Chronic Overuse Sports Injuries in the Adolescent/Pediatric Population
The evaluation and management of chronic overuse sports/athletic injuries is one of the most pervasive concerns in sports medicine today. Overuse sports injuries outnumber acute, instantaneous injuries in almost every athletic activity. Because overuse sports injuries are not instantly disabling, they attract less medical attention that those that cause an acute and obvious loss of function. Therefore, their frequency of occurrence is almost always underestimated in surveys of athletic injuries. The treatment of overuse sports injuries is made difficult by various factors. Due to their insidious onset, they are commonly initially ignored and, when athletes actually present for treatment, the injuries are well established and more difficult to manage successfully. Additionally, these injuries seem less serious to the athlete and makes it difficult to convince the athlete of the importance of intensive treatment for correction.
Physicians’ attitudes toward athletes with chronic overuse sports injuries are often inappropriate and frequently result in the athlete seeking inappropriate treatment options. All too often the athlete-patient is told: “If you only abstain from performing your sport, the injury will resolve.” The athlete-patient has sought treatment not because of the injury, but rather because they are unable to continue the athletic participation. Therefore, the ability to return the athlete to functional activity is as much part of the treatment as the alleviation of the symptoms.
This article highlights a few of the most common injuries seen in athletics with a focus on the overuse/repetitive strain injury. It is important to note that with most athletes, up to 60% of the “overuse” type injuries are related to training errors. Interaction with the coach/trainer is critical in solving this problem. Pain will get the athlete into the clinic but the tricky part can be figuring out exactly what is causing the pain. The old acronym PRICE (Prevention, Rest, Ice, Compression, & Elevation) along with NSAIDS can do a very nice job of decreasing/eliminating the chemical pain associated with the inflammatory response. However, the real challenge is to identify the underlying dysfunction.
Overuse injuries are almost always a result of change in three general areas: the athlete, the environment, or the activities. Identifying these changes requires patience, precision in history-taking, and a great understanding of the demands of the specific sporting activity. The most common cause of overuse athletic injuries is continued athletic participation despite the presence of symptoms associated with another injury (e.g., pitcher who continues to throw despite persistent elbow tendonitis). Continued participation with an existing injury also occurs as the result of inadequate rehabilitation. Some overuse dysfunctions are the result of normal physiological changes such as rapid growth spurts in which musculotendinous flexibility often decreases and indirectly causes tendonitis (e.g., Osgood-Schlatter knee syndrome). Environmental alterations may occur in the athlete’s personal environment (e.g., equipment and clothing) or the more global sports environment (e.g., running hills in a training regiment previously limited to running flat surfaces). Advancing to a higher level of athletic proficiency involves both quality and quantity of workouts. Merely increasing workout time in an abrupt manner can result in overuse athletic injuries, especially when an athlete attempts to perfect a single, isolated skill. It should be obvious that discovering the changes that cause overuse problems requires an emphasis in history-taking—more so than the diagnosis and management of acute injuries. Ultimately, the physician’s role becomes one of reinforcing and reminding the athlete to identify the appropriate changes to be made in their regimen.
The prevention of recurrences of overuse injuries is the most important aspect of managing overuse injuries. Generally, overuse injuries involve bone, ligaments or, in a majority of cases, musculotendinous structures. Muscle fatigue can occur because of relative lack of either strength or endurance. Then when the muscle unit tightens, it may undergo physiological structural damage (i.e., hemorrhage or localized edema). The muscle then undergoes spasms and shortening, which indirectly lead to weakness so that subsequent re-injury occurs with less provocation. Thus, the “overuse-tightness-pain-disuse-weakness-easier-overuse cycle” continues until broken by active treatment interventions.1-5
As society’s emphasis on continued physical activity and athletics throughout the lifespan has increased, so have the knowledge and skill required by the community of health care providers involved in managing the related injuries. It is essential for all sports medicine providers to realize that a team approach (physicians, physical therapists, athletic trainers, coaches, etc.)—that takes advantage of the collective knowledge, talent, and expertise of all these specialists in a collaborative effort—affords the athlete the optimal conditions for successful return to sport.
A thorough physical exam, biomechanical assessment, and functional movement analysis can all provide great insight into how the body moves and reveal any joint dysfunction and/or muscle imbalances. A muscle imbalance leads to changes in the length-tension relationships of involved muscles. This change in force coupling decreases neuromuscular efficiency and leads to more rapid fatigue. As the muscles fatigue, there is often a biomechanical compensation which may overload tissues not used to that new stress. Eventually, breakdown must occur and the athlete enters the cumulative injury cycle of pain.
Special considerations and unique aspects of musculoskeletal conditions in children should be revealed. Musculoskeletal growth may reveal significant progression in treatments. The underlying principle is that the skeletal system grows and the musculoskeletal system needs to “catch up.” With muscle imbalance plus growth, a possible result may be muscle contracture and, possibly, bony deformities. As children grow, their coordination and psyche are developing and therefore competitive sports may require an adaptation of the sport to the age/size of the growing child. While overuse syndromes in adults may result from microscopic tears or ruptures in the musculoskeletal system, in children, the bone-tendon junction is the primary weak point that indirectly leads to different types of overuse syndromes. For example, Osgood-Schlatter disease re-sults from microscopic avulsion fractures at the insertion of the patellar tendon during adolescence when the child is active and developing and when the relatively weak secondary ossification center of the proximal tibia is developing.3