Overuse Syndrome

When Young Athletes Push Too Hard

Print This Post Print This Post

Regardless of whether the athlete is a professional, an amateur, an Olympian, or a young recreational athlete, the number of sports injuries is increasing—but the escalation of injuries in kids is the most alarming.

James R. Andrews, MD, president of the American Orthopaedic Society for Sports Medicine

More than 30 million children in the United States between the ages of 6 and 18 years participate in organized and recreational sports, which helps keep those children fit and feeling good about themselves.[1] But according to Thomas M. DeBerardino, MD, Associate Professor of Orthopaedics at the University of Connecticut Health Center, adolescent sport-related injuries are on the rise so much that they have become a “silent epidemic.”[2] This is partly due to more young people participating in sports year-round without any seasonal breaks, which leads to increasing numbers of musculoskeletal injuries. This phenomenon, known as overuse syndrome, includes acute injuries to the muscle, tendon, and the growth plate.

The opportunities for students to participate in athletic activities have expanded to include lacrosse, field hockey, golf, cheerleading, and dance; the season has been extended to include summer camps and weekend travel teams; and many students play a different sport through each of the four seasons. But at what cost?

Related Injuries

Overuse syndrome is a relatively new phenomenon and is the result of increased participation in organized sports and fitness activities on a year-round basis, leading to injuries such as “Little League elbow,” “swimmer’s shoulder,” or “gymnast’s back.” Injuries tend to be more common during peak growth velocity, and some are more likely to occur if underlying biomechanical problems are present. The majority of sports and overuse injuries are due to minor trauma involving soft tissue injuries—injuries that affect the bone, muscles, ligaments, and/or tendons.

Some data suggest that overuse syndrome represents 50% of all pediatric sports injuries.[3,4] The underlying cause of overuse injuries is repetitive tissue microtrauma, with an inability of the tissue to keep up with the repeated injury.[5] A type of overuse injury unique to children is injury to the growth plate, an area of developing tissues at the end of long bones in children and adolescents who are still maturing. Trauma that would cause only an adult sprain may cause a growth plate fracture in a young person, possibly interfering with the normal growth of a child’s bone. These injuries to the growth plate are a type of stress fracture that often occur in the foot after training for basketball or running and usually produce pain and tenderness but no swelling.

Sports involving throwing typically cause overuse injuries to the shoulder and elbow (Little League elbow or shoulder), whereas running and jumping sports most often strain the leg from the knee to the ankle (shin splints; jumper’s knee) or the heel or forefoot (Sever’s disease, plantar fascititis). The forearm and hand are common sites for overuse injuries in sports that require gripping, such as gymnastics, golf, and tennis. Back pain may be present in athletes who routinely flex and extend the lower back, such as football linemen, gymnasts, and ice skaters. Athletes who participate in multiple sports emphasizing the same body part—such as swimmers and baseball pitchers—are at a much higher risk of overuse injuries than those who participate in multiple sports that stress different parts of the body, such as track and golf.[1]

Overuse injuries can result from an athlete’s desire to compete, parents’ desire to have their children succeed and climb the ladder to professional sports, intensive training regimens, or by an organized sport itself. While Little League baseball has standards for how many pitches can be thrown during a game (85) by 11- and 12-year-olds, the regulations don’t include warm-up pitches before the game or any pitches thrown between innings. This is somewhat alarming as research suggests that pitchers who throw more than 80 pitches per game are three to four times more likely to develop injuries that require shoulder surgery.[6] As well, young female gymnasts who train more than eight hours a week are known to have a significantly increased rate of injury of the knee, ankle, and wrist.[7]

Treating Overuse

Overuse injuries can be classified into four stages: 1) pain in the affected area after physical activity; 2) pain during the activity, without restricting performance; 3) pain during the activity that restricts performance; and 4) chronic, unremitting pain even at rest.[8] According to the American Academy of Orthopaedic Surgeons, the following signs indicate that a visit to a healthcare provider is in order[9]:

  • Inability to continue play because of pain following an acute or sudden injury
  • Decreased ability to play over the long term because of persistent pain following a previous injury
  • Visible malformation of the child’s arms or legs
  • Severe pain from acute injuries that prevent the use of an arm or leg

Prompt treatment can often prevent a minor injury from becoming worse or causing permanent damage.

The basic treatment for many simple injuries is often “RICE”—Rest, Ice, Compression, and Elevation. Depending on the injury’s severity, treatment may range from simple observation with minor changes in athletic activities to a recommendation that the athletic activity be discontinued. Some combination of medication, physical therapy, crutches or a wheelchair, strengthening exercises, and bracing may also be prescribed. If the injury is recurring or is causing persistent pain, surgery may be indicated.

