Course:KIN366/ConceptLibrary/Overuse Injuries

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Movement Experiences for Children
KIN 366
Instructor: Dr. Shannon S. D. Bredin
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Overuse injuries in adolescent athletes occur as a result of repetitive loading to a bone, tendon, or muscle (Brenner & Council on Sports Medicine and Fitness, 2007; DiFiordi, 1999). Without adequate recovery time, the body cannot adapt to the stress and an inflammatory response is initiated from the micro trauma, damaging the surrounding tissues (DiFiordi, 1999). In chronic instances, repetitive loading produces degenerative problems such as weakness, decreased flexibility, and persistent pain (DiFiordi, 1999). These types of injuries have the potential to negatively impact a child's lifelong movement experiences.

Prevalence in Society

In Canada as of 2005, 51% of children aged 5 to 14, approximately 2.0 million children, participated in sport regularly (Statistics Canada, 2009). As a result of increased participation, there is also an increase in the amount of sports-related injuries in children (Valovich McLeod, Decoster, Loud, Micheli, Parker, Sandrey, & White, 2011). However, more than 50% of these adolescent sport injuries are preventable (Brenner et al., 2007). Statistics on overuse injuries are often underestimated, as an injury is typically defined as losing time from participation (DiFiordi, Benjamin, Brenner, Gregory, Jayanthi, Landry, & Luke, 2014).

Classifications of Overuse Injuries

Overuse injuries can be generally classified into three groups: stress fractures, apophysitis, or tendinitis (Biber & Gregory, 2010; DiFiordi, 1999; Committee on Sports Medicine and Fitness, 2000).

Stress Fractures

Stress fractures are a result of placing repetitive, sub-maximal loads on the body; examples include spondylolysis and spondylolisthesis. (DiFiordi, 1999). Chronic fractures to the epiphyseal plates, known as the growth centres, can result in deformity or cessation of long bone growth (Committee on Sports Medicine and Fitness, 2000). These conditions seen at the epiphyseal plates are usually a result of compression forces (Valovich McLeod et al., 2011). A previous medical history of amenorrhea also increases the risk of developing a stress fracture (DiFiordi et al., 2014).


Adolescents are highly susceptible to stress-induced injuries of growing bones (Biber & Gregory, 2010). Traction and repetitive tension forces are responsible for these types of injuries occurring at the apophysis, the area of attachment on a bone for a muscle-tendon unit (Biber & Gregory, 2010; Valovich McLeod et al., 2011). Chronic stress can result in swelling, pain, and potentially osteogenesis or calluses (Biber & Gregory, 2010). Examples of these disorders include Osgood-Schlatter disease, appearing as a lump at the tibial tubercle, Sever disease, which is the calcification of the heel and Little League Elbow, occurring at the medial epicondyle of the humerus (Valovich McLeod et al., 2011; Biber & Gregory, 2010).


Tendinitis is the chronic inflammation of, or breakdown of tendon tissues caused by overuse of the associated muscle (Robinson, 2002). Redness, pain, stiffness, decreased movement or swelling of the joint, tendon, or muscle are characteristic symptoms of this condition (Robinson, 2002).

Signs and Symptoms of Overuse Injuries

The signs and symptoms of overuse injuries include, but are not limited to gradual onset of pain, aching pain, no prior acute injury, stiffness and aching during or after competition, increasing time for pain resolution, point tenderness, swelling, and missing training due to persisting pain (Valovich McLeod et al., 2011). An adolescent will often complain of pain at the injury site that is worsened with physical activity; strength and range of motion are typically normal, but pain can be triggered by stretching or testing the strength of the muscle-tendon unit (Biber & Gregory, 2010).

Factors Contributing to Overuse Injuries

Intrinsic Factors

Growth Factors

The susceptibility of growth cartilage to repetitive stress and the rate of long bone growth in relation to their muscle-tendon attachment site are two growth factors contributing to overuse injuries (DiFiordi, 1999). Growth cartilage exists at the apophyses, epiphyses and on the articular surfaces; each area is vulnerable to a specific type of force which stresses the tissue (DiFiordi, 1999). When bones grow faster than the muscle-tendon units, inflexibility, muscle imbalances, or an increase in the traction forces at the apophysis can occur (DiFiordi, 1999).

Prior Injury

Prior injury is often an indication of repetitively utilizing poor technique during training, incomplete rehabilitation, or a misdiagnosed original injury, all of which predisposes an individual to develop an overuse injury (DiFiordi, 1999). An athlete's medical history is one of the strongest indicators of developing an overuse injury (DiFiordi et al., 2014).

Overweight Athletes

Excess weight is the source of additional force being applied to bones; therefore overweight children are more prone to overuse injuries as their bones must withstand more stress than the average child (O'Connor, 1998).

Anatomic Misalignment

Structural or functional abnormalities such as pes planus, tibial torsion, ligament laxity, or excessive pronation can increase the likelihood of developing an overuse injury (DiFiordi, 1999).

