When you think of injuries in youth sports, what comes to mind?
Most parents might imagine a jaw-clenching incident involving a slide tackle gone wrong, a miscoordinated landing after a block, or a high-speed slide into the boards—each followed by a laundry list of sound effects from a Rice Krispies commercial.
Snap. Crackle. POP.
But what about the injuries that develop slowly over time and don't require an early morning rush to the ER? What about the injuries that begin to fester gradually, right under our noses, causing pain and discomfort with each day worse than the previous? Overuse injuries aren't glamorous injuries. They develop over time—sometimes weeks, months, years, or even decades. But just as these injuries are slow to reveal themselves, their recovery can also follow a similar prolonged timeline, making prevention and early recognition essential in keeping our kids out on the pitch.
The mechanisms behind overuse injuries in young athletes
So, what do we mean by overuse? Every day, we stress the musculoskeletal system of our body (think muscles, tendons, bones, ligaments, etc.). This stress isn’t bad. In fact, it’s necessary for growth and repair. When we're physically active, we partake in a balancing act between stress (i.e., the loading of the body's tissues) and structural adaptation. Most of us are familiar with the principles of strength training—the breaking down of muscle fibres to rebuild them stronger and better suited to tolerate the new demands caused by resistance training. The same principles apply to bones, tendons, and ligaments. With overuse, however, a structure undergoes repeated force without the appropriate rest required for adaptation—the structural change that allows it to rebuild and come back stronger. In other words, the scale tips; repetitive stress outpaces the ability to rebuild, and we enter the realm of overuse injuries.
Alright, that's the end of the physiology lesson.
Most parents, whether they realize it or not, are pretty familiar with a variety of overuse injuries. Whether from the first-hand experience of a persistent ache after deciding to train for your first 10k, or from listening to your golfing buddy blame his golfer's elbow for his drive straight into the pond. We often forget, however, that similar injuries can also develop in children and adolescents, especially those participating in high volumes of sports and related training.
As participation in youth sports increases, so does the incidence of overuse injuries. Further complicating the matter is the rising pressure for high-volume training and early sport specialization, both of which increase the risk for injury. In the sections below, we will take a look at the factors known to increase the risk of injury, the impact of sports specialization on our youth athletes, and strategies for preventing avoidable injuries in pediatric sports.
Common overuse injuries in youth sports
Many overuse injuries in younger athletes can be similar to repeated stress injuries seen in skeletally mature individuals. These can include Achilles tendinopathy, medial tibial stress syndrome (AKA shin splints), tennis and golfer's elbow, stress fractures, plantar fasciopathy, and patellofemoral syndrome. The list is as diverse as our anatomy. In addition to those commonly seen in adults, youth athletes are also vulnerable to overuse injuries that are unique to the skeletally immature. As kids grow, their bones grow both in thickness and length. Lengthening occurs at a plate near the ends of the bones—a site known as the epiphyseal or growth plate. In people who have not yet reached skeletal maturity, these plates can be the sites of injury—injuries that are often provoked by repetitive stress and overuse. Whereas in adults, these growth plates are sealed, in children, they remain more vulnerable, allowing repeated stress and force to cause injuries and often disrupting their regular participation in sports and play.
These injuries in the skeletally immature can occur all over the body and often involve sites where structures such as tendons or ligaments pull on the bone. Osgood-Schlatter disease, for instance, occurs due to repeated stress at the tibial tubercle, where the patellar tendon attaches to the shin bone (also the location of a growth plate). Prolonged overuse can lead to the thickening of the bone at this attachment, which can further exacerbate symptoms and result in a visible and palpable bump. Similarly, Sever's disease occurs at the insertion of the Achilles tendon, where our calf muscles attach to the bone of the heel. After repeated and frequent running and jumping, the growth plate at this site can become irritated and grow rapidly, leading to a bony bump on the back of the heel and tremendous pain. Children who participate in sports that require tight, stiff shoes (e.g., ice hockey) are also more susceptible to overuse injuries like Sever's disease due to the compression that occurs at the back of the heel.
Other overuse injuries include gymnast's wrist, Little League elbow, and Little League shoulder. These injuries typically occur at growth plates that undergo significant stress due to the specific demands of the sport. Young baseball players (especially those who specialize as pitchers) may experience symptoms associated with Little League shoulder or elbow. These injuries are caused by the rotational forces associated with throwing the ball at a high velocity, where they affect the growth plates of the upper arm (Little League shoulder) or at a site just beside the inside of the elbow (Little League elbow). These injuries can quickly result in pain, tenderness, and loss of ability to move the affected joint. For young gymnasts and climbers, increased pressure and force at their wrists can lead to a condition known as Gymnast's wrist, which presents with similar symptoms (pain, tenderness, and loss of range of motion) but typically occurs on the thumb side of the wrist. In terms of sports activities, these injuries may initially manifest as signs of decreased sports performance. A coach may notice a pitcher losing the accuracy and velocity of their throw, or see that their usually eager gymnast is resistant to weight-bearing onto their hands during a floor routine.
These common overuse injuries can develop quickly or gradually. But they're prevention, recognition, and rehabilitation require a close and careful consideration of how overuse injuries occur and what we can do to keep our children playing and competing in the activities they love. Overuse injuries can also contribute to burnout in young athletes, making it essential to prevent and address these injuries to encourage lifelong physical—and whole-body—health and wellness.
