Pediatric Overuse Sports Injury and

Injury Prevention
Karen M. Myrick, DNP, APRN

ABSTRACT
Participation in sports by the pediatric population has grown vastly over the years.
Overuse injuries in the pediatric population signify a signicant health care interest.
Some reports and clinical observations designate 50% of all pediatric sport-related
injuries as overuse or repetitive trauma. Furthermore, it is ventured that more than half
of these injuries may be preventable with straightforward strategies. Nurse
practitioners are well positioned to identify these injuries and implement injury
prevention in their practices.

Keywords: injury prevention, orthopedics, overuse, sports medicine

2015 Elsevier, Inc. All rights reserved.

N urse practitioners (NPs) have a solid foun-

dation of health assessment, and this article
will build on that foundation and provide
the framework of the specialty focus of orthopedic
and sports medicine to providing clinical pearls for
improving care for athletes who present with overuse
injuries. The emphasis is on the identication of risk
factors, preparticipation physical examination best
habits, proper supervision, suggestions for best prac-
tices in treatment and referral, sports alterations op-
tions, available training and conditioning programs,
and an explanation of the concept of delayed
specialization.
Characterized as microtraumatic damage to bone or
soft tissues, overuse injuries occur in structures that
have been subjected to repetitive stress without suf-
cient recovery time.1 Soft tissue comprises the muscles,
tendons, cartilage, and ligaments. In the pediatric
population, the skeletally immature physeal and
apophyseal growth cartilage is particularly vulnerable.
Injuries can occur to healthy tissue as a result of
repetitive force or the repeated application of lesser
quantities of energy to pathologic or maturing tissue or
bone.2 Overuse injuries of developing tissue include
the growth-related disorders of Osgood-Schlatter
disease (OSD), Sever disease and other apophyseal
(growth plate) injuries such as little leaguer shoulder
(humeral epiphysiolysis) and elbow (medial apophy-
sitis), and radial epiphysiolysis (gymnast wrist). Overuse
injuries resulting from recurring microtrauma and
chronic submaximal loading of tissues include stress
fractures, osteochondral defects (OCDs), and tendi-
nitis. Training errors, unsuitable technique, extreme
sports training, insufcient rest, muscle weakness and
imbalances, and early specialization in 1 sport are all
viable mechanisms for overuse injuries to occur.
Overuse injuries typically present with an insidious
onset of pain and can worsen to be present at rest and
prevent play. The Table represents a commonly used
symptom-guided grading system of overuse injuries
with a 1 to 5 scale.
RISK FACTORS
Elements that are indicated in overuse injuries are
typically multifactorial. These factors can occur as
intrinsic or extrinsic to the athlete and can also have
both overarching types of factors at the root of the
overuse. At the level of the athlete, these factors
include participation on multiple teams, participating
in year-round involvement in sports without adequate
rest, previous injury, core weakness including the hip
and trunk, and specializing in 1 sport at an early age.
Extrinsic factors that are indicated in overuse in-
juries include pressure on the young athlete in the
form of the requirements of a weekend sports tour-
nament, such as those common in the sports of
swimming, soccer, lacrosse, and baseball. These
tournaments may include 6 hours each day of play.

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Table. Symptom-guided Grading of Overuse Injuries
Injury
Severity Symptom Characteristics
Grade 1 Symptoms occur at the end of the activity or
only at the initiation and then diminish
Grade 2 Symptoms develop during activity, late onset,
diminish after activity is completed
Grade 3 Symptoms develop during activity, early onset,
and persist during the remainder of activity,
diminish after activity has ended
Grade 4 Symptoms develop during activity and limit
training frequency, intensity, or duration
Grade 5 Symptoms prevent training
Modied from Diori.3
Over a full weekend, the athlete might be involved
with playing for more than 12 hours. Other extrinsic
factors indicated in overuse injuries may also be in the
form of parental insistence, coaching pressure, and
peer or sibling competition.
