Overuse Injuries in Pediatric

and Adolescent Athletes

Heather W Harnly, M.D.

Overview
Epidemiology
Unique pediatric anatomy
Upper and lower extremity overuse
injuries and growing pains
Sport specific injuries
Treatment

Prevention of overuse injuries

Epidemiology of Youth Sports

Participation increasing
over the past 20 years
Estimated 7,600,000
adolescents participating in
high school sports
Approximately 40 to
60,000,000 youth who
participate in nonscholastic
sports annually
National Council of Youth Sports, 2008 Report

Sports Injuries
Estimated 4.3 million
injuries per year
Sports injuries account for
1/3 of all injuries in this age
group
Half of pediatric sports
injuries are due to overuse

Etiology

Paradigm Shift
Increasing participation in organized athletics
among skeletally immature athletes
Younger ages & increasing intensity of participation
Specialization & Year-Round Focus

Shift in Etiology

Macrotrauma
Fractures & Dislocations

Repetitive Microtrauma
Increasing Prevalence of
Overuse injuries

Why Do Overuse Injuries

Occur?

Longer seasons
Increased preseason training
Sports camps
Select teams
Rapid transition between sports
Emphasis on competition
Poor coaching

What is an Overuse Injury?

Chronic injuries related to constant high
levels of physiologic stress without
sufficient recovery time
1) rapidly increase level of activity
2) play w/ poor technique/ mechanics
3) fit/ good technique but over exposure

Overuse Injuries Seen In...

Previously
Unfit Athlete

Extremely Fit
Athlete

A condition caused
by submaximal
stress to previously
normal tissues

Young Athletes
The growing athlete is not merely a
smaller version of the adult
There are marked differences in
coordination, strength, and stamina
In young athletes, bone-tendonmuscle units, growth areas within
bones, and ligaments experience
uneven growth patterns, leaving them
susceptible to injury.

Pediatric Anatomy
Epiphysis:
bone between joint and
the growth plate

Physis:
Growth plate: cartilage
layer which allows growth
in length

Apophysis:
attachment site for tendon
to bone

Pediatric Growth
Puberty
Growth spurts begins
Age 9 for girls with peak height velocity at 11-12
Age 11 for boys, with peak height velocity at 13-14

Growth accounts for 17-18% of final height

Boys double total muscle mass between ages 1017

Often imbalance between strength and

flexibility in preadolescent/ adolescent years

Upper Extremity Overuse

Injuries

Distal Radius Physeal Stress syndrome

Little Leaguers Elbow and Shoulder
Stress Fractures
Swimmers shoulder
Osteochondritis Dessicans

Physeal Overuse Injuries

Distal radius physeal
stress syndrome
Seen in gymnasts
Wrist pain with weight
bearing
Usually no acute injury
Xrays show widening
of the growth plate,
cysts, sclerosis
Roy et al, AJSM, 1985

Physeal Overuse Injuries

May require a wrist brace for comfort, especially if pain
with daily activities
Usually resolves with 6-8 weeks of rest
Slow progressive return to activities if clinically
improved and radiographs resolve

Distal Radius Growth Arrest

9 cases of distal radial growth arrest in gymnasts
Serial radiographs
showed
Stress-related changes
of the distal radial
growth plate
Progressed to closure
of the distal radial
growth plate before that
of the ulna

Difiori, AJSM, 2006

Classic Presentation

Medial Epicondyle Apophysitis or

Little Leaguers Elbow
Insidious onset of medial elbow pain
Progressively worsening
Exacerbated w/ throwing
Triad of Symptoms:
Localized Pain in Late Cocking &
Early Acceleration Phases
Loss of Velocity & Distance
Diminished Throwing Effectiveness

Classic Physical Exam:

Point tenderness @ medial epicondyle
5-8 degree flexion contracture
Pain w/ valgus stress, but No frank instability
+/- Swelling

