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From the National Athletic Trainers' Association

Preventing Overuse Injuries in Youth Athletes

Position statement urges participation limits, delayed sports specialization; says half are preventable


Overuse injuries account for fifty percent of all youth sports injuries, but half may be preventable, says the National Athletic Trainers' Association in a new position statement.Baseball pitcher winding up

Prevention advice

The NATA says there are five ways parents, coaches and athletes can help to reduce the number of repetitive stress injuries in children and adolescents.

1. Proper education and supervision.

  • Athletes, parents and coaches should know the warning signs or symptoms of overuse injuries;
  • Athletes need to notify an adult if they experience signs of an overuse injury;
  • Coaches should be trained in sports safety, training techniques and skills, psychosocial aspects of childhood and adolescence, child development and common health and medical concerns.
  • Organized youth and interscholastic sports should be supervised by adults with knowledge of and training in monitoring for overuse injuries.

2. Pre-participation physical exams (PPEs).  Student athletes should undergo a PPE before beginning a new sport (or prior to the start of a new sports season) to screen for potential risk factors, including:

  • Previous injury
  • Psychololgical issues
  • Muscle imbalances
  • Inflexibility
  • Muscle weakness
  • Instability
  • Conditioning

3. Rule changes and participation limits. Studies suggest that the most consistent predictor of overuse injury is the sheer volume of sports activity, whether measured as number of throws/pitches or quantity of time participating. The NATA recommendations:

  • As general rule, athletes should limit sports to no more than 16 to 20 hours a week. 
  • Athletes should take at least 1 to 2 days off per week from competitive practices, competitions, and sport-specific training. Coaches and administrators should consider these required days off when organizing schedules for the season.
  • Athletes should participate on only 1 team of the same sport per season when participating on 2 or more teams in the same sport (e.g. high school and club) would involve practices or games (or both) more than 5 days per week. 
  • Adult rules for sports should be modified for children and adolescents, such as:
    • shorter quarters or halves
    • bases closer together
    • less frequent games or practices
    • age-related limits on number and type of pitches for baseball pitchers (for specific recommendations on preventing overuse injuries in baseball pitchers, click here)
    • gear-ratio limits for cyclists
    • age-related distance limits for runners (e.g. 5 km at age 12, 10 km at age 14 etc.),
    • limits on number of practices and length for swimmers at various levels of competitive age-groups swimming)

4. Training and conditioning programs. Proper training and conditioning, both before and during the season, may prevent overuse injuries:

  • The general decline in physical activity (e.g. free play, walking to school, and regular physical-education classes), coupled with a general increase in sedentary activities (e.g. watching television, spending time on a computer, texting, playing video games, physical activity limited to sports participation) means that there are more athletes with poorer levels of general fitness or conditioning who may not be able to tolerate the demands of training required for sport participation.
  • Athletes should begin a general-fitness routine encompassing strengthening, endurance, and flexibility training as well as lifestyle physical fitness (e.g. taking the stairs instead of the elevator) at least 2 months before the sport season starts.
  • Once a general foundation of fitness has been established, athlete should begin to gradually increase training loads following the 10% rule, which allows for no more than 10% increase in the amount of training time, distance, repetitions, or load per week.
  • Coaches should be encouraged to use a structured warm-up program which includes technique training, neuromuscular control, and balance and strengthening exercises.  Programs such as the PEP Program have shown in studies to reduce the risk of noncontact anterior cruciate ligament (ACL) injuries.
  • Coaches should develop an overall-prevention mentality, including improved warm-up, cool-down, taping unstable ankles, rehabilitation, promoting fair play, and exercises to improve joint stability, flexibility, strength, coordination, reaction time and endurance.

5. Delayed sports specialization.

  • Although there is little evidence-based research to demonstrate that early specialization of athletes participating in the same sport year-round from a young age has negative consequences on physical growth or psychological outcomes, many clinicians, health care organizations, and youth sports experts, have advocated for diversity in sport participation or delayed specialization.
  • The theory is that participation in only 1 sport can result in increased risk for repetitive microtrauma and overuse, and that multisport athletes who do not obtain adequate rest between daily activities or between seasons, and those who participate in 2 or more sports that emphasize the same body part are at higher risk for overuse injuries than those in multiple sports with different emphases.
  • Specialization in 1 sport may also be associated with nutritional and sleep inadequacies, psychological or socialization issues, and ultimately burnout which might be avoided with a balanced lifestyle and a strong support system made up of parents, friends, coaches, and health care providers.
  • Young athletes who participate in a variety of sports tend to have fewer injuries and play longer, thereby maintaining a higher level of physical activity than those who specialize before puberty.
  • Youth athletes should be encouraged to participate in multiple sports and recreational activities throughout the year to enhance general fitness and aid in motor development.
  • Athletes should take time off between sports seasons and take two to three non-consecutive months away from a specific sport, if they participate in a single sport year-round.
  • Athletes who participate in simultaneous (e.g. involvement in high school and club sports at the same time) or consecutive seasons of the same sport should follow the recommended guidelines with respect to the cumulative amount of time or pitches over the year.

Cost of overuse injuries

In addition to the direct and indirect medical costs, overuse injuries also result in lost participation time, numerous physician visits and lengthy -- and often ongoing -- rehabilitation. Furthermore, athletes who sustain recurrent overuse injuries may stop participating in sports and recreational activities, which can add to the increasing number of sedentary and obese individuals across the country.

"Repetitive stress on muscles and joints without adequate and appropriate conditioning and rest can result in chronic or overuse injuries in athletes of any age," said athletic trainer Tamara McLeod, PhD, ATC, associate professor of the Athletic Training Program at A.T. Still University and lead author of the position statement. "This situation in children is complicated by the growth process, which can result in a unique set of injuries among pediatric athletes."

Among young athletes, overuse injuries can include Osgood Schlatter's disease and Sever's disease among other growth-related disorders; medial epicondylitis, commonly called little league elbow; patellofemoral pain syndrome; as well as stress fractures caused by overuse and/or repetitive stress over time. 

Source: Valovich McLeod TC, Decoster LC, Loud KJ, Micheli LJ, Parker JT, Sandrey MA, White C.  National Athletic Trainers' Association Position Statement: Prevention of Pediatric Overuse Injuries.  J Ath. Tr. 2011;46(2):206-220.

Posted March 15, 2011