A New Youth Epidemic?

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July 2005

By Jennifer Swanson, DPT

Sport specialization can lead to overuse injuries in young athletes.

A record eight high school seniors were drafted in the first round of the 2004 NBA draft—almost double the number of college seniors selected in the same round. That same year, Freddy Adu entered the ranks of professional soccer, at a mere 14 years of age. There are similar stories in other sports as well, with young sports prodigies excelling in tennis, golf, gymnastics, and swimming, to name just a few. These elite youth athletes are the role models who today’s children aspire to be, and it is this level of success that many hope to someday attain.

In an era in which alleged steroid use has taken a leading role, a more pressing issue needs to be considered. During the past several decades, the opportunities for children to participate in organized sports have grown significantly, with more than 30 million children and adolescents involved in athletics in the United States each year. There are many benefits to participation in organized sports programs, as they provide youth with opportunities to interact with their peers, improve their self-esteem, acquire leadership skills and self-discipline, develop their motor skills, and improve their overall level of fitness and conditioning.¹ However, this increased participation is not without risk, as it has been paralleled by an increase in sports-related injuries in both the pediatric and adolescent populations. According to the National SAFE KIDS Campaign, each year an estimated 3.5 million injuries are sustained by children under the age of 15 while playing sports or participating in recreational activities.² Contact sports hold a tremendous potential for injury, but with the advent of sports specialization in a single sport year-round, overuse injuries are becoming increasingly prevalent.

Today’s win-at-all-costs sports culture fosters an environment in which it is becoming more common for young athletes to specialize in a single sport of choice, competing far beyond the traditional season. For young athletes to excel in sports in this ultracompetitive environment, they are forced to train for longer durations, at increased levels of intensity, and, perhaps most alarming, at earlier ages. Combined involvement in school sports teams, club programs, sports camps, and private instruction has provided these young athletes with opportunities to train and compete far beyond each individual sports season. With year-round participation in a single sport, however, there is inadequate recovery time for bones, cartilage, tendons, and ligaments to adapt to the repetitive stresses resulting from running, jumping, twisting, or throwing, thus placing athletes who are still growing at a greater risk of injury.³

OVERUSE INJURIES
In previous decades, overuse injuries were nearly unheard of in pediatric and adolescent athletes. However, with the recent trend toward sports specialization and its subsequent emphasis on repetitive movement patterns, there has been a clear recognition of what many deem as changing injury patterns in the young athlete.⁴According to recent data, 30% to 50% of all pediatric sports injuries have been attributed to overuse.⁵ Injuries that were once typically seen only in adults are now present in increasing numbers of adolescents; and, thus, acute injuries including tendinitis, bursitis, and stress fractures are being seen in this age group with increasing frequency. In addition, there are certain overuse sports injuries exclusive to child athletes that develop as a consequence of the bone softness and relative tightness of the ligaments and tendons during growth spurts.⁶

Young athletes are particularly prone to sustaining musculoskeletal injuries as a result of increased demands placed on the immature growing skeleton at a time in which it is most vulnerable. The open growth plates become more susceptible to stresses during adolescent growth spurts, with injuries occurring at the epiphyseal plate, the articular joint surfaces, and the apophyses. Joint tightness, inflexibility, and dynamic muscle imbalances often can develop when bones lengthen at a greater rate relative to the muscle-tendon units. This growth discrepancy between bone and soft tissue may also increase traction on the apophyses and stress the joint surface, all of which lead to an increased risk for overuse injuries. With minimal time to heal or recover from repetitive microtrauma, inflammation, pain, and deformity can occur about the joints in both the upper and lower extremities and the spine.

Acute physeal fractures are common during adolescence, as the ligaments and joint capsule are an estimated two to five times stronger than the growth plate during this time period. Thus, it is more likely for a young athlete to sustain an injury to their bony structure rather than to their soft tissue, which is opposite to what is seen in an adult. Apophyseal injuries are relatively common among children who are active, and include conditions such as Osgood-Schlatter and Sinding-Larson-Johansson at the knee or Sever’s disease at the calcaneus.⁷These injuries result from traction-induced microtrauma at the tendon-bone attachment. Contributing factors include the weakness of cartilage at the growth plate relative to the tendon, poor flexibility, and increased traction on the apophyses during the adolescent growth spurt. Physeal injuries may produce partial or complete growth arrest and thus must be treated appropriately with this consideration.

FACTORS CONTRIBUTING TO OVERUSE INJURIES
The daily repetition required to perfect sport-specific skills often leads to injuries, as the same skills are practiced over and over again. These repetitive-movement patterns exclusively strengthen specific areas of the body at the expense of others. Children who play more than one sport tend to get a more balanced workout, but they also have the potential to sustain overuse injuries. Sports readiness, the time in which a child has attained the necessary motor, physical, cognitive, social, and adaptive ability to meet the demands of a particular sport, is an important concept to consider when managing young athletes.⁸ Therefore, it is critical for children to gain experience in a wide array of activities, providing them with exposure to different movement patterns and allowing them to develop age-appropriate skills.