Medial Epicondyle Apophysitis or

Little Leaguers Elbow
Study of 343 Taiwanese Little Leaguers:
Avg Age: 11.6 y/o
Pitchers: 58% Soreness, 63% Separation, 19% Fragmentation
Catchers: 63% Soreness, 70% Separation, 40% Fragmentation
Fielders: 47% Soreness, 50% Separation, 15% Fragmentation
Hang et al, AJSM, 2004

Treatment

Medial Epicondyle Apophysitis

Treatment:
Focuses on elimination of repetitive stress
Requires stopping all throwing activities
- Recommended minimum 6-week restriction from throwing
Ice, NSAIDs for symptomatic relief
Physical Therapy can help with loss of range of
motion

Return to Throwing:
Predicated on:
complete resolution of symptoms &
absence of tenderness on physical examination
Documented radiographic healing is not essential for return to athletics
Gradual return = Critical Strict throwing program emphasizing proper mechanics

Little Leaguers Shoulder

Delee & Drezs Orthopedic Sports Medicine, 2003

Affects proximal humerus

growth plate at the
shoulder
Related to torsional stress
during cocking and early
acceleration phase of
overhand throw
Radiographs may
demonstrate widening of
the growth plate

Little Leaguers Shoulder

Management:
Rest the throwing arm
May require complete
cessation of throwing,
or switching to another
position that requires
less throwing
Usually requires
minimum of 6 weeks

Swimmers Shoulder
Repetitive motion of swimming can cause
rotator cuff impingement
Pressure on the rotator cuff from part of the
shoulder blade or scapula as the arm is lifted
Can result from fatigue and weakness of the
rotator cuff and muscles surrounding the
shoulder blade
Treated with physical therapy,
strengthening exercises

Olecranon Stress Fracture

Seen in older adolescent thrower
Persistent posterior elbow pain aggravated by
activity
Usually no history of acute injury
Posterior elbow pain in acceleration / followthrough
Tenderness at Olecranon tip
Pain on resisted elbow extension

Radiographic Findings
Persistence of olecranon apophysis +/- widening
Must compare to opposite elbow

Case #3

Treatment of Olecranon Stress Fracture

Conservative
Rest & avoidance of throwing
Splinting, ice, elevation
Restrict throwing for minimum 6 wks

Operative
Indications
Persistent symptoms > 3-6 months of
conservative treatment
Radiographically documented failure of
apophyseal closure despite conservative mgmt

Single screw

OCD

Osteochondritis Dessicans
Focal injury to subchondral bone resulting
in loss of structural support for the
overlying cartilage

Can lead to fragmentation of

the cartilage and formation
of loose bodies

OCD

Non-Surgical Treatment
Stable Lesions:

STOP THROWING
NSAIDs
early splinting for acute symptoms
maintain range of motion
periodic radiographic follow-up
gradual return to activity when
asymptomatic and healed

OCD

Surgical Treatment
Unstable Lesions may require surgery
Arthroscopic
Drilling
Removal of loose bodies
Fixation

Lower Extremity Overuse

Injuries

Iliac Crest Apophysitis

Osgood-Schlatters
Sinding-Larsen-Johanssen
Patellofemoral Pain or Runners Knee
Shin Splints
Stress Fractures
Osteochondritis Dissecans

Pelvic Apophysitis
Occurs in runners 8-15
Iliac crest apophysitis
Pain at the top of the pelvis,
occurs bilaterally with trunk
rotation

Ischial apophysitis
Pain localized to ischial
tuberosity or sitting bone
Onset insidious

Treatment
Rest, ice, NSAIDS, stretching

Osgood-Schlatter Syndrome
Traction apophysitis of tibial
tubercle
1903: Osgood and Schlatter
published independent papers
on this clinical syndrome
Athletes 10-15 years of age
Jumping sports
Boys > girls (? Historic sports
participation)
Bilateral 25-50% of cases

