Overuse Injuries and Burnout in School Sport

SETTING THE SCENE

* School sport participation offers many benefits including the development of self-esteem, peer socialisation, and general fitness.

* However, an emphasis on competitive success has seemingly become widespread.

* This has resulted in increased pressure to begin high-intensity training at young ages.

* Such an excessive focus on early intensive training and competition at young ages rather than skill development can lead to overuse injury and burnout.

DEFINITION OF OVERUSE INJURY

* Overuse injuries occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.

* Injury can involve the muscle-tendon unit, bone, bursa, neurovascular structures, and the physis.

* Overuse injuries unique to young athletes include apophyseal injuries and physeal stress injuries.

NOTES

* The National Council of Youth Sports survey (USA) found that 60 million children aged 6 to 18 years participate in some form of organized athletics, with 44 million participating in more than 1 sport.

* There is very little research specifically on the incidence and prevalence of overuse injuries in children and adolescents.

* Overall estimates of overuse injuries versus acute injuries range from 45.9% to 54%.

* The prevalence of overuse injury varies by the specific sport, ranging from 37% (skiing and handball) to 68% (running).

* Overuse injuries are underestimated in the literature because most epidemiologic studies define injury as requiring time loss from participation.

RISK FACTORS

* Prior injury is a strong predictor of future overuse injury.

* Overuse injuries may be more likely to occur during the adolescent growth spurt.

∘ The physes, apophyses, and articular surfaces in skeletally immature athletes in a rapid phase of growth are less resistant to tensile, shear, and compressive forces than either mature bone or more immature prepubescent bone.

∘ Other factors that may contribute are a relative lack of lean tissue mass, an increase in joint hypermobility, and imbalances in growth and strength.

* A history of amenorrhea is a significant risk factor for stress fractures.

* Higher training volumes have consistently been shown to increase the risk of overuse injury in multiple sports.

* Other factors that may contribute to overuse injury but lack clinical data include:

∘ Poor-fitting equipment, particularly when not adjusted for changes in growth.

∘ Overscheduling, such as multiple competitive events in the same day or over several consecutive days. This factor may be better considered as a marker for a high ratio of workload-to-recovery time.

READINESS FOR SPORTS

* Readiness for sports is related to the match between a child's level of growth and development (motor, sensory, cognitive, social/emotional) and the tasks/demands of the competitive sport.

* Chronological age is not a good indicator on which to base sport developmental models because motor, cognitive, and social skills progress at different rates, independent of age.

* Coaches and parents may lack knowledge about normal development and signs of readiness for certain tasks, both physically and psychosocially.

∘ This can result in unrealistic expectations that cause children and adolescents to feel as if they are not making progress in their sport.

∘ Consequently, children may lose self-esteem and withdraw from the sport.

SPORT SPECIALISATION

* Sport specialisation may be considered as intensive, year-round training in a single sport at the exclusion of other sports.

* There is concern that early sport specialisation may increase rates of overuse injury and sport burnout, but this relationship has yet to be demonstrated.

* Diversified sports training during early and middle adolescence may be more effective in developing elite-level skills in the primary sport due to skill transfer.

HIGH-RISK OVERUSE INJURIES

* “High-risk” overuse injuries are those that can result in significant loss of time from sport and/or threaten future sport participation.

* These include certain stress fractures, physeal stress injuries, osteochondritis dissecans