In its June 2007 Clinical Report, "Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes," the American Academy of Pediatrics (AAP) addresses the alarming increase in the number of overuse injuries, which it defines as "microtraumatic damage to a bone, muscle or tendon that has been subjected to repetitive stress without sufficient time to heal or undergo the natural reparative process."

According to Safe Kids Worldwide, more than 3.5 million children age fourteen and under get medical treatment for sports injuries each year (quadruple the number in 1995). Of those, the AAP estimates that fully fifty percent are overuse injuries.

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Some of the most common overuse injuries are:

• Sever's disease (a heel problem often associated with soccer)

• Osgood-Schlatter disease (knee pain common in male soccer and basketball players)

• Gymnast's wrist

• Runner's knee

• Swimmer's shoulder (rotator cuff tendonitis)

• Shin splints (common in soccer, basketball and track), and

• Little League elbow or shoulder (usually from throwing breaking balls, an ability that professional baseball players and coaches say isn't needed early in a player's career to rise to the professional level).

Overuse injuries are being seen more and more in younger and younger kids. Injuries which were seen mostly in kids ages 15 to 18 are now being seen in kids as young as 8 or 9.

Twenty-five years ago, only 10 percent of the patients treated by Dr. Lyle Micheli, a pioneer in the field of treating youth sports injuries and founder and director of the Sports Medicine Division at Children's Hospital Boston, were overuse injuries. Now overuse injuries represent 70 percent of the cases he sees. When the Sports Medicine clinic opened in 1974, it saw 250 athletes a year. Now it sees more than 300 children per week.

Dr. James Andrews, medical director of the American Sports Medicine Institute in Birmingham, Alabama and one of the country's leading orthopedic surgeons, estimates that the number of overuse injuries he treats, including torn elbow ligaments in pitchers requiring so-called "Tommy John" surgery, has quadrupled just in the last seven years. Where once he performed Tommy John surgery only on adults, in 2004 he performed more than fifty on children (at $8,000 per surgery).

There are myriad reasons for the explosion in the number of overuse injuries suffered by youth athletes. Among them are the following:

• Youth sports are adult- not child-centered. Adults have turned what should be play into work. Kids are expected to train and play like adult professionals, and, like pros, don't feel they can stop to rest an injury, even when they are in constant pain. Too many are practicing two to three hours a day, often working out with professional instructors. Adults are fostering and promoting a "no pain, no gain" philosophy, which, when applied to children and adolescents, can be extremely detrimental.

• The time when workloads and expectations increase coincides with puberty: With adolescence comes rapid growth (bones don't stop growing in girls until around age 13, for boys around 15). Kids in a growth spurt are less flexible. Their tight tendons and ligaments are particularly prone to injury. The growth plates at end of major bones in arms and legs are particularly vulnerable to overuse injuries because they are spongy, rather than hard, as in adults. The repeated stress from such activities as throwing a baseball or swimming causes a widening of growth plate at top of the humerus, arm bone between shoulder and elbow.

• Athletes playing on more than one team per season and not taking time off. "The No. 1 risk factor [for overuse injuries] is year-round playing of a sport," says Dr. James Andrews in a recent article in The Cincinnati Enquirer. Not surprisingly, the children requiring Tommy John surgery by Dr. Andrews only took two weeks off (Thanksgiving and Christmas) a year!

• Early specialization: Young athletes with overuse injuries typically play on competitive teams or compete in an individual sport at a competitive level, have done so since an early age, and, more often than not, play that sport continually, twelve months a year. There is no doubt that early specialization and playing on a select team take their toll on a child's growing bones, joints and muscles by repeatedly stressing the same muscle groups. Prior to high school, most children are simply not physically mature enough to handle the stress that playing the same sport on a year-round or nearly year-round basis places on their bodies. Parents feel that early specialization is a matter of competitive survival, but the fact is that concentrating on a single sport is not supported by hard scientific evidence and appears to be fueled by folklore, myths, half-truths, a herd-mentality, the ever-burgeoning youth sports industry, and by adults too intent on winning.

• Unregulated "travel ball" not affiliated with Little League. Participation in travel ball programs, which typically play 70 to 90 games per year, is particularly risky, especially for younger kids, because most travel baseball programs don't limit pitch counts or require rest between pitching performances as does Little League rules.

• Outdated high school sports model. The current public high school model – one-first year team, one varsity, one subvarsity – might have made sense at the time it was adopted in 1924, when the number of roster spots was roughly equal to the number of those who wanted to play. But it makes no sense today, when the number of those who want to continue playing sports in middle and high school far exceeds the finite number of spots available under such a system. Too many kids are competing for too few spots on high school teams, which significantly intensifies the competition at earlier and earlier ages, which, in turn, leads directly to too many practices and games and overuse injuries.

• Parents. There is far too much parental pressure on kids these days to compete and succeed. Too many fathers are installing pitching mounds and home plates in their back yards. Little League rules place strict limits on pitch counts and mandate rest between appearances, yet some of those same pitchers go home and pitch the equivalent of ten times the limit, putting their arms and shoulders at risk of injury.