Factors affecting child (younger than 11) and
adolescent (age 12-18) athletes differ. The child athlete is
at risk because of muscle imbalance and tissue immatu-
rity, and the adolescent athlete is more likely to develop
overuse injuries because of rapid periods of growth.3,4
EPIDEMIOLOGY
NPs are very likely to encounter pediatric patients who
are actively participating in organized sports. In the
United States, participating in sports is increasing
steadily. Currently, there are an estimated 30 to 40
million children who participate in organized sports
activities each year.5 Additionally, half of pediatric
patients presenting for sports medicine chief complaints
are not presenting with acute injuries but rather injuries
that are chronic in nature.1 Furthermore, approximately
50% of all pediatric sport-related injuries ensue through
overuse or repetitive trauma mechanisms.1
SELECT COMMON CLINICAL OVERUSE INJURY
DIFFERENTIALS
Upper Extremity
Child. Little Leaguer Shoulder (Humeral
Epiphysiolysis) The pathophysiology of little leaguers
shoulder is the result of the tension from repetitive
throwing in overhead athletes, which can lead to a
widening of the humeral growth plate or physis.
1024 The Journal for Nurse Practitioners - JNP
Typically, a combination of repetitive throwing,
weak physeal cartilage at growth centers, muscle
tightness associated with rapid long bone growth,
increased laxity of soft tissue structures, and decreased
development of neuromuscular movement patterns
will foster an increased risk of injury to the athlete.5
The common age for little leaguer shoulder is 11
to 15 and is typical in the throwing athlete popula-
tion. The diagnosis of humeral epiphysiolysis is made
when the athlete presents with proximal shoulder
pain with activity. When asked to try and pinpoint
the discomfort, the athlete will typically point to the
area of the humeral growth plate. Radiographs will
show widening of the proximal humeral physis and
changes in the appearance of the bone including
sclerosis, fragmentation, and changes that appear
cystic in nature.5 Figure 1 shows the ndings that are
typical for humeral epiphysiolysis. Treatment is
geared toward rest, including cessation of all
throwing activities. Follow-up with radiographs is
indicated for the determination of healing and
improvement. An important pearl, yet frequently
overlooked, is that the pediatric patient needs to
be reminded of what constitutes throwing. Some
will take this literally to mean a baseball or a
softball. However, playing catch, throwing a
football or Frisbee, fetch with their dog, and even
Figure 1. Radiograph of Little Leaguer Shoulder
(Humeral Epiphysiolysis).
Volume 11, Issue 10, November/December 2015
a good-natured snowball ght all include throwing
and must be avoided.
Suggestions for best practices include increased
clinician suspicion based on the history of the athlete,
and the history of the present illness will improve ac-
curate diagnosis and treatment of humeral epi-
physiolysis. Overhead athletes with complaints of
aching and tenderness on physical examination over the
growth plate of the humerus should be considered for
this diagnosis and evaluated with radiographs. Taking
comparison x-rays of the contralateral and noninvolved
side may aid the less experienced clinician in seeing the
difference in the growth plates. Typically, athletes pre-
sent with mild to severe posterior tightness and may also
show weakness in the midback, contralateral hip, and
trunk in general when evaluated. These areas should all
be a focus for a sound strength and conditioning pro-
gram once symptoms reside, and a formalized physical
therapy prescription is recommended.
Panner Disease The pathophysiology behind
Panner disease is a failure within the ossication
center of the capitellum within the elbow.6 The
problem is not known to be caused from reduced
blood ow or from an infarction. There are many
theorized mechanisms in the literature.
Typically, the child is in the age range of 7 to 10
years old, and the presentation is a history of dull,
aching elbow pain that is worsened with activity and
improves with rest. The aggravating activity is
generally throwing. Diagnosis is made with x-rays; in
Figure 2, there is an area delineated with an arrow
showing an irregular surface on the capitellum.
Treatment is aimed at complete rest from throwing.
Suggestions for best practices include referral to an
orthopedic or sports medicine specialist once the
disease is suspected. Recalling that this disease affects
primarily the younger athlete, suspicion needs to be
high on the radar of the practicing clinician in order
to make an accurate diagnosis and prompt referral.