It is important to remember that children are not miniature adults. Youth training programs deserve special consideration, as there are issues unique to the immature musculoskeletal system. As mentioned earlier, young athletes have a higher susceptibility to injury from repetitive compression, tension, torsion, or shear stresses on bone, ligaments, tendons, or cartilage at junctional areas. Therefore, training programs designed for adults are not appropriate for young athletes and must be modified accordingly.

Parental involvement is on the rise in youth athletics as well. However, this too has the potential to lead to an increased incidence of overuse injuries, as many of these parents promote excessive training frequency and intensity in hopes of their child securing a college scholarship or, in some cases, a professional contract. Other motivating factors include the possibility of living out one’s own personal dreams, or even simply gaining another “slash” in the win column.

COMMON SPORTS INJURIES
Overuse injuries typically develop over time as a consequence of prolonged, repetitive motion or impact. The sports most commonly implicated in overuse injuries include baseball, softball, gymnastics, swimming, and running.⁹ Sports requiring repetitive overhead activities are typically associated with injuries sustained to the shoulder and elbow. Injuries to the hip, knee, ankle, and foot, in contrast, are often attributed to running and jumping sports due to the stresses related to impact on the lower extremities. The forearm and wrist are common sites for overuse injuries in sports as well, particularly in those requiring gripping, such as tennis, golf, and gymnastics.

Overhead-throwing sports such as baseball, volleyball, and tennis are characterized by a large arc of motion. Repetitive movements into external rotation and horizontal abduction, combined with an eccentric loading phase, place the athlete at risk for a wide array of injuries, including internal impingement, rotator cuff tendinitis, and proximal humerus apophysitis. The latter, better known as “Little Leaguer’s Shoulder,” occurs when the growth plate or physis is overstressed by repetitive throwing, causing increased pain and disability.

Repetitive valgus stress on the elbow during overhead-throwing sports results in lateral compression, medial instability, and shear forces on the olecranon, with associated injuries including medial epicondyle avulsions, stress fractures of the olecranon, and osteochondritis dissecans of the capitellum and radial head.¹⁰ While injuries sustained to the elbow tend to be age-dependent, recent evidence is beginning to show support for medial collateral ligament tears in 13- and 14-year-old athletes, an injury traditionally seen in older athletes who participate in throwing sports.

Shoulder injuries are extremely common in swimmers, responsible for an estimated 90% of the injuries requiring them to seek medical attention.¹¹ “Swimmer’s Shoulder” is the catch-all phrase used to describe the injuries in these athletes related to impingement, laxity, and overuse. As a year-round sport, practices demand upward of 10,000 to 15,000 yards per day, equivalent to an average of 16,000 arm revolutions per week and more than 1 million strokes annually. Swimming is characterized by a combination of horizontal adduction and internal rotation, with repetitive movement into the impingement zone. Overdevelopment of anterior musculature is common, as 75% of the strokes emphasize these structures and result in muscle imbalances, which can lead to increased translation and chronic subluxation.¹¹

Overuse injuries are common among gymnasts as well, with repetitive loading responsible for an increased risk of injury at the spine, elbow, and wrist. The repetitive loading associated with tumbling and bar work can injure the distal radial growth plate of the wrists.¹² In terms of the spine, young female gymnasts are four times more likely to develop spondylolysis, a stress fracture of the pars interarticularis of the lumbar vertebral body. If left untreated, this fracture can lead to displacement and slipping of one vertebral body over the other, leading to spondylolisthesis.

TREATMENT
The field of pediatric and adolescent sports medicine is evolving as well in response to these changing injury patterns. Unlike adult sports medicine, previous treatments addressing injuries sustained to the musculoskeletal system were typically much more conservative among patients in this age group. With the emergence of overuse injuries in these young athletes, however, the focus has shifted and a much more aggressive approach is being utilized to return them to full activity without risking further injury.⁴

Relative rest is a key component during the initial phase of treatment, as it is essential to protect the injured tissues from repetitive loading by temporarily modifying activities. The amount of rest necessary to allow healing to occur is dependent on the severity of the injury itself. Modalities including ice and heat can be used to help modulate pain and reduce inflammation. Gentle range of motion and flexibility exercises can be implemented into the rehabilitation program as tolerated. Strengthening is emphasized in the intermediate phase of treatment in an attempt to restore muscle balance and enhance dynamic stability. Sport-specific functional training is incorporated during the advanced phase in preparation for return to full activity. Proper body mechanics and technique are emphasized as stresses are gradually reintroduced in an attempt to prevent reinjury.

