Ensuring positive outcomes in sports by encouraging key preventative measures in youthful athletes.

by Kimberly R. Witkowski, PT, DPT, OCS,

Youth sports injuries are on the rise and, from a clinician’s standpoint, the age of athletes affected by overuse injuries seems to be getting younger. Youth athletes often begin competitive sports as
early as age 7 years, with some participating in organized sports activities as early as age 4, if not sooner. With an estimated 25 million scholastic, and another 20 million organized community-based, youth programs in the United States, the opportunity for injury is enormous. Youth sports injuries are the second leading cause of emergency room visits for children and adolescents, and the second leading cause of injuries in school. Roughly 3 million youth are seen in hospital emergency rooms for sports-related injuries, and another 5 million are seen by their primary care physician or sports medicine clinic for injuries. These numbers do not account for athletes who are not seen formally for their injuries. Table 1 shows estimates of only annual emergency room visits for youth sports injuries in children ages 5 to 14 years.

In the United States, about 30 million children and adolescents participate in some form of organized sports, and experience more than 3.5 million injuries each year. Children and adolescents ages 5 to 14 years account for 40% of sports related injuries for all age groups. The highest rates of injury occur in sports that involve contact and collision, and about 62% of sports-related injuries occur during practice. Consider the following statistics: 28% of football players, 25% of baseball players, 22% of soccer players, 15% of basketball players, and 12% of softball players in organized sports will sustain an injury
between the ages of 5 and 14 years old.

Physical activity is necessary for normal growth and development in children. However, when the activity level becomes too intense in a short time period, tissue breakdown and injury can occur. In the past, overuse injuries were more frequently seen among adult recreational athletes, but are now appearing much more frequently among youth. Overuse is considered excessive and repeated use resulting in injury to the bones, muscles, or tendons involved in the action. The single biggest contributing factor to the increase in youth sports injuries is the focus on more intense, repetitive, and specialized training along with year-round participation at much younger ages. Some of the risk factors that may predispose youth athletes to overuse injuries are: sport specializing at a young age, training errors, imbalance of strength or joint range of motion, anatomic misalignment, improper footwear, preexisting condition, growth cartilage less resistant to repetitive microtrauma, and intense repetitive training during periods of growth. Immature bones, insufficient rest after an injury, and poor training and conditioning also may contribute to overuse injuries.

Proper technique is critical in avoiding overuse injuries, as slight changes in form may cause additional stress. Youth sports related injury severity also increases with age. Children who are less developed than a more mature child of the same age and weight are at increased risk for injury. Before puberty, girls suffer more sports injuries than boys, whereas during puberty, boys suffer injuries more severely than girls. One in every 100 high school female athletes will tear her anterior cruciate ligament (ACL). Female athletes are four to eight times more likely to tear their ACL than their male counterparts.

Overuse injuries occur in a wide variety of sports, from baseball to soccer, gymnastics, ice skating, or football, and can affect muscles, ligaments, tendons, bones, and growth plates. The most common overuse injuries involve the knee and foot. Below are several common overuse injuries sustained by youth athletes.

Common Overuse Injuries in Children
• Sever’s Disease: An inflammatory condition of the growth plate in the heel bone (calcaneus), one of the most common causes of heel pain in children, often caused by running, jumping, and being active, leading to repetitive stress on the growth plate as the foot strikes the ground. This causes inflammation and swelling in the growth plate resulting in pain.

• Osgood-Schlatter Disease: An inflammatory condition of the growth plate on the tibial tubercle, where the patellar tendon attaches to the tibia. When a child is active, the quadriceps muscle pulls on the patellar tendon, which then pulls on the tibial tubercle. This repetitive traction on the tubercle leads to inflammation, swelling, and tenderness. The prominence of the tibial tubercle may become very pronounced, and continued stress could potentially lead to a fracture in the tubercle prominence. Painful symptoms are often caused by running and jumping. Most symptoms will completely disappear when a child completes the adolescent growth spurt, around 14 for girls and 16 for boys; however, the prominence of the tubercle will persist.

• Jumper’s Knee: Also known as patellar tendonitis, the repetitive contraction of the quadriceps muscle can stress the patellar tendon where it attaches to the patella, causing inflammation and tissue damage. Symptoms can range from mild to severe and are seen mostly with jumping activities, but can be seen in all sports.

• Throwing Injuries (Medial Apophysitis and Osteochondritis Dissecans): One of the most common elbow problems, medial apophysitis, more commonly known as “Little Leaguer’s elbow,” causes pain and inflammation on the medial epicondyle of the humerus at the growth plate due to the stress of the wrist flexors at this attachment point. Osteochondritis dissecans is a common source of pain at the lateral aspect of the elbow where excessive overhand throwing can compress the immature bones of the elbow joint, causing small pieces of cartilage and bone to loosen and float inside the joint.

