Prevention and Wellness

Athletes and Overuse Injuries

Premier Health’s Jeffrey James, DO, and Jon Sulentic, DO— both with Premier Orthopedics — and Justin Perkins, athletic trainer, answer Frequently Asked Questions about sports related overuse injuries.

What is an overuse injury?

Dr. Jeffrey James describes sports-related overuse injuries. Click play to watch the video or read the transcript.


An overuse injury is any type of muscle, tendon, bone or joint injury such as tendinitis or a stress fracture that's caused by repetitive trauma. Most commonly, we think of this with sports or recreational activities when you're doing the same things over and over and maybe over-training, but it can also be associated with workplace-type injuries where you're doing repetitive motions at work.

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What are the most common sports overuse injuries?

Athletic trainer Justin Perkins discusses the most common sports overuse injuries. Click play to watch the video or read the transcript.


The most common sports-related overuse injuries vary depending on the season. In the spring we see running-type overuse injuries from track and field like shin splints, patellar tendinitis and achilles tendinitis. With baseball and softball, we see a lot of biceps tendinitis and rotator cuff tendinitis and more shoulder overuse injuries. In the fall we see running injuries with cross-country athletes. A lot of football quarterbacks get shoulder-related problems.

In the winter, we see deconditioned wrestlers experience lower leg overuse issues. Basketball players can hurt their arms and shoulders with too much overhead shooting.

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Are certain overuse injuries more common in student athletes from middle school through college?

Dr. Jon Sulentic discusses sports overuse injuries that happen most often with student athletes. Click play to watch the video or read the transcript.


With the upper extremities we mostly see shoulder overuse injuries, primarily in the throwing sports or repetitive overuse type sports like swimming, racket sports and baseball/softball. These injuries usually result from simple biomechanics. Humans weren't designed to throw or make those repetitive movements. We tend to see rotator cuff symptoms and problems in the support muscles of the shoulder blade and around the shoulder.

For the lower extremities, we mostly see injuries related to the patellar tendon of the knee in young athletes who are past the age of open growth and development of the bony anatomy and growth plates. In runners we commonly see iliotibial band syndrome. This is an overuse injury of the connective tissues on the outer part of the thigh and knee.

We also sometimes see foot injuries, stress fractures and injuries to some of the tendons associated with the onset of stress fractures and shin splints.

For both types of overuse injuries an exam will tease out the specific muscles that are involved.

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What's the difference between overhand (baseball pitching) and underhand (softball pitching) throwing?

Dr. Jon Sulentic discusses the different mechanics involved with overhand and underhand throwing. Click play to watch the video or read the transcript.


The differentiation between overhand throwing and underhand throwing, in baseball and softball respectively, is based on the muscles involved in those specific motions. The core mechanism of how the overuse symptoms happen is very similar for both movements. It involves an acceleration of the arm, redirecting the direction of throwing the ball and then the deceleration of that moving arm. The difference involves the specific muscles that are involved. Some of the stressors on the support anatomy, the ligament anatomy and even the bony anatomy of the shoulder are different, but the general concept is the same. You're trying to propel a projectile very fast, and that is demanding to the shoulder.

Underhand throwing certainly is a less biomechanically stressful movement. It is a more natural movement. In typical throwing-related injuries, we think of the overhand pitch, or overhand throw, primarily because of the stored energy that you need to cock the ball and then to rapidly accelerate it.

More importantly is the deceleration phase of both of those throws. Both throwing styles cause risk for an overuse injury because of the deceleration of the arm.

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What are the most common overuse injuries seen in “weekend warrior” adults?

Dr. Jon Sulentic discusses common overuse injuries experienced by “weekend warriors.” Click play to watch the video or read the transcript.


The overuse injuries in the older population or the non-collegiate athletes are somewhat similar. For example, with the knee, we'll see patellar tendinitis or patellar tendon overuse injuries in the young. As a person ages, the quadriceps tendon tends to become more involved. The mechanism by which that happens is not well understood, but it is probably related to simple degenerative changes of the anatomy.

Other differences are related to the types of sports people participate in at different stages of life. As the aging population continues to be as competitive as the younger population, the IT band syndrome injury occurs equally as much. The older you get, the more the risk of overuse injury increases. As more athletes continue to stay athletic at a more elite level, those overuse demands are potentially going to increase and be harder to solve because of the aging physiology.

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What are the risk factors for overuse injuries?

Dr. Jon Sulentic discusses the risk factors for sports overuse injuries. Click play to watch the video or read the transcript.


Overuse injuries in the young have multiple contributing factors, but the primary ones are related to the amount of training volume, training intensity and inadequate recovery time. Each individual sport has its biomechanical problems, and the emphasis on high volume training in the throwing athlete, for example, is the risk that puts them on the injury list. In an older person, however, there are many more physiological changes that contribute to the overuse.