Menstrual Dysfunction

This condition is often associated with lower bone mineral density, increasing the susceptibility of stress fractures (DiFiordi, 1999).

Psychological Factors

   A child’s self-esteem and maturity level will often influence their level of focus, which can dictate the amount of attention and care devoted to practicing proper technique (DiFiordi, 1999).

Extrinsic Factors

Increased Participation in Organized Sport

Although physical activity is essential to combat obesity, excessive participation can contribute to overuse injuries (Brenner et al., 2007). Weekend athletic tournaments often involve approximately six hours of competition per day (Brenner et al., 2007). Children who train year-round on multiple athletic teams have long hours of intense training (Brenner et al., 2007).

Adult or Peer Pressure

Pressure from coaches and especially parents can encourage excessive training (DiFiordi, 1999). Many parents have high, and sometimes unrealistic expectations that their child will one day reach elite levels, receive an athletic scholarship, or become a professional athlete (Brenner et al., 2007).

Overly Accelerated Training Progression

Advancing training progressions too quickly can put excessive stress on the body, and when performed repetitively, can contribute to overuse injuries (DiFiordi, 1999). A guideline of a 10% weekly increase in either intensity or duration, but not both has been suggesting when dealing with adolescent athletes (Valovich McLeod et al., 2011).

Inadequate Rest

Without enough rest between training sessions, the body will not be able to repair the micro trauma caused by the exercise, which results in chronic damage to the surrounding tissues (DiFiordi, 1999). Over-scheduling an adolescent athlete in organized sport may increase their work to recovery ratio (DiFiordi et al., 2014).

Early Specialization

Specialization in sport is defined as intense, year-round training in one sport, while not participating in any other sports (DiFirodi et al., 2014). Higher intensities and frequencies are associated with the training schedules of athletes who specialize early, which increases the volume of activity and susceptibility of developing an overuse injury (Valovich McLeod et al., 2011).

Poor Technique

Poor technique can improperly stress muscles, bones and tendons; therefore, it is important to have coaches who can provide proper instruction and are skilled in error correction (DiFiordi, 1999).

Inappropriate Footwear and Equipment

Worn out running shoes can lose their shock absorbing capabilities, placing greater forces and more stress on the body (DiFiordi, 1999). Poor fitting equipment can one's biomechanics resulting in poor technique (DiFiordi et al. 2014).

Uneven or Hard Surfaces

Introducing new training surfaces such as sand or hills stresses the body in unique ways, which can be a source of injury when performed repetitively (DiFiordi, 1999).

How Overuse Injuries Affect Movement Experiences

Overuse injuries are a result of applying repetitive stress to the body tissues, which is an inevitable part of physical activity (DiFiordi, 1999). Essentially, the more frequently a child participates in organized sport, the more movement experiences they obtain. However, when the volume of exercise becomes excessive, such as with early specialization, the more stress the body has to withstand and the child becomes increasingly susceptible to developing an overuse injury. DiFiordi et al. (2014) define a “high risk” overuse injury as one that results in lost participation time and threatens the adolescent's future participation in sport. This category includes epiphyseal injuries, certain stress fractures, some apophyseal injuries, effort thrombosis, and osteochondritis dissecans (DiFiordi et al., 2014). This type of injury can require many visits to practitioners and are accompanied with medical expenses, both of which can financially strain the athlete's family (Valovich McLeod et al., 2011). A lengthy rehabilitation time and the possibility of injury reoccurrence can lead to decreased participation time, influence drop-out decisions, and ultimately lead to a sedentary lifestyle (Valovich McLeod et al., 2011).

Practical Applications

With child participation rates in organized sport increasing, more children will be at risk for developing an overuse injury. Therefore it is important to be informed as a coach or parent and be able to recognize the signs an symptoms of this injury. Prevention strategies are targeted towards the parents and coaches responsible for the adolescent athlete's health, as they have a primary influence on the volume of physical activity. Treatment strategies are provided by practitioners, but recovery from an overuse injury is self-motivated and the responsibility of the athlete and their parents.


Injury Surveillance

There is a need for researchers and physicians to produce more empirical data about overuse injuries in adolescent athletes (Valovich McLeod et al., 2011).

Pre-participation Physical Examination

A pre-participation physical examination (PPE) screen functions to detect various severities of medical conditions including musculoskeletal conditions that make athletes susceptible to further injury or illness (Valovich McLeod et al., 2011). Establishing sport specific risk factors for overuse injuries in each sport, and assessing the skeletal maturity, skill level and motivation for participation in sport, allows practitioners to identify high-risk athletes can and initiate preventative measures (DiFiordi, 1999; O'Connor, 1998; Valovich McLeod et al., 2011).

Coach and Parent Education

Coaches and parents should have a general knowledge of the signs and symptoms of overuse injuries, so preventative measures can be taken (DiFiordi, 1999; Valovich McLeod et al., 2011). Coaching seminars are an effective way to keep coaches well-informed and up to date with current information (DiFiordi, 1999).