The sad fact is that most overuse injuries are preventable. Here are some ways parents can help:

• Utilize good common sense and basic parenting skills. It is your responsibility as a parent to do what is best for your child and to protect their health. Limiting sports should be no different than limiting other activities. After all, you don't hesitate to limit the amount of time your children spend on other activities they enjoy, e.g., television and video games. Why shouldn't you also place appropriate limits on the amount of time they spend practicing and playing ultracompetitive, superorganized sports? Don't get lulled into believing that competitive youth sports are somehow exempt from health concerns.

• Set participation limits during the season. Before letting a child play on two or three soccer or baseball teams at the same time, consider that while all those extra practices and games may help her achieve athletic success in the short term, all the extra wear and tear on her body may not only lead to overuse injuries years later, but chronic, life-long ailments that plague them as adults. As a 2004 public service campaign by the National Athletic Trainers' Association and the American Academy of Orthopaedic Surgeons ask parents, "What will they have longer, their trophies or their injuries?" Consider limiting your child to one competitive sport per season until high school.

• Set limits all year round. Your child is far less likely to suffer an overuse injury if you limit his participation. In particular, your child should:

• Take one season (two to three months) off out of four, time that the American Academy of Pediatrics says is needed to let injuries heal, refresh the mind, and work on strength and condition in the hopes of reducing injury risk. "[I]f the body is not given sufficient time to regenerate and refresh," warns the AAP, "the youth may be at risk of burnout. Unfortunately, too many parents realize too late – after their child suffers a severe overuse injury requiring surgery in high school because of wear and tear accumulated since he or she was eight or nine – that they should have made their child take three months each year instead of allowing them to play year-round. Taking time off from baseball is particularly important: many experts consider it the worst sport to play year-round because, whether it is batting or pitching, it requires movements which are completely unnatural and particularly hard on a child's body.

• Play and practice no more than twelve hours per week in any one sport or twenty hours per week for multiple sports (because different muscles are used).

• Take at least one day off a week from sports. The American Academy of Pediatrics Council on Sports Medicine recommends limiting 1 sporting activity to a maximum of 5 days per week with at least 1 day off from any organized activity.

• Be monitored by a sports doctor if he or she is spending more than 18 to 20 hours per week in a given sport.

• Resist the trend towards early specialization. As the AAP points out in its June 2007 Clinical Report, "Young athletes who participate in a variety of sports have fewer injuries and play sports longer than those who specialize before puberty." They also "have the highest potential to achieve the goal of lifelong fitness and enjoyment of physical activity while avoiding some of the pitfalls of overuse, overtraining, and burnout provided that they participate in moderation and are in tune with their bodies for signs of overuse and fatigue."

Kids are far better off playing different sports until high school, not only because it allows them to develop a variety of transferable motor skills such as jumping, running and twisting, which ultimately helps them become better at their chosen sport, but because other sports use different muscle groups, thus significantly reducing the risk of overuse injuries. The best way to prepare your child to be a successful high school athlete is to instill a love of sports, not to apply so much pressure on him at an early age by exposing him to the stress of ultracompetitive elite sports programs that he soon sees sports as fun but as a job and burns out. Some experts advise against specialization before age 10; others not before high school. I say, err on the side of caution and trust your intuition. If you choose not to allow your child to specialize or play on a select tem too early, not only will you be doing your child a huge favor, but if enough of us just say no to select teams and early specialization, we can help create a balanced, child-centered youth sports system our children deserve.

• Watch for signs of injury. It is sometimes hard for parents and coaches to know when child is playing injured. Prompted by self- or externally-imposed pressure to keep playing so as to not disappoint parents, or a fear that if he admits to an injury, he will lose his place on the team, a youth athlete may keep his injuries to himself, sometimes with devastating long-term consequences. Parents need to observe young athlete carefully for signs of overuse (limping, grimacing when pitching etc.), even if they are not training any harder than usual. Stress fractures are an obvious red flag.

• Don't allow your child to play injured; make sure he has fully recovered from his injury before he plays again. Be sure to follow a six-step process for recovering from a sports injury. If you don't, you are just asking for trouble. Nothing is worth endangering your child's health.

• Avoid unregulated travel ball programs.

• Look for programs or coaches with philosophies on injury prevention that are aligned with yours. Pull your child off a team whose coach is placing his or her health at risk for the sake of winning.

• If your child is playing baseball, only allow him to play in programs that follow, at a minimum, the new Little League rules limiting the number of pitches pitchers can throw in any one day (including practices) and how long they have to rest between pitching.

• In addition, look for programs that go further by prohibiting the throwing of curve balls until high school.

• If your child throws curve balls, insist that the coach teach him to throw the "Little League" curveball, a way of throwing curve ball that doesn't put as much strain on elbow as a regular "snap" curveball. The Little League curveball is thrown with same action as tossing a football; at the top of the delivery, the pitcher rolls his fingers over the ball, creating curve. Not only is the alternate curveball easier on arm, but it may actually be a more effective pitch because it looks to the batter like a fastball when it comes out of the pitcher's hand.

Brooke de Lench is the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins Sept. 2006) a Youth Sports Expert and editor-in-chief of MomsTeam.com.

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