Risk factors for overuse injuries in young athletes
A vital component in addressing youth overuse injuries is understanding who is most vulnerable and what we can do to decrease the risk of occurrence. The American Medical Society for Sports Medicine released a consensus statement examining the risk factors associated with overuse injuries in youth sports. These factors include a history of previous injury, increased training workload, dense competitive schedules, ill-fitting equipment, sport specialization, and an increased risk during a rapid growth spurt. Additionally, the presence of menstrual dysfunction can also make female athletes more susceptible to injury. All of these risk factors can help us indicate when a young athlete's participation in sport is more likely to lead to overuse injury.
Therefore, if we understand the factors that can increase the risk for overuse injuries, we can identify those who are most susceptible. But what can we do to prevent overuse injuries before they occur?
Preventing overuse injuries and burnout in young athletes
Some of these risk factors are difficult to control. We can't—and don't want to—remove an athlete from their sport altogether if they are experiencing a growth spurt. However, we can ensure that they are getting enough recovery and rest by maintaining a gradually progressive training program that includes scheduled time-off and rest. Similarly, if we identify a child who is at an increased risk of injury (e.g., experiencing a growth spurt, menstrual dysfunction, or having a history of previous overuse injuries), we can ensure that we are recognizing the importance of minimizing the factors that we can control.
Promoting a diversity of physical activity is essential to reducing the risk of overuse injuries. The more focused our kids are on playing one sport year-round, the more likely they are to experience overuse injuries due to repeatedly putting their bodies under the same stress. Think of a baseball pitcher or hockey goalie, who repeats the same sports activities and movement patterns each time they practice or play a game. Repeated stress can quickly outpace the body's ability to rebuild its tissues, especially when engaging in off-season training that extends the season to over eight months per year. On the other hand, athletes who play multiple sports throughout the year (whether recreational or organized sports) have a decreased likelihood of burnout and injury, as the variety of movement is easier for the body to tolerate. Early specialization in ice hockey, for instance, has been linked to high rates of hip and groin dysfunction, including cam deformities (a bony change of the hip). The American Academy of Pediatrics recommends a minimum rest from a specific sport for 2 to 3 months per year, as well as at least 1 to 2 days of rest per week. Another common recommendation is not to train more hours per week than the child's age. Adhering to these guidelines can help prevent the development of overuse injuries and athlete burnout, leading to long-term participation in organized sports activities.
The role of parents and coaches in sports injury prevention
It's no secret. There's a lot of pressure on child and adolescent athletes to perform. A child may experience pressure internally (within the athlete's own motivation) or externally from parents, siblings, coaches, or peers. We all expect a lot from our youth athletes, but the truth is that we often fail to provide the support they truly need. Physical fatigue can significantly increase the risk of injury and frequently results from overtraining. But parents and coaches often miss the signs, instead believing that further intensive training is the key to getting the athlete out of their 'slump'. Coaches and parents should regularly monitor their young athletes for signs of fatigue. Physical exhaustion, mood changes, frequent injuries, and declines in performance (also signs of overtraining syndrome) can all help warn parents and coaches that their athlete is unable to maintain the current workload. Failing to respond to these warnings can result in injury and burnout of young athletes. Regular adaptation of training volume and intensity, as well as the routine implementation of scheduled—and unscheduled—rest can significantly decrease the likelihood of both injury and burnout in youth sports. Additionally, we can encourage a variety of movements and types of training to reduce the repetitive stress on key areas of the body. This can be performed by diversifying training or by resisting sports specialization—an increasingly common practice that involves focusing on a single sport by sacrificing other forms of sport and play. By encouraging a diversity of training, whether by participating in different activities or simply modifying training on a day-to-day basis, we can begin to support our kids as they pursue a life of play.
Prioritizing safety and health in young athletes
In a survey examining the motivations behind sport specialization, parents of competitive youth hockey players were asked about the motivations behind early sport specialization. The results showed that parents believed early sport specialization would improve their children's chances of receiving college scholarships and playing in professional athletics. But we know that variety in growth and play is a key component in preventing overuse injuries. Some countries recognize the hazards of early sport specialization and the intensity of structured, high-level youth sports. Norway, for instance, tries to encourage a sporting environment that fosters free play and access above competition and rankings. Children and adolescents are encouraged to participate in a variety of sports and activities, and there are no national youth rankings that may contribute to the push for specialization.
But what about the youth athletes who aspire to play at an elite level?
Overtraining may not be the key to success
We like to think that all pro athletes were born to play their sport—that the McDavids of the world were learning to skate before taking their first step. But is this really true? Despite the regulations that work against sport specialization, Norway still consistently places in the top ten of total Olympic medals and gold medals per capita. Additionally, surveys looking at professional hockey players have found that most players didn't specialize in the sport until after the age of 14. In fact, one study found that only 24% of the professional hockey players questioned had specialized before turning 14 years old (and only 11% had specialized before the age of 12). What does this mean? General sport participation does not risk the ability of your child to develop into a high-ranking athlete. Furthermore, straying away from early sport specialization can reduce the risk of overuse injuries and athlete burnout—keeping your child on the field longer and injury-free. By prioritizing playful exploration over competitive rankings, we can help our children develop into strong, multifaceted athletes with a lower risk of sports-related injury.
Of course, overuse injuries in young athletes won't disappear overnight (or ever). The good news is that overuse injuries only require surgery in the most severe and persistent cases. For most overuse injuries, recovery time and physiotherapy are the cornerstones of evidence-based treatment. A guided physiotherapy program from a clinician familiar with pediatric sports medicine can help your child return to play and prevent serious injuries, while also promoting safe and healthy sporting habits for their future development as young athletes.
If you have any questions about a current injury or simply want to help your child stay injury-free, you can contact REP Physio for more guidance on dealing with youth sport injuries.