• Stress Fractures: Stress fractures occur when muscles become fatigued and transfer the overload of impact stress to bones. If a child participates in excessive activity and too much stress is being placed on bones, the child’s growing body will not be able to build up bone fast enough. Eventually, the bone fails and a small crack (stress fracture) develops. The repetitive force that causes a stress fracture is not great enough to cause an acute fracture, such as a broken arm caused by a fall.

• Stress Reaction of Growth Plates (Physis): Overuse stress reaction leads to irregularity or widening of the growth plate, leading to pain in the arms or legs, possibly impairing growth. If repetitive stress continues, the growth plate can become permanently damaged and may actually stop growing prematurely, possibly leading to deformity.

• Strains and Sprains: Soft tissue structures, such as muscles, ligaments, and tendons, can be injured from overuse, especially growing structures in children and adolescents. Common soft tissue injuries may include sprains (stretch or tear of the ligaments), strains (injury to either muscle or tendon in the form of a stretch or tear), contusions (bruise to a muscle, tendon, or ligament resulting in blood pooling around the area of injury), tendonitis (small, repetitive stress aggravating a tendon resulting in inflammation of the tendon or the tendon’s covering), or bursitis (inflammation to a fluid-filled sac located between a bone and a tendon or muscle causing swelling and irritation).

Any of these can be the result of a single episode, such as a fall, sudden twist, or blow to the body, or may be sustained because of repeated overuse, accumulating slowly, but steadily.

Early recognition and treatment of injuries is crucial in returning adolescent athletes to their sport safely. Any injury involving swelling, deformities, and/or loss of normal function, for example, range of motion or strength, should be seen by a physician or physical therapist immediately. If pain or what seems like a simple injury does not go away on its own and full activity is unachievable due to pain, the athlete should be seen by a physician or physical therapist. Overuse injuries require time off from the repetitive stress in order to heal. Without allowing the tissue proper time to heal, a nagging injury can turn into a chronic problem, which may require longer time away from the sport to allow healing to take place. Some recommendations for treating an overuse injury include: cutting back on the intensity, duration, and frequency of an activity; adopting a hard/easy workout schedule and cross training with other activities to maintain fitness levels; learning proper training methods and technique from a coach or athletic trainer; performing proper warm-up and cool-down activities before and after activity; and using ice after activity for minor aches and pain.

From a physical therapy standpoint, modalities such as electrical stimulation and ice help calm the inflammatory process. Ultrasound is typically used to facilitate healing in the inflammatory and proliferative phase following soft tissue injury (tendonitis, bursitis, acute soft tissue injuries), but is contraindicated over growth plates, unless using pulsed, low intensity settings (<0.5 w/cm2) over the epiphyseal plates. The application of low level laser therapy also may be an option for the therapist, producing the proposed effects of three primary reactions including reduction of inflammation, cell regeneration, and increased blood flow (circulation). Iontophoresis represents yet another therapeutic technology some use to treat inflammation and pain. Furthermore, some athletes themselves may choose to use topical analgesics for temporary pain relief.

Prevention of youth sports injuries is key to preserving the bodies of adolescent athletes. In our clinic, the Functional Movement Screen (FMS) is frequently administered to assess the potential risk for injury in an athlete. It attempts to identify imbalances in mobility and stability during movement patterns exposing the athlete’s compensatory movement problems, and allows the clinician to identify movement flaws that may cause injury. It is also used to help direct a treatment plan for injury prevention based on the findings of the testing process. The FMS can identify muscle flexibility, proprioceptive deficits, and strength imbalances along with previous injuries that have been acknowledged as significant risk factors for injury.

Youth sports overuse injuries are avoidable. With education, prevention, and common sense, therapists can help adolescents enjoy the process of growing up playing sports. Physical therapists are great resources for assessing potential overuse injuries in youth athletes and treating those already sustained. Sports are a fundamental part of health and development for adolescents and should be a positive experience rather than riddled by preventable and avoidable injuries. RM

Kimberly R. Witkowski, PT, DPT, OCS, is a staff physical therapist at Mariners Physical Therapy, South Coast Metro, Calif. She received her DPT from Loma Linda University, graduating with honors and receiving the Fred B. Moore Award for excellence in clinical practice. She has worked with many types of orthopedic diagnosis at many different levels and utilizes manual therapy, functional rehabilitation, and movement science techniques in her practice.