Pediatric Injuries

Overuse Injuries in Children

Anatomy

Growth plates are the areas of developing cartilage where bone growth occurs in children. The growth plates are weaker than the nearby ligaments and tendons. A child's muscles, ligaments, tendons, bones and growth plates are still growing, and that growth is generally uneven. Bones grow first, which pulls at tight muscles and tendons. This uneven growth pattern makes younger athletes more susceptible to muscle, tendon and growth plate injuries.

Description

Sports participation promotes the physical and emotional well-being of children while encouraging a lifelong habit of exercise. Although the benefits of athletic activity are significant, young athletes are at greater risk for injury than adults because they are still growing.

Doctors have begun to see a significant increase in overuse injuries in children during recent years. Typically, these injuries are associated with activity in sports ranging from baseball and basketball to track, soccer and gymnastics. Some overuse injuries are unique to a certain sport, such as throwing injuries of the elbow and shoulder that are prevalent in baseball players, or shoulder injuries that are associated with swimming. The most common overuse injuries involve the knee and foot.

Overuse injuries occur gradually over time, when an athletic activity is repeated so often that the affected areas of the body do not have enough time to heal between activities. This can result in injuries that impair or disrupt normal bone growth, and may lead to long-term health problems.

Cause

In the past, children changed sports throughout the year along with the seasons. Today, as organized youth athletics has continued to grow in popularity, it is common for some children to play on more than one team at the same time while others participate in a single sport, all year long. This repetitive use of the same muscle groups places unchanging stress to specific areas of the body, leading to muscle imbalances that, when combined with overtraining and inadequate rest periods, can put children at serious risk for overuse injuries.

Symptoms

Coaches and parents should be aware of common signs and symptoms of overuse injury, including:

• Pain that often increases with activity, and cannot be tied to an acute injury (such as from a fall)
• Swelling
• Changes in form or technique
• Decreased interest in practice

When a young athlete repeatedly complains of pain, a period of rest from the sport is necessary. If the pain persists, it is important to seek proper medical treatment. To ensure the best possible recovery, athletes, coaches and parents must all follow safe guidelines for returning to the game.

Common Overuse Injuries in Children

• Sever's disease—One of most common causes of heel pain in children, Sever's disease (also known as osteochondrosis or apophysitis) is an inflammatory condition of the growth plate in the heel bone (calcaneus)—typically caused by repetitive stress of the foot striking the ground during running, jumping or other activities. Sever's disease often occurs during adolescence when children hit a growth spurt. Although recurrence is not unusual, properly supportive footwear may help prevent it. Once a child is fully grown and the growth plate has hardened into bone, Sever's disease will not return.
• Osgood-Schlatter disease—When a child participates in running, jumping and other sports-related activities, repetitive movements can stress the patellar tendon where it attaches to the kneecap, leading to inflammation, swelling, and tenderness. A child with Osgood-Schlatter disease has pain at the front of the knee due to inflammation of the growth plate (tibial tubercle) at the upper end of the shinbone (tibia), where the tendon from the kneecap (patellar tendon) attaches to the bone.
  
  Treatment may include: stretching exercises, nonsteroidal anti-inflammatory medication, limiting exercise activity until pain resolves, and possibly immobilization with a cast or brace if pain interferes with walking and daily activities. Symptoms typically disappear after the adolescent growth spurt, around age 14 for girls and age 16 for boys. However, If Osgood-Schlatter disease is not allowed to heal properly, more severe problems such as a break in the tubercle bone may occur, requiring the child to refrain from sports for a prolonged period of time.
• Jumper's Knee—In growing children, the patella tendon attaches to the growth plate of the patella (kneecap). When painful symptoms, ranging from mild to severe, occur where the patellar tendon attaches to the patella, they are referred to as Jumper's knee. This condition is most common in children who are active in basketball, volleyball or other sports that involve jumping, but it can also occur in children who participate in almost any sport.
  
  Whether the problem stems from the tendon or growth plate, the child may require an appropriate period of rest from the sport to allow recovery and prevent additional injury. Your physician may recommend nonsteroidal anti-inflammatory medication to relieve painful symptoms, as well as application of an ice pack for a few days, until the pain begins to go away.
• Throwing injuries in the elbow—Repetitive overhand throwing, such as pitching a baseball, can create stress on the growth areas of a child's immature elbow and if overdone, may cause excessive inflammation of ligaments, cartilage and growth plates. Medial apophysitis and osteochondritis dissecans are among the common elbow problems seen in active children. Throwing injuries to the elbow in children most commonly occur in pitchers, but can be seen in any child who participates in repetitive overhand throwing.
• Stress fractures—When muscles become fatigued and transfer the overload of stress to bones, a stress fracture can occur. Bone is a living tissue and is constantly in a balanced cycle of building up and breaking down. If a child overdoes activity and too much stress is placed on bones, the body is unable to build up bone quickly enough. Eventually, the bone fails and a small crack (stress fracture) develops.
  
  Most stress fractures occur in the weight bearing bones of the lower leg and foot and often result from a sudden increase in activity, such as when a child begins cross country running after a summer of rest. During the 6-8 weeks typically required for a stress fracture to heal, a cast or brace may be needed and the child cannot participate in the activity that caused the injury. Resuming activity too quickly can cause larger, harder-to-heal stress fractures to develop, which could lead to chronic problems that permanently prevent proper healing.
• Stress reaction of growth plates (physis)—Repetitive stress on a growth plate (physis) in the arms or legs can be painful for a child, and, if ignored, can impair growth. This leads to irregularity or widening of the growth plate, and if it continues, the growth plate can be permanently damaged and may stop growing prematurely, which could lead to a deformity. Among the most common sports activities that can cause stress reaction in growth plates are gymnastics and overhand throwing. If the growth plate appears abnormal in an X-ray of a child who participates in a high risk sport, treatment requires stopping the aggravating activity for 2 to 3 months.
• Growth Plate Injuries—A child's long bones do not grow from the center outward. Instead, growth occurs in areas of developing cartilage near the ends of long bones. Called growth plates, these areas are the last portion of bone to harden (ossify) into solid bone. Ossification doesn't take place until a child is fully grown, making a child's bones more vulnerable to growth plates fractures.
  
  Because growth plates actually regulate growth and help determine the length and shape of adult bone, injuries in this area can disturb bone growth and result in bone deformity. Growth plate injuries occur most often during football, basketball or other contact sports, and in high-impact sports such as gymnastics.
• Strains and Sprains—Soft tissues such as muscles, ligaments, and tendons can be injured from overuse during nearly any sports activity. An appropriate period of rest from the sport and nonsteroidal anti-inflammatory medication will typically relieve pain associated with strains and sprains. Physical therapy exercises may be recommended to help restore strength and mobility.

Prevention

By helping children avoid overdoing any single sport and giving their growing bodies adequate rest between practices or games, many overuse injuries in children can be prevented. The American Academy of Orthopaedic Surgeons has partnered with STOP Sports Injuries to help educate parents, coaches, and athletes about how to prevent overuse injuries. Specific tips to prevent overuse injuries include:

• Limit the number of teams in which your child is playing in one season—Children who play on more than one team are especially at risk for overuse injuries.
• Do not allow your child to play one sport year round—Taking regular breaks and playing other sports is essential to skill development and injury prevention.