There is a high chance of long-term consequences
and progression of the disease.7 Certainly, to decrease
incidence, adherence to pitch counts and adequate
rest are prudent for the athlete and for those involved
with the athletic population to enforce.
Adolescent Patients. OCD Elbow The
pathophysiology of OCD comes from throwing
activities that involve strain across the elbow joint,
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Figure 2. Radiograph of Panner Disease (OCD of the
Capitellum).
stretching the ulnar side of the joint and compressing
the radial-capitellar joint. It is theorized that there
is a disruption in subchondral blood ow to the
capitellum from repetitive compressive forces as the
pathophysiology behind OCD.5,7
The age for patients with OCD is typically 12 to
16 years old. This is in comparison with Panner
disease, which affects the younger athlete, but also
presents with elbow pain with a similar symptom-
atology. OCD usually occurs when the bones have
completed their growth phase. Throwing athletes
often present with pain during throwing, and upper
extremity weight-bearing athletes present with pain
during weight bearing. A common clinical complaint
is one of locking or catching of the joint caused by
loose bodies from the OCD. Gymnasts are a com-
mon group of athletes in the upper extremity
weight-bearing category. There is frequently a his-
tory of increased throwing activity, and on exami-
nation the athlete has pain at the lateral elbow with
both extremes of motion (exion and extension and
occasionally supination and pronation). There may
be changes on plain radiographic examination,
showing a lucency in the area of OCD. However,
diagnosis is conrmed with magnetic resonance im-
aging (MRI), which indicates signal changes around
the lesion.7 Figure 3 shows the increased signal on
T2-weighted images. MRI will not only conrm
diagnosis but also will aid the orthopedic specialist in
the treatment plan, determining the extent of the
defect and the condition of the surrounding cartilage
The Journal for Nurse Practitioners - JNP 1025
Figure 3. MRI of OCD of the Elbow (OCD of the
Capitellum).
and bone. Treatment consists of relative rest with the
stress of throwing removed and a gentle increase in
range of motion and exibility when pain has
decreased. Relative rest means that the athlete may
continue some strengthening and cardiovascular ex-
ercises but needs to remove the stress of throwing
from the upper extremity.
Suggestions for best practices include being aware
of the high potential for long-term consequences;
therefore, a referral to an orthopedic or sports med-
icine specialist is recommended. The symptoms of
arm pain, fatigue, and decreased throwing perfor-
mance need to be recognized by athletes, coaches,
parents, and medical personnel as early warning signs
of potential overuse injuries in pediatric athletes.1 If
the athlete is in fact a pitcher, decreasing the volume
of pitches is recommended along with early
recognition of risk factors such as generalized laxity
and hypermobility, which should be discovered
during the preparticipation physical examination.1
Ulnar Collateral Ligament Tear The pathophysi-
ology involved with ulnar collateral ligament (UCL)
tears rests on activities that typically involve strain
across the elbow joint, stretching the ulnar side of the
joint and compressing the radial-capitellar side. In the
1026 The Journal for Nurse Practitioners - JNP
younger athlete, the potential for muscle imbalance is
high; particularly upper/midback and core weakness,
including trunk and hip weakness, may play a role in
increasing the forces across the elbow when
throwing. This relates to the periods of growth with
bones typically growing at a faster rate than the
supporting and surrounding soft tissues, including
muscles, ligaments, and tendons. Additionally,
athletes may pitch or throw when fatigued, and this
increases the risk for injury. Throwing when fatigued
decreases the power from other parts of the body,
such as the trunk or core or lower extremities, and
increases the strain across the elbow itself.
The diagnosis of a UCL tear is made when the
history and physical examination clearly show medial
arm pain at the elbow, typically a low-grade ache,
and possibly 1 traumatic throw when the athletes
may perceive the injury occurring. Many athletes will
know and painfully recall the 1 pitch or throw that
culminated in the cessation of their play. The ex-
amination will show pain over the length of the UCL
laxity with valgus stressing of the joint and a positive
milking maneuver.
