A Q&A With Seattle Children’s Sports Medicine Specialists

Image of Monique Burton

Monique Burton

Experts from Seattle Children’s Sports Medicine Program, including Drs. Monique Burton, Celeste Quitiquit and John Lockhart, address questions about overuse injuries in young athletes.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Seattle Children’s medical staff and executive director of Digital Health, and author of the Seattle Mama Doc blog, for submitting these questions.

What are the most common overuse injuries you see in school-age children and teens? Are there particular sports that primary care providers should screen for more judiciously?

One of the most common types of overuse injuries in children and teens is traction apophysitis – a condition caused by inflammation in the growth centers where tendons attach muscle to bone.

In the chain of muscle, tendon and bone, the weak spot is actually the bone, which is subject to chronic stresses from repetitive use and is susceptible to overuse injury. Common types of apophysitis include Sever’s (calcaneal apophysitis) in school-age children and Osgood-Schlatter’s (tibial tuberosity apophysitis) in teen athletes.

Image of Celeste Quitiquit

Celeste Quitiquit

There are many other overuse injuries that occur throughout the body as well. Factors that increase the likelihood of suffering from these include balance between strength and flexibility, growth spurts, demanding schedules, early sports specialization and increase in competition level.

We recommend pediatricians screen all young athletes for overuse injuries, including traditional sports like soccer, but also activities like dance and martial arts. Depending on the patient’s physical activity, you may focus more closely on certain areas that are most vulnerable to overuse.

Adolescent female athletes should also be screened for menstrual irregularities as a predisposing factor to bone stress injuries and a warning sign of insufficient nutrition. This may also alert the provider to other underlying concerns like eating disorders.

Typical treatment for overuse injuries includes ice and elevation, and modification or avoidance of activities causing pain and rest. But those recommendations can be challenging for young athletes to accept. Are there any exceptions to these rules?

Often, overuse injuries will limit sports participation based on discomfort, but not all injuries have to limit participation entirely. For a young athlete who is passionate about their sport, it can be hard for them to avoid all participation.

In many cases we recommend “relative rest,” suggesting that patients avoid actions that cause pain or may worsen the injury, but remain active in other ways.

Image of John Lockhart

John Lockhart

For example, patients with Osgood-Schlatter’s may still attend practices, as long as they avoid running and repetitive jumping that stresses their lower extremities. This allows them to work on their technique and perform alternative conditioning and core work while still allowing their injuries to heal.

Young athletes should never try to “push through” an injury. This will only cause further pain and damage, and may increase the amount of time they will be out of play.

Additionally, for some inflammatory or aggravating injuries – like an ankle sprain or overuse injuries – trials of anti-inflammatories can be recommended. These should not be used for more than 14 days in a row and should not be taken right before exercise, as they can mask injury symptoms.

Overall, it’s important to discuss appropriate activities and a rehabilitation plan with the child and their family so everyone is in agreement and understands the restrictions and plan for recovery.

When doing sports physicals for children and teens, what questions can illuminate risk for overuse injuries?

Sports physicals are a great opportunity for primary care physicians to connect with young athletes, especially adolescents who are often seen by healthcare providers less frequently.

Providers can assess a child’s risk of overuse injuries by asking several questions during their pre-participation sports physical examination:

  • Which sports and other physical activities do you participate in?
  • What time of the year do you participate in each activity?
  • Do any of your sports seasons overlap?
  • How many total hours per week do you participate in organized activities?
  • Are you experiencing any ongoing pain or discomfort?
  • Have you experienced discomfort while playing sports in recent months or past seasons?
  • For females, what was the age of your first period and how frequent are your menstrual cycles?

If there are any risk factors for injury, primary care providers may want to recommend physical therapy for their athletes prior to the start of the season to help decrease or prevent injury.

How can providers partner with parents to support young athletes to participate in sports in a healthy way?

Primary care providers can serve as a wonderful source of support for young athletes and their families. Office visits are a great opportunity to check in with the athletes and make sure they are enjoying their sports, screen for signs or symptoms of overuse and investigate cues for overtraining or burnout.

Most parents want to support their child’s areas of interests and goals. At times this enthusiasm can lead to missed cues, such as a decline in athletic performance, which may suggest the child is no longer enjoying the activity. Often, talking with the patient alone can give the provider insight into a potentially difficult situation where parental, coach or other pressures are affecting an athlete.

Finally, providers should partner with parents and encourage them to engage the young athlete in multiple sports and physical activities rather than single sports specialization. This prevents a child from overusing the same muscle groups to perform the same sport-specific skills. It has not been shown that early specification leads to more elite performance in most sports. In fact, there is evidence in the collegiate population that more Division 1 athletes tend to specialize later than their non-athlete cohorts.

How can providers help prevent burnout in young athletes?

Factors that may lead to burnout include high training demands, frequent intense competition, negative performance criticism and little personal control for the athlete. Warning signs may include frequent visits for minor complaints or injuries, lack of expected improvement from an injury, fatigue, change in mood, etc.

To prevent burnout and overuse injuries, the American Academy of Pediatrics recommends children and adolescents have at least one day of rest each week to allow for both physical and psychological rest and recovery.

Additionally, all athletes need to take breaks from their sports to rest physically and mentally. Young athletes should spend about two months a year refraining from playing sports. This does not have to occur consecutively, and athletes can spend that time playing a different sport or activity that stresses the body in a different way.

Sometimes we have to remind our patients and ourselves that sports should be fun! If it is no longer enjoyable, taking an extended break or switching sports may be in order.