center attached to a tendon/ligament and the weakest point in the mechanical chain. These injuries can vary by sport and are generally self-limited. The apophysis may be tender on examination. Some common apophysitides are listed in Table 1.Patellofemoral pain syndrome (PFPS; ie, runner’s knee) is caused by excessive and/or abnormal motion of the patella within the femoral groove. It can be associated with patella alignment issues. Athletes who participate in excessive running, particularly without appropriate footwear and/or good technique, are susceptible to PFPS.Stress fractures are due to pressure on the bone that exceeds its general capacity but not too much to cause a complete break. Common associations include running and tibial stress fractures and marching and metatarsal stress fractures.Spondylolysis, a stress fracture of the pars interarticularis (unilateral or bilateral), is due to repetitive hyperextension and loading of the spine. It is found in half of all adolescent athletes with back pain. A bilateral pars fracture can allow increased instability of that area of the spine, leading to anterior slippage of that vertebral body (ie, spondylolisthesis). Athletes who participate in sports with frequent hyperextension (eg, gymnasts, throwers, weightlifters) may develop this injury.The last overuse injury we will discuss is tendinopathy (eg, patellar, Achilles). Tendinopathy is caused by excessive, repetitive, and chronic traction on a tendon. These athletes are typically older athletes with closed growth plates, including mid-to-late teenagers and college athletes. The activities that lead to tendinitis are the same as those that would lead to apophysitis in younger athletes (eg, patellar tendinitis in jumpers).The first part of the treatment plan should involve pain management, rest, and activity modification. Pain management might include topicals, such as ice, heat, massage, and wraps/braces. It can also include medications, typically nonsteroidal anti-inflammatory medications. Athletes can also consider mindfulness activities and body awareness, which could help their recovery and future performance.Athletes should enter a period of relative rest, avoiding activities that exacerbate their pain. This would typically require cessation of the activity in question for some amount of time. When this rest period is completed, the athlete should resume their sport with activity modification, which could include a change in the frequency, intensity, time, and type of exercise as well as the equipment and/or playing surface used.Rehabilitation should also be part of the treatment plan. Athletes can be given home exercises to improve strength, flexibility, and conditioning or referred to a sports physical therapist. Athletes should also be encouraged to evaluate their personal risk factors, including their training load, athletic technique, and athletic equipment. Once they are pain free with activities of daily living (eg, squatting, climbing stairs, light jogging), athletes can start a gradual return to their athletic program. If working with an athletic trainer (AT) in school (typically high school athletes), the AT can assist with this transition back to full participation.As with most behavior-related conditions, education is important. Athletes, along with their parents and coaches, should understand the potential for overuse injuries and their risk factors. All should be able to recognize the early signs and symptoms of overuse injuries, so they can be addressed early. Athletes should be encouraged to participate in skill-building and cross-training activities. Adequate periods of rest and recovery should be built into each week’s training plan. Early sports specialization should be avoided. Athletes should also be encouraged to maintain healthy living behaviors, including appropriate nutrition, sleep, and stress management. Those who participate in sports with specific participation guidelines, such as pitching in youth baseball, should also be counseled to follow them.Those who care for our young athletes can also help minimize overuse. Coaches can implement injury prevention programs and follow guidelines when it comes to training and competition. Health care providers should provide regular preventive visits and sports physicals as well as counsel on overuse injuries and mitigating risk factors.It is important to obtain a thorough history for a young athlete’s pain. This would include not only an injury history but also the athlete’s training load, recent training changes, and the impact the pain has on the athlete’s sporting and regular activities. The examination should include an assessment of the athlete’s general function and the specific area in question. The assessment and plan should include not only considerations for rehabilitation but also considerations for the athlete’s sports training program and schedule.Comment: Can society reduce overuse injuries counterintuitively by increasing the number of children playing high school sports? According to a 2025 US nationwide survey from the Aspen Institute, more than half of the responding parents felt pressure to have their children specialize in a sport and that the pressure was appropriate because their children wanted to play high school sports. This finding highlights the recognition by some parents that competition to make the high school team can be fierce, with 5 times as many students trying out for some popular teams as the number of available spots. If schools had the funds to offer a greater number of freshman-only and intramural-only teams, more children could participate in multiple sports for fun rather than focusing on one just to make the cut.On the other end of the spectrum from those parents just hoping their children will make the high school team are the parents with unrealistically high expectations for their children’s longer-term prospects. According to the Aspen Institute, more than 1 in 5 surveyed parents believed their children could become Division I college athletes and more than 1 in 10 could become professional athletes. Researchers have deemed this psychological phenomenon “achievement by proxy distortion.” If pediatricians can help parents recognize when they have adopted this unhealthy mentality, they may reduce their patients’ risk of overuse injury due to excessive parental pressure to succeed in sports.Linda Y. Fu, MD, MSAssociate Editor, In Brief