Osgood-Schlatter Syndrome
Clinical Features:
Pain, swelling, tenderness
directly over tibial tubercle
Symptoms worse with running,
jumping, stairs
Wax and wane with time
Severity spectrum of pain only
after activity to constant pain that
limits sports and daily activity

Osgood-Schlatter Syndrome
Radiographic Features:
X-rays not required, usually are
normal
X-rays can show fragmentation
of tubercle or loose ossicle
separate from tuberosity

Osgood-Schlatter Syndrome
Natural History:
Self-limited over a period of 1224 months
Pain usually remits at skeletal
maturity
Prominence of tibial tubercle
persists
Small percentage of patients
have painful ossicle : surgical
excision very successful

Management of OsgoodSchlatters
Reassurance and teaching of natural history
Patients can play sports as tolerated
Treat symptomatically: relative rest , ice, hamstring
and quad stretching, neoprene knee sleeves,
NSAIDS
Corticosteroid injections are not recommended
Rarely, 2-4 week course of immobilization is
indicated for severe cases that resists simple
activity modification
Temporarily improves symptoms, does not alter
natural history

Sinding-Larsen-Johansson
Lesion
Closely related to Osgood-Schlatter
Occurs at the opposite end of the
patella tendon at attachment to patella
No apophysis is involved, tendon
attaches to patella directly
With repetitive tension, periosteum
becomes inflamed and lays down more
bone

Sinding-Larsen-Johansson
Lesion
Similar complaints of activity
related pain but located at
the end of the patella
Slightly younger patient
population ages 8-12
Treatment
Rest, ice, analgesia
Usually self-limiting
No evidence that having had OS or SLJ as a child
predisposes adults to patella or quad tendinopathy

Patellofemoral Pain Syndrome

Pain in front of the knee
Cause unclear, usually
overuse
Pain with sitting, climbing,
running

Examination
Diffuse peripatellar
tenderness
Normal knee mechanics
No joint swelling
Normal gait
Normal radiographs

Patellofemoral Pain Syndrome

Treatment
Relative rest
NSAIDS
Icing
Quadriceps strengthening
Avoidance of bent knee activities
Graduated return to activities

No role for surgery!

Shin Splints
Medial Tibial Stress Syndrome
Shin pain that produces pain
and discomfort due to repetitive
running
Pain along posteromedial border
of the tibia
Treatment: rest/ ice/ NSAIDS/
stretching
Recurrence common if return to
activity too quickly

Stress Fractures
Stress Fractures

Increasing incidence in pediatric pts

Tibial shaft most common location (50%)
Fibula (20%)
Spine (15%)
Femur (3%)
Tarsal Navicular (2%)
Metatarsals

The Stress of Running

Running 1 mile:
Force = 1.5 - 5x body weight
Stride length of 4.5 ft = 1175 steps
150 lb runner absorbs

110 tons / foot

Stress Fractures
Occasionally occur in
prepubescent pediatric
athletes
More common in
adolescent or high school
age athletes
Running sports higher risk:
Cross country, soccer,
basketball

Sport Specific Stress Fractures

Stress Fractures
Diagnosis often delayed
13.4 wks (1-70)
Vague complaints of pain

Examination
Local tenderness 65.7%
Swelling 24.6%
Pain with single leg jump

Imaging
Xrays: only 9.8% abnormal @ presentation, but usually positive if
more than 3 or 4 weeks of symptoms
Bone scan and MRI positive 100%

Stress Fracture
Usually heals with 612 weeks of rest
Some require
crutches/ brace
treatment
Usually means
missing that season
2 weeks

8 weeks

Stress Fractures
Some high risk stress fractures fail to
heal or risk progression to a complete
fracture and need surgery

Juvenile Osteochondritis
Dissecans (JOCD)
Acquired condition of the joint that affects the
articular surface and subchondral bone in pts
with open growth plates
Most commonly presents w/ vague knee pain
that is poorly localized, without history of
recent trauma
80% symptoms more than 15 months

