Paeds · rheumatology-musculoskeletal-and-sports
Sports injury prevention and overuse injuries
Also known as overuse injury · microtrauma injury · traction apophysitis · Osgood-Schlatter disease · Sever disease · calcaneal apophysitis · Sinding-Larsen-Johansson syndrome · little league elbow · medial epicondyle apophysitis · physeal stress injury · bone stress injury · stress fracture · sport specialization injury · relative energy deficiency in sport · load management
A fellowship approach to the overuse, or microtrauma, injuries of the young athlete — anchored by the acute-versus-overuse distinction, the vulnerability of the open physis and traction apophysis to repetitive load, the traction apophysitides (Sever, Osgood-Schlatter, Sinding-Larsen-Johansson, medial epicondyle), the injury-risk triad of sport specialization, training volume and inadequate recovery, the load-management principle of relative rest with a graded return to play, the neuromuscular warm-up prevention programmes, and the red-flag screen for the bone stress injury or stress fracture that points to relative energy deficiency in sport.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Pain that wakes the child at night, or pain on walking at rest, is a stress fracture or bone stress injury until proven otherwise and is not a simple overuse injury
- A limp with an activity-related limb pain demands imaging and referral rather than reassurance
- Focal bony tenderness on a single point of bone, especially the tibia, metatarsal or femur, is a stress fracture until excluded
- Weight loss, food restriction, or loss of menses in an athlete with overuse pain points to relative energy deficiency in sport and its bone, reproductive and cardiovascular consequences
- An overuse pain that progresses despite activity modification is being under-treated and needs the load, the diagnosis, or both, revisited
Life stages
Care settings
Clinical exam formats
Board mappings
- Musculoskeletal medicine - assess the child or adolescent with an activity-related limb pain and recognise the overuse injury
- Adolescent medicine - recognise the influence of training load, sport specialization and growth on the musculoskeletal system
- Acute presentations - recognise the red flags that separate a stress fracture or relative energy deficiency in sport from a simple overuse injury
- Musculoskeletal medicine and sport - apply the load-management and graded-return-to-play principles to the overuse injury
- Adolescent medicine - recognise relative energy deficiency in sport and its bone, reproductive and cardiovascular consequences
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Musculoskeletal 10-12
- Growth and Development 10-12
- Clinical Applications
- Short Cases
- Long Cases
- 9. Musculoskeletal medicine - overuse injuries and the prevention of sports injuries in children and adolescents
- 3. Behaviour, safeguarding and child protection - recognising the over-training and relative energy deficiency in sport at-risk athlete
- 4. Professional skills and knowledge: Patient management and health promotion
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline - Sports medicine and the musculoskeletal system
- General Pediatrics Content Outline - Adolescent medicine and the female athlete triad
- General Pediatrics Content Outline - Universal Task 5: Patient Management
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 2: Conditions common in pediatric primary care including sports and overuse injury
- Systems-Based Practice 2: Coordinated acute and chronic care and injury prevention
- Systems-Based Practice 1: Cost-conscious stewardship and avoidance of unproven interventions
- Medical Expert
- Pediatrics: Foundations EPA #5 - Performing a focused physical examination
- Pediatrics: Rheumatology and musculoskeletal applied domain including sport and exercise
A thirteen-year-old boy who plays basketball for three teams presents with six weeks of knee pain that comes on with jumping and eases with rest — Osgood-Schlatter disease, the traction apophysitis at the tibial tubercle, in a child whose twenty training hours a week exceed his age. An eleven-year-old runner has a month of bilateral heel pain reproduced by squeezing the calcaneus — Sever disease, the traction apophysitis at the calcaneal apophysis, in the prepubertal jumper. A fifteen-year-old distance runner has three months of shin pain that now wakes her at night, with weight loss and lost periods — a tibial stress fracture driven by relative energy deficiency in sport, the case that load management alone will not fix. The task in each is to read the load, to name the failing tissue, and to separate the apophysitis that resolves with growth from the stress fracture that demands imaging and referral. [7] [2]
Hold the assessment as three questions in order. Is it overuse or acute? Overuse is gradual and activity-related, acute is sudden and traumatic. Which tissue is failing in the growing skeleton? Name the traction apophysis, physis, bone, or the tendon, because the immature physis and apophysis fail before the adult tissue. What is the load, and is there a red flag? Read the training hours and the specialization, then screen for night pain, a limp, focal bony tenderness, weight loss, and menstrual loss. Load without a red flag is managed with relative rest; a red flag is managed with imaging and referral. [2] [1]
Overview & Definition
Overuse injuries are the injuries of repetition. They are the cumulative damage that builds when a tissue is loaded more often, or more intensely, than it can repair between sessions, and they stand in contrast to the acute injuries that come from a single high-energy event such as a collision, a twist, or a fall. In an adult, the tissue that gives way under repetition is usually the tendon, the bone, or the joint surface. In a child or an adolescent, the tissue that gives way first is the growing skeleton — the open physis and the traction apophysis — because cartilage is weaker than the tendon that pulls on it, and the growing bone has not yet reached its adult density. [2]
The clinical importance of this distinction is that the overuse injury is, in large part, preventable. An acute ligament tear is hard to prevent because it depends on a chance event, but an overuse injury depends on a load that the clinician, the family, and the coach can change. The fellowship task is therefore two-handed: recognise the overuse pattern and manage it with load modification, and, more broadly, prevent it through the specialization, volume, and recovery choices that the American Academy of Pediatrics and the American Medical Society for Sports Medicine have set out. [1] [2]
The terms matter because they point to the tissue. A traction apophysitis is inflammation at a growth-centre where a tendon pulls, and the common examples are Sever disease at the calcaneus, Osgood-Schlatter disease at the tibial tubercle, Sinding-Larsen-Johansson syndrome at the lower pole of the patella, and medial epicondyle apophysitis at the elbow. A physeal stress injury is repetitive microdamage across an open growth plate. A bone stress injury is the spectrum from bone stress reaction to a frank stress fracture, where repetitive impact outruns the bone's remodelling. A tendinopathy is overload of a tendon itself, and it is less common in children than in adults precisely because the apophysis and the physis yield first. [2] [8]
References11ShowHide
- [1]Brenner JS Sports Specialization and Intensive Training in Young Athletes. Pediatrics, 2016.PMID 27573090
- [2]DiFiori JP, Benjamin HJ, Brenner J, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med, 2014.PMID 24366013
- [3]Jayanthi NA, LaBella CR, Fischer D, et al. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med, 2015.PMID 25646361
- [4]Post EG, Trigsted SM, Riekena JW, et al. The Association of Sport Specialization and Training Volume With Injury History in Youth Athletes. Am J Sports Med, 2017.PMID 28288281
- [5]Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med, 2023.PMID 37752011
- [6]Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ, 2008.PMID 19066253
- [7]Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood-Schlatter disease: review of the literature. Musculoskelet Surg, 2017.PMID 28593576
- [8]Stracciolini A, Casciano R, Levey Friedman H, et al. Pediatric sports injuries: an age comparison of children versus adolescents. Am J Sports Med, 2013.PMID 23739684
- [9]Tenforde AS, Parziale AL, Popp KL, et al. Low Bone Mineral Density in Male Athletes Is Associated With Bone Stress Injuries at Anatomic Sites With Greater Trabecular Composition. Am J Sports Med, 2018.PMID 28985103
- [10]Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med, 2016.PMID 26758673
- [11]Morancie NA, Irvin L, Rayala BZ. Heel Pain: Diagnosis and Management. Am Fam Physician, 2025.PMID 41533410