PREVENTION
An increased level of participation in youth sports has been accompanied by an upsurge in sport specialization and subsequent elite levels of training and competition.¹³ This increased level of participation is not without its drawbacks, however. The recognition of previously undescribed injuries is a realistic possibility, as different groups of individuals are now involved in athletic activities to which they were not previously exposed.⁴ New patterns of injury may be emerging in this age group as well, in part due to the large influx of girls into sports. In the past, overuse injuries such as Osgood-Schlatter disease have been predominant among young active males. It remains to be seen, however, as to whether these ratios will be changing. The timing of the adolescent growth spurt is another key issue related to injury prevention, as it differs across genders. The mean adolescent growth spurt occurs at approximately 10 years of age for girls, whereas this maturation occurs 2 years later in boys, at an average age of 12. Injury-prevention programs must keep this in mind when targeting at-risk individuals.

Evidence suggests that injuries sustained during adolescence may also be responsible for problems surfacing later in life. With an increased incidence of overuse injuries in adolescence, it is likely that the curve associated with the onset of degenerative changes will be pushed up, such that impairments typically present in the fifth or sixth decade would begin prematurely, possibly as early as when our children are preparing to go off to college.

Heavy training loads, early sport-specific training, inadequate recovery periods, and improper conditioning are all contributors to the growing epidemic related to overuse injuries. The American College of Sports Medicine estimates that 50% of overuse injuries in children and adolescents are preventable.¹⁴ Therefore, training programs should emphasize a gradual progression that focuses on general fitness, conditioning, and flexibility, while monitoring both intensity and volume. It is important to recognize that motivation and the ability to focus on safety will be influenced by each child’s level of maturity, peer pressure, and self-esteem. Preparticipation screening should be advocated for all children involved in organized athletics to help identify athletes at risk for injury. These screenings are multipurpose, as they can also be used to assess maturity, skill level, and motivation for the sport itself. Proper supervision and coaching, combined with age-appropriate activities, may also help reduce injury rates among the pediatric and adolescent populations. Finally, it may be beneficial to closely monitor training during the adolescent growth spurt; and in some cases, it may be appropriate to temporarily modify training during this time period, particularly among individuals at risk for injury. Success in sports extends far beyond the basketball court or the swimming pool, and it is our job as health care professionals to ensure that such opportunities continue for today’s youth.

Jennifer Swanson, DPT, is a staff physical therapist and sports physical therapy fellow with Centers for Rehab Services at the UPMC Center for Sports Medicine, Pittsburgh.

REFERENCES

DiFiori JP. Overuse injuries in children and adolescents. Phys Sports Med. 1999; 27:75.

National SAFE KIDS Campaign (NSKC). Sports Injury Fact Sheet. Washington (DC): NSKC, 2004. Available at: www.safekids.org. Accessed on April,17, 2005.

Hughes P. Kids and sports: How much is too much? Available at: http://www.smcma.org/Bulletin/BulletinIssues/March05issue/Kids&Sports.html . Accessed on April 17, 2005.

Outerbridge AR, Micheli LJ. Adolescent sports medicine: changing patterns of injury in the young athlete. Sports Medicine and Arthroscopy Review. 1996;4:93-98.

Dalton SE. Overuse injuries in adolescent athletes. Sports Med. 1992;13(1):58-70

Micheli L. Overuse injuries: the new scourge of kids sports. National Centers for Sports Safety. Available at: http://www.sportssafety.org/Articles. Accessed on April 17, 2005.

Peck DM. Apophyseal injuries in the young athlete. Am Fam Physician. 1995;51(8):1887-1888, 1891-1895.

Patel D, Pratt HD, Greydanus DE. Pediatric neurodevelopment and sports participation: when are children ready to play sports? Ped Clinics N Amer. 2002;49(3):505-531.

American Academy of Pediatrics—sports injuries a growing problem in kids. “Kids’ Health” supplement in the October 18-20, 2002 weekend edition of USA Today.

Hughes PE, Paletta GA Jr. Little Leaguer’s Elbow, medial epicondyle injury and osteochondritis dissecans. Sports Medicine and Arthroscopy Review. 2003;11:30-39.

McMaster WC. Assessment of the rotator cuff and a remedial exercise program for the aquatic athlete. Medicine and Science in Aquatic Sports. 1994;213-217.

Albanese SA, Palmer AK, Kerr DR, et al. Wrist pain and distal growth plate closure of the radius in gymnasts. J Pediatr Orthop. 1989;9(1):23-28.

Anderson SJ, Griesemer BA, Johnson MD, et al. Intensive training and sports specialization in young athletes. Pediatrics. 2000;106:154.

Current comment from the American College of Sports Medicine: The prevention of sport injuries of children and adolescents.
Med Sci Sports Exerc. 1993;25(suppl 8):1-7.

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July 2005