Medical Supervision

Proper supervision of athletes ensures early recognition of the signs and symptoms of various overuse injuries (Valovich McLeod et al., 2011).

Sport Alterations

Rule modifications for adolescent and pediatric sport may decrease the risk of developing an overuse injury (Valovich McLeod et al., 2011). Examples include pitch counts, which have been imposed in the Little League World Series for baseball players, and shortening the length of playing periods such as quarters or halves in an attempt to reduce overall volume of activity (Valovich McLeod et al., 2011).

Training and Conditioning Programs

Pre-season and in-season training might prevent overuse injuries; however, this has become a challenge as youth today are not as active as older generations were at that age (Valovich McLeod et al., 2011). Training, especially during time of accelerated growth should be modified and carefully monitored, as bones are porous and weaker than mature bones, and muscles and tendons are prone to injury during this phase (DiFiordi, 1999; O'Connor, 1998).


By systematically cycling training loads and incorporating well-defined rest periods, the body will have adequate recovery time that is appropriate for the intensity, duration and frequency of the physical activity (DiFiordi, 19999).

Delayed Specialization

Research suggests that children who specialize post-puberty tend to have fewer injuries (Committee on Sport Medicine and Fitness, 2000). Training rigorously in one sport increases the chance of developing an overuse injuries that multi-sport athletes (O'Connor, 1998). However, multi-sport athletes who utilize similar muscles groups, for example a child who is a baseball pitcher and a competitive swimmer, is at higher risk for injury (Brenner et al., 2007).


It is important that parents, coaches and the athlete are involved in the diagnosis of an overuse injury, so they can be aware of the underlying cause(s), address the risk factors, and create a strategy to prevent injury recurrence (DiFiordi et al., 2014). Overuse injuries tend to be self-limiting and require a conservative approach to treatment (Biber & Gregory, 2010). Modifying and reducing the volume of activity, ice application, the use of anti-inflammatory drugs, and physical therapy to improve flexibility and strength are recommended, but complete rest from the movement causing the injury is ideal (Biber & Gregory, 2010). However, children are unlikely to adhere to orders for complete rest (Committee on Sport Medicine and Fitness, 2000).


Physicians, coaches and parents play a pivotal role in a child’s athletic development; they should be aware and recognize the symptoms of overuse injuries, and not encourage a child to “push through” an injury (Committee on Sport Medicine and Fitness, 2000). The American Academy of Pediatrics suggests limiting each sporting activity to five times per week including sport-specific training, scrimmages and competitive play, with at least one complete rest day from organized sport (Armstrong, 2007). It is also recommended that a child have two to three months without organized sport each year (Armstrong, 2007). Training session intensity, duration, and volume should not increase by more than 10 percent each week (Armstrong, 2007). There is a critical balance needed between encouraging movement experiences for the adolescent athletes to develop their motor skills, while monitoring exercise volume and rest time to ensure an overuse injury does not develop. Currently, there is a need for more research to specify the prevalence and incidence of overuse injuries in children (DiFiordi et al., 2014).


Armstrong, C. (2007). AAP releases recommendations on overuse injuries and overtraining in child athletes. American Family Physician, 76, 1725. Retrieved from

Biber, R. & Gregory, A. (2010). Overuse injuries in youth sports: Is there such a thing as too much sports? Pediatric Annals, 39, 286-292. doi: 10.3928/00904481- 20100422-09

Brenner, J. S. & Council on Sports Medicine and Fitness. (2007). Overuse injuries, overtraining, and burnout in child and adolescent athletes. Official Journal of the American Academy of Pediatrics, 119, 1242-1245. doi: 10.1542/peds.2007-0887

DiFiordi, J. P. (1999). Overuse injuries in children and adolescents. The Physician and Sports Medicine, 27, 75-76. Retrieved from

DiFriordi, J. P., Benjamin, H. J., Brenner, J., Gregory, A., Jayanthi, N., Landry, G. L. & Luke, A. (2014). Overuse injuries and burnout in youth sports: A position statement from the American Medical Society for Sport Medicine. Clinical Journal of Sport Medicine, 24, 3-20. Retrieved from

Statistics Canada. (2009). Kids' Sport. (Report No. 11-008XWE) Retrieved from

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On Sports Medicine and Fitness, Committee. (2000). Intensive training and sport specialization in young athletes. Pediatrics, 106, 154-157. doi:10.1542/peds.106.1.154

Robinson, K. (2002). Tendinitis. Physiotherapy, 88, 446-446. doi: 10.1016/S0031-9406(05)61292-8

Valovich McLeod, T. C., Decoster, L. C, Loud, K. J., Micheli, L. J., Parker, J. T., Sandrey, M. A. & White, C. (2011). National Athletic Trainers’ Association position statement: prevention of pediatric overuse injuries. Journal of Athletic Training, 46, 206-220. doi:10.4085/1062-6050-46.2.206