Osteochondritis Dissecans
Skeletally immature athletes with an OCD lesion and
an intact articular surface have a potential for healing
by stopping repetitive impact loading
May require immobilization, crutches for 6-12 weeks
May take 6-18 months to heal
Skeletally mature athletes with an OCD lesion have a
poorer prognosis

Natural History
If healing does not occur
Subchondral fracture
Fragmentation of
cartilage
Full thickness defect
Ultimately loss of
fragment stability and
loose bodies

Operative Treatment
Indications
Loose bodies
Failure to improve over 6
months
Unstable lesion
Approaching skeletal maturity

Surgery
Drilling and or Fixation

Wright RW, McLean M, Matava MJ, Shively RA: Osteochondritis dissecans of the knee: Long-term results of excision of the fragment. Clin Orthop 2004;424:2

Treatment of Overuse Injuries

Most overuse injuries will heal with rest,
occasional bracing or splints, and
gradual return to activities
Very rarely require surgery
Most overuse injuries can be prevented
with proper training and common sense
Teach kids to listen to their body,
remember that "no pain, no gain" does
not apply

Recognizing Injuries
Athletes should pay close attention to
the physical limitations of their bodies
by quickly responding to pain and
allowing rest when needed
It is important to recognize injuries at
their earliest stages and to diagnose
and treat them appropriately so that
play is not impeded

Prevention of Overuse Injuries

Baseball data has shown:
Excessive throwing, measured by number
of pitches per game or pitches per season,
results in higher injury rates.
Better pitchers throw a higher number of
pitches and have higher injury rates.
Year-round participation without rest
results in higher injury rates.
Specialty pitches such as curve balls and
sliders may play a role.

Current Recommendations

Recommended Maximum Number of Pitches

Age

Max. Pitches / Game

Max. Games / Week

810

50

1112

65

1314

75

1516

90

1718

105

recommendations were modified with permission from the USA Baseball Medical & Safety Advisory
Committee in Petty et al. Ulnar Collateral Ligament Reconstruction in High-School Baseball Players
AJSM, 2004.

Petty, et al., AJSM 2004

Current Recommendations

Recommended Rest Between Pitching

Age, y

1 Day of
Rest

2 Days of
Rest

3 Days of
Rest

4 Days of
Rest

810

20

35

45

50

1112

25

35

55

60

1314

30

35

55

70

1516

30

40

60

80

1718

30

40

60

90

aRecommendations were modified with permission from the USA Baseball Medical & Safety Advisory Committee in
Petty et al. Ulnar Collateral Ligament Reconstruction in High-School Baseball Players AJSM, 2004.

Petty, et al., AJSM 2004

Current Recommendations

Age to Learn Types of Pitches

Pitch

Age, y

Fastball

Change-up

10

Curveball

14

Knuckleball

15

Slider

16b

Forkball

16b

Splitter

16b

Screwball

17b

aReprinted

with permission from the USA Baseball Medical & Safety Advisory Committee.1

Ages reflect results from a survey by the USA Baseball Medical & Safety Advisory Committee. Petty et al.
believe that these pitches should not be thrown before the player is 18 years old.
b

Petty, et al., AJSM 2004

Overuse Injuries In Baseball

Pitchers
Recent 10 year longitudinal study
followed pitchers and documented injury
rates
Pitchers who pitched > 100 innings in at
least one year were 3.5x more likely to
be injured during the study
Only 2.2 percent were still pitching by
the 10th year of the study.

Prevention of Overuse Injuries

Injury surveillance
Preparticipation Exams
Identify potential risk factors

Proper adult supervision and coaching

Teach correct technique
Teach stretching, warming up
Promote proper safety gear

Healthy diet
Calcium, vitamin D

Prevention of Overuse Injuries

Training Programs

Gradual progression: 10% rule

Varied practice
Planned rest
Cross-Training
Avoid excessive training volumes

Delaying sport specialization

One team of the same sport per season
Keep sports fun, keep perspective

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