Suggestions for best practices include obtaining
MRI of the elbow joint and referral to an orthopedic
and sports medicine expert. MRI will show discon-
tinuity of the bers of the UCL, as shown in
Figure 4. The likelihood for surgical repair is high in a
complete tear, and careful examination and follow-
up are keys for healing.
Medial Apophysitis (Little Leaguer Elbow) The
medial epicondyle apophysis is under strain with
overhead throwing motions.4 These biomechanics
allow for increased strain across the apophysis of the
skeletally immature athlete. Repetitive strain without
adequate rest and muscle imbalance may lead to
apophysitis.
Pain that is worse with throwing activities and
better with rest is typical in the history of the present
illness for patients with medial epicondyle apophy-
sitis. Diagnosis is typically made with clinical exam-
ination only. However, radiographs can be helpful to
show hypertrophy, widening, and fragmentation of
the apophysis, especially with a comparison view of
the contralateral side.7 Figure 5 shows radiographic
ndings with widening noted of the medial
epicondyle apophysis.
Volume 11, Issue 10, November/December 2015
Figure 4. MRI of an Ulnar Collateral Elbow Tear.
Keeping the athlete from all throwing activities
until there is no pain typically consists of a 4- to
6-week initial trial of rest. Upon completion of this
rest period, a follow-up appointment is encouraged.
Dependent on the history and physical examination
ndings at that follow-up visit, as with other over-
head athlete overuse injuries, a solid strength program
focusing on hip, trunk, and back musculature is
paramount.
Gymnast Wrist (Distal Radial Epiphysiolysis) In a
gymnast, the dorsiexed wrist position is a common
position for many stunts and activities. This extreme
position coupled with repeated weight-bearing
activities cause progressive disruption in the
ossication at the distal epiphysis of the radius in
the wrist.4
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Figure 5. Radiograph of Little Leaguer Elbow (Medial
Apophysitis).
Physical examination along with a thorough his-
tory will likely lead the clinician to the diagnosis.
Radiographs may not be necessary for diagnosis but
can be helpful in documenting progression or
severity. In order to rule in epiphysiolysis and rule
out tendinitis, a thorough evaluation of range of
motion and a strict evaluation of tenderness to
palpation are essential. The ndings of normal range
of motion and pain only with axial loading of the
wrist are positive in epiphysiolysis and negative with
tendinitis.4 Pain with axial loading is a common
physical examination nding for fractures of
most bones.
Suggestions for best treatment include relative
rest, specically from any weight-bearing activities.
Depending on the level of the athlete and the nature
of their compliance, immobilization may be a
necessary strategy to ensure rest and protection.
Torso
Spondylolysis. Repetitive spine extension is com-
mon in sports such as basketball, volleyball, gym-
nastics, and gure skating. The pathophysiology of
spondylolysis includes recurring loading of the
vertebral bodies, especially with spine extension; in
many sports, it may cause a defect in the posterior
element, the pars interarticularis.
The Journal for Nurse Practitioners - JNP 1027
 The diagnosis of spondylolysis is made with direct
visualization of the pars interarticularis on radio-
graphs, observing the oblique images.8 The Scotty
dog sign is shown on these radiographs when
spondylolysis is present. Figure 6 represents this
Scotty dog nding on radiographs. This nding is uncommon. Findings on radiographs typically show
likened to the collar or a break in the dogs neck.8
Treatment is relative rest of the spine, with
elimination of extension activities. Bracing may be
indicated, and eventual rehabilitation with a focus on
core strengthening will be in the treatment plan.
Suggestions for best practices include keeping the
suspicion for spondylolysis among adolescent athletes
with low back pain as a chief complaint high and
even rst on the differential diagnosis list. The inci-
dence has been reported to be as high as 47% of
athletes presenting with low back pain compared
with an incidence of only 5% in adult controls.9 Of
note is that spondylolysis may occur at any vertebral
level, but 85% to 95% of pediatric lesions have been
found to occur at the L5 vertebra.10
Lower Extremity
Pediatric Patient. Calcaneal Apophysitis (Sever
Disease) The cause of Sever disease is traction of the
Achilles tendon on the calcaneal ossication center,
and it is the most common apophysitis.11 The rapid
bone growth, coupled with the slower growth of the
soft tissues, places this area at high risk.