How You Can Help

In March 2011, the National Athletic Trainers’ Association issued a position statement on the prevention of injuries in athletes ages 6 to 18 years.[3] The paper outlines seven recommendations to make school athletics safer thereby reducing the occurrence of overuse injuries. Two of the recommendations are directed at primary care practitioners. The first encourages you to be aware of physical risk factors that may predispose an athlete to overuse injuries: these include bowed legs, knock knees, pelvic rotation, and joints that easily move beyond their normally expected range. The second recommendation urges student athletes to undergo a pre-participation physical examination prior to beginning a new sport (or prior to the start of a new sports season), in order to screen for potential risk factors, including injury history, stature, maturity, joint stability, strength, and flexibility. You can find the forms here.

In addition to a general medical examination, you should a check a child’s balance, strength, flexibility, joint stability, range of motion, posture, and gait. Illustrations of the physical examination components can be found here. If you identify a medical or orthopedic problem, the issue is whether to disqualify the athlete from the sport or allow the athlete to play with restrictions, with or without treatment. Most athletes are healthy; only 3% to 13% require further evaluation, and the disqualification rate for 10 million annual examinations is less than 1%.[10]

You can also offer some basic recommendations from the American Academy of Pediatrics[1,11] to reduce the risk of overuse injuries:

  • Encourage athletes to have at least one to two days off per week from competitive athletics, sport-specific training, and competitive practice (scrimmage) to allow them to recover both physically and psychologically.
  • Advise athletes that the weekly training time, number of repetitions, or total distance should increase by no more than 10% each week.
  • Encourage the athlete to take at least two to three months away from one specific sport during the year and play a different one instead.
  • Emphasize that the focus of sports participation should be on fun, skill acquisition, safety, and sportsmanship rather than individual achievement.
  • Encourage the athlete to participate on only one team of the same sport during a season. If the athlete is also a member of a traveling or select team, then that participation time should be incorporated into the aforementioned guidelines.
  • If the athlete complains of nonspecific muscle or joint problems, fatigue, or poor academic performance, be alert for possible burnout. Questions pertaining to the athlete’s motivation—as well as questions regarding sports/school/life balance—may be appropriate.
  • STOP the activity if there is pain.
  • Convey a special caution to parents with younger athletes who participate in multigame tournaments in short periods of time.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases has also published injury prevention recommendations that focus on the mechanics of physical activity (Table 1).[12]



A public health campaign created by a coalition of organizations and corporations to help prevent athletic overuse and trauma injuries in kids.






Jill Shuman, MS, ELS
Published September 27, 2011



  1. Brenner JS; American Academy of Pediatrics Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. 2007;119(6):1242-1245.
  2. DeBerardino TM. Athletic injuries in the adolescent athlete. Presented at: 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS); March 2010; New Orleans, LA.
  3. Watkins J, Peabody P. Sports injuries in children and adolescents treated at a sports injury clinic. J Sports Med Phys Fitness. 1996;36(1):43-48.
  4. Dubravcic-Simunjak S, Pecina M, Kuipers H, et al. The incidence of injuries in elite junior figure skaters. Am J Sports Med. 2003;31(4):511-517.
  5. Micheli LJ, Fehlandt AF Jr. Overuse injuries to tendons and apophyses in children and adolescents. Clin Sports Med. 1992;11(4):713-726.
  6. Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011;39(2):253-257.
  7. Purnell M, Shirley D, Nicholson L, Adams R. Acrobatic gymnastics injury: occurrence, site and training risk factors. Phys Ther Sport. 2010;11(2):40-46.
  8. Mellion MB, Walsh WM, Madden C, et al. Team Physician’s Handbook. 3rd ed. Philadelphia, PA: Hanley & Belfus Inc; 2002.
  9. A guide to safety for young athletes. American Academy of Orthopaedic Surgeons Website. http://orthoinfo.aaos.org/topic.cfm?topic=A00307. Updated October 2007. Accessed September 17, 2011.
  10. Smith DM. Preparticipation Physical Evaluation. 2d ed. Minneapolis: Physician and Sportsmedicine; 1997.
  11. 2011 sports injury prevention tip sheet. American Academy of Pediatrics Website. http://www.aap.org/advocacy/releases/aprsportsinjurytips.cfm. Accessed September 16, 2011.
  12. Sports injuries. What can groups at high risk do to prevent sports injuries? Sports Injuries. National Institute of Arthritis and Musculoskeletal and Skin Diseases Website. http://www.niams.nih.gov/Health_Info/Sports_Injuries/default.asp#ra_8. Published April 2009. Accessed September 17, 2011.