Training errors still play a role in older athletes, but there are changes occurring at the cellular level that put them at greater risk. I often use the analogy of an old rubber band when I'm talking with patients. You pull an old rubber band out of a drawer and you pull it once and it could snap and break. You take a young person, who is akin to a fresh rubber band, and they can snap back over and over and over again. Even though we might emotionally and mentally feel that we're 22, when we're 55, our bodies don't adapt to the same training demands that they did at a younger age.

Our society is moving towards keeping people active, and now we have training venues for young athletes to be at elite levels. So we counsel folks to modify how they go about their training and that is equally as important as the training itself. A good athlete or an excellent athlete who is injured is just an average athlete.

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What other factors contribute to overuse injuries?

Dr. Jeffrey James describes factors that contribute to sports-related overuse injuries. Click play to watch the video or read the transcript.


Many things contribute to overuse injuries. Most commonly it is training errors. When you're involved in multiple sports and you're doing repetitive activities over time and you're not giving yourself adequate time to rest, your body can't recover. That can lead to overuse injuries. Think of a runner. We expect people to gradually build up their mileage, but some people just go out and run two or three miles and they end up with stress fractures or other injuries because their body's not used to it.

A second cause is technique errors. If you're swinging a bat or a golf club and your body has muscular imbalances, or you're doing it in the wrong fashion, it can lead to an injury.

How can an athlete determine if pain is from training or from an injury?

Athletic trainer Justin Perkins discusses pain from training vs. pain from an overuse injury. Click play to watch the video or read the transcript.


The difference between pain from training, and pain from injury, is that pain from an injury lasts longer. With most overuse injuries, a kid will come to us, and say, "Hey, I've had pain for five to seven days." Pain from training comes from the direct onset of muscle soreness, which normally lasts about 48 to 72 hours. If the pain lasts longer than that, that’s when they come see us and we go ahead and start treating them.

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When should an athlete seek medical attention for pain or an injury?

Athletic trainer Justin Perkins discusses when athletes should see their doctor for pain or injury from sports. Click play to watch the video or read the transcript.


Seeking medical attention can vary from patient to patient, from diagnosis to diagnosis. We try to give them five to seven days of decreased activity. If we cannot increase activity at that time due to pain, then we normally send them off to get further medical attention, such as imaging or a different opinion on the injury.

How are overuse injuries diagnosed?

Dr. Jeffrey James discusses how overuse injuries are diagnosed. Click play to watch the video or read the transcript.


Generally, overuse injuries are diagnosed with an adequate history and physical exam, along with some x-rays. That's generally done in the office. If an athlete doesn't respond to conservative treatments like stretching and rehab programs and rest, more advanced imaging like an MRI or a CAT scan or a musculoskeletal ultrasound can help make a diagnosis.

What is a musculoskeletal ultrasound?

Dr. Jeffrey James discusses how musculoskeletal ultrasound is used to diagnose overuse injuries. Click play to watch the video or read the transcript.


A musculoskeletal ultrasound uses sound waves to create images of tissues inside the body, just like when you get an ultrasound of a baby when you're pregnant. It's the same technology, but we use it to look at the tendons, the ligaments and bones, to see if there are any signs of injury.

What are the treatment options for overuse sports injuries?

Dr. Jeffrey James discusses treatment options for overuse injuries. Click play to watch the video or read the transcript.


Most overuse injury treatments consist of a period of rest followed by some therapy or home rehab exercises. Sometimes the cure is straight rest from the activity for a period of time, along with therapy or flexibility exercises to maintain good muscle strength and flexibility. Along with this, depending on the injury, you may require a period of immobilization in a cast or a brace to allow the injury to heal.

Athletic trainer Justin Perkins discusses treatment options for overuse injuries. Click play to watch the video or read the transcript.


Treatment options vary depending on the injury. Often we decrease activity, in order to decrease the athlete's pain. With a decrease in activity, we encourage the use of over the counter anti-inflammatories. We also encourage a lot of cold therapy, such as ice bags to the area, cold whirlpools, or using a BioCryo machine. BioCryo is icing and cold compress at the same time. It helps with any sort of swelling, or any sort of achiness that the athlete has in that area.

After that, we tend to slowly increase activities. When we increase activities, we might offer some minor rehab for the area, in terms of exercises and stretches. Once we build on the increase in activity, then we'll slowly integrate more sport-specific exercises that the athlete can do.

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If an athlete’s injury does not improve after a decrease in activity and initial treatment, what are the next steps?

Athletic trainer Justin Perkins discusses additional treatment options for overuse injuries. Click play to watch the video or read the transcript.


After about five to seven days, if the athlete does not get better in our care, we will refer them to a sports medicine physician for further evaluation. The sports medicine physician can decide if the athlete needs some imaging, such as an MRI or an X-ray of the injured area.

They can also do a lot of in-house treatment, including an anti-inflammatory shot to the area, to help decrease pain.

The doctor may also refer the patient for further rehabilitation. Rehab can expand on the things we do here in the training room, such as more stretching, more strengthening type exercises. They can also incorporate other tools, including the AlterG, which is most often used for a lower extremity injury.

What is the AlterG?