Patients will generally complain of pain that is
worse during running, and, commonly, the sport is
soccer. The age of presentation is generally 9 to 13,
Figure 6. Radiograph of Spondylolysis (Scotty Dog
Sign).
1028 The Journal for Nurse Practitioners - JNP
and it is earlier in females compared with their male
counterparts because of growth spurt timing.4
Suggestions for best practices include treating the
athlete bilaterally. Although the patient will generally
complain of unilateral pain, bilateral ndings are not
widening of the calcaneal apophysis, as shown in
Figure 7. Treatment should be considered for both
lower extremities. Although not commonly
performed, casting the athlete for a week or longer
has been effective. Flexibility should be a focus, with
a particular emphasis on gastrocnemius/soleus.
OSD Traction on the tibial tubercle ossication
center by the patellar tendon (part of the extensor
mechanism) is the causative factor in OSD. This
traction occurs at the physis and at the insertion
of the extensor tendon.
Pain that is worse with running and jumping ac-
tivities and better at rest along with a painful bump
over the tibial tubercle are the trademarks of OSD.
Figure 7. Radiograph of Sever Disease (Calcaneal
Apophysitis).
Volume 11, Issue 10, November/December 2015
Radiographs demonstrate widening of the tibial tu-
bercle physis, as shown in Figure 8. Comparison
views may be helpful to either conrm the diagnosis
or educate the patient and family but are
not necessary.
Suggestions for best practices, although not
common treatment, include placing the athlete in a
cylinder cast and allowing ambulation. This cast is the
length of the proximal third of the upper leg to the
distal two thirds of the lower leg. This allows for rest
of the ossication center from the extensor mecha-
nism traction. A caution is that only 1 week should
be considered for the length of treatment, and the
risk and benets need to be carefully weighed. It is
Figure 8. Radiograph of OSD (Proximal Tibial Avulsion).
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possible to have a stiffness result, which typically is
overcome quickly in the pediatric population.
Adolescent Patient. Shin Splints (Medial Tibial
Stress Syndrome) The actual pathophysiology at the
root cause of shin splints is not well understood. It is
thought that discomfort arises from repetitive strain
on muscles that are weak in the lower extremity,
with bending forces of the tibia.12
Frequently, female runners who are inexperi-
enced, have a higher body mass index, and have at
feet are common presenting risk factors. Diagnosis is
made by clinical history and examination, with
tenderness to palpation over the posteromedial tibia
being the hallmark.
Suggestions for athletes include slow increases in
activities, generally no more than 10% a week.
Appropriate and well-tted shoe wear is extremely
important for support. Strengthening should also be a
focus with an emphasis on the hip and upper leg.
Stress Fracture When the forces applied to a bone
are not sufciently coupled with adequate rest and/or
nutrition, a stress fracture may occur. It is typical for a
combination of these 2 factors to be present in the
patients history of the present illness. Common sites
for a stress fracture include the bula, the distal tibia,
and the metatarsals.
The diagnosis for stress fracture will be made by
high clinical suspicion from the athletes history of
the present illness coupled with imaging. Imaging
should begin with radiographs, but stress fractures
often are not visualized without MRI.13 Treatment
for stress fractures includes rest until pain has resolved
and may include follow-up imaging. Immobilization
may be required for cure, and each individual case
will need to be considered, with risks and bene-
ts weighed.
Jumpers Knee (Patellar Tendinitis) Patellar tendi-
nitis includes a spectrum of pathology from chronic
degeneration to partial tearing.14 Repetitive stress on
the patellar tendon from running, jumping, and
kicking coupled with decreased exibility and rapidly
growing tissues place athletes at a higher risk for
patellar tendinitis.
The diagnosis of patellar tendinitis is made in the
jumping, kicking, or running athlete when the chief
complaint is anterior knee pain over the tendon,
The Journal for Nurse Practitioners - JNP 1029
worse with activity and better with rest. The treat-
ment is relative rest and avoidance of the aggravation
of the tendon with activities that exacerbate the
condition. Improving exibility, especially of the
quadriceps, will help to prevent recurrence.
Suggestions for best practices include keeping a
high suspicion for patellar tendinitis in patients who
are athletes who tend to jump, kick, and run. Patellar
tendinitis should be considered early and heavily
weighted in the differential diagnosis possibilities.
Evaluation of the athlete for overuse and exibility
imbalances will assist in early recognition or
prevention.
Heat-related Illness As a condition of overactivity,
heat-related illness may occur in the pediatric
population. Heat-related illnesses are a result of the
inability of the body to respond to the elevation of
body temperature. There is an imbalance in the body
temperature elevation and the increased need for the
circulatory system to adapt appropriately to exercise
and therefore regulate internal temperatures.15 Heat-
related illnesses occur on a continuum from heat
cramps to heat exhaustion to heat stroke. Tightening
and muscle spasms characterize heat cramps.
Commonly, heat cramps are preceded by heavy
perspiration and large electrolyte losses.16 Treatment
for most variations of heat-related illness is geared
toward cooling the athlete, gentle stretching, and
electrolyte replacement with sports drinks or other
easily and quickly digested sources of sodium. Heat
exhaustion presents as profuse sweating, dehydration,
fatigue, lightheadedness, rapid pulse, and low blood
pressure.15,16 Treatment should include cooling the
athlete with legs elevated; application of cool, wet
towels; drinking cool uids; and monitoring of vital
signs.15 With heat stroke, the athlete will have an
elevated body temperature (104 F or higher). They
may have red, hot, dry, or moist skin. Vomiting can
occur, and athletes may be incoherent or lose
consciousness, have bradypnea, and possibly have a
weak pulse.15 Because shock, convulsions, coma, or
death are possible consequences, treatment consists of
life support, rapid cooling by any means possible, and
involving the emergency medical system.15,16
Prevention is of extreme importance in heat-
related illness. Heat stroke has been found to be even
1030 The Journal for Nurse Practitioners - JNP
more preventable in high school athletes than the
general population.15 With athlete evaluation with
adequate preparticipation physical examination,
preparation for sports with acclimatization protocols,
and avoidance of excess exercise in hot environments,
the number of heat-related illnesses could be largely
eliminated in the US.15
DISCUSSION
Preventing pediatric sports injuries includes the
assessment of several variables and the education and
implementation of practices that have been proven to
be effective. Recommendations for prevention on
the individual level include using a strategy of well-
rounded training and conditioning, including cross
training and adequate time off from the sport (1-2
days a week and 2-3 months a year). Furthermore,
delaying specialization in any one sport has been
recommended, emphasizing instead on a focus of
seeking lifelong tness.
From a coaching perspective, recommendations
for prevention include a focus on wellness and
learning skills, not just the competition of the sport
and a focus on winning. Proper supervision would
include adhering to pitch counts and providing
accurate and astute injury prevention through proper
mechanics and surveillance of their young athletes.
NPs can play a large role in prevention through
performing an adequate preparticipation physical
examination and taking every opportunity to
identify overuse and through education. An
adequate preparticipation physical should include
obtaining a physical activity history and a thorough
physical examination and taking the opportunity to
promote health participation and preventive mea-
sures. The opportunity to educate on all levels (ie,
parents, athletes, and coaches) is well within the
scope of NP practice. NPs are also uniquely posi-
tioned for a role in advocating for advisory board
oversight of weekend athletic tournaments, the
development of educational opportunities, and
policy making.
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14. Tuong B, White J, Louis L, Cairns R, Andrews G, Forster B. Get a kick out of
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May 10, 2015.
Karen M. Myrick, DNP, is an assistant professor of nursing and
a nurse practitioner at the Quinnipiac University School of
Nursing in Hamden, CT. She can be reached at karen.
myrick@quinnipiac.edu. In compliance with national ethical
guidelines, the author reports no relationships with business or
industry that would pose a conict of interest.
1555-4155/15/$ see front matter
2015 Elsevier, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2015.08.028
The Journal for Nurse Practitioners - JNP 1031