Athletic trainer Justin Perkins discusses how the AlterG is used to treat overuse injuries. Click play to watch the video or read the transcript.


The AlterG is an antigravity treadmill that suspends the athlete above the treadmill and allows for a decrease in bodyweight on the injured area, such as the knee or the ankle. This allows the athlete to continue running without the pounding of their body weight on the injured area.

Do you ever use injections to help treat an overuse injury?

Dr. Jeffrey James discusses injections used to treatment overuse injuries. Click play to watch the video or read the transcript.


We can provide treatments in the office to reduce swelling, address pain and promote healing. Different injections include corticosteroid injections and platelet-rich plasma (PRP) injections, which help heal damaged tendons.

What is the return to activity protocol for athletes recovering from overuse injuries?

Athletic trainer Justin Perkins discusses the protocol for when athletes can return to play after an overuse injury. Click play to watch the video or read the transcript.


Whether an athlete’s overuse injury is with an upper extremity or a lower extremity, we tend to give them little bits at a time. If it's an upper extremity injury, we decrease activity until the pain goes away, then we slowly increase activity day to day, as long as the symptoms don't reoccur. The first day or two, we might have them throw 15, 20 times, if it's a shoulder injury. If no symptoms reoccur, then we might increase that slowly, day by day. Normally we try to get athletes back to their normal mobility in about seven to 10 days. If they have no symptoms after that, we go ahead and clear them to play.

With a lower leg injury, we tend to slowly increase their activity. We decrease activity until pain goes away, then we'll slowly increase it. One day we might walk for 15 or 20 minutes. The next day, we might bike, ride the elliptical, and then we eventually want them to run again.

Are overuse injuries preventable?

Dr. Jeffrey James discusses how overuse injuries can be prevented. Click play to watch the video or read the transcript.


Most overuse injuries are 100 percent preventable. There are several things you can do to prevent overuse injuries. One is gradual escalation of a training program. This means not trying to run a marathon the first day, but gradually building up your mileage. The same thing goes for athletic activity on sports teams. We like to gradually start with a pre-season where you have limited activity and gradually build up over time. Adequate rest and nutrition are key to preventing injuries. Give yourself some time off between changing sports. This is a good way to avoid an overuse injury. It’s also a good idea to only take part in one sport each season. Some people do soccer and track at the same time and it eventually leads to problems. Cross training is also important, so that you're not just using the same muscles over and over again.

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Why are overuse injuries in student athletes on the rise?

Dr. Jon Sulentic discusses why overuse injuries are increasing among student athletes. Click play to watch the video or read the transcript.


What we've seen with that trend still needs to be worked out with clinical trials or research trials. The basic opinion is that the training methodologies used in modern sports do not incorporate enough rest. The motivation to achieve elite levels at a younger age is, I think, at the core of many injuries.

Accelerated training programs are common even in low-end clubs, and many kids are not prepared, even though the intent is to progressively advance their training volume and training intensity. Not all programs are the same. Sometimes a program may be labeled as organized accelerated training program, but those running it are not skilled enough to apply the principles of training to young athletes. That’s when overuse injuries occur. When you're a younger athlete, you can't have as much volume. Young athletes need adequate time to recover after an intense program. The balance between training and recovery requires knowledge of the physiology and anatomy of the younger age group.

Kids need to rest. They need cross training, to use an old term, and our modern sports are not set up for that in this country, at least.

Is it better for kids to play multiple sports or to specialize?

Dr. Jeffrey James discusses why student athletes should play multiple sports. Click play to watch the video or read the transcript.


As far as youth sports go, it's much better for kids to play multiple sports. The specialization shouldn't come until high school, if not college. That’s because doing the same activity all year long does lead to overuse injuries and a lot of muscular imbalances. If you're specializing, you often don't get adequate rest because you're doing the same sport for the entire year. If you're a baseball player and you change sports, it can give your arm, your shoulder or your elbow time to recover while you're doing basketball or football. This also allows you to use a completely different set of muscles and tendons and bones. Over time, that's good for preventing muscle imbalances and problems that come with overuse injuries.

Are there long-term consequences from overuse injuries?

Dr. Jeffrey James discusses the long-term effects of overuse injuries. Click play to watch the video or read the transcript.


Most of the time, overuse injuries don't pose any long-term issues as long as they're diagnosed appropriately and caught early. Getting enough rest and using adequate training programs can prevent long-term consequences. If you continue activities and just push through the pain, you can certainly cause some long-term problems. A few examples of this would be youth baseball or softball players who continue to pitch or play with elbow pain. They can develop fractures to the growth plates in their arm or even tears to the ligaments in the elbow that may require surgery. A second example would be runners who continue to run through the pain. They can develop stress injuries to the bone that eventually can lead to true fractures that can be serious or require surgeries.

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Source: Jeffrey James, DO, Jon Sulentic, DO, Premier Orthopedics; Justin Perkins, Premier Health athletic trainer; American Medical Society for Sports Medicine; National Institute of Arthritis and Musculoskeletal and Skin Diseases

Content Updated: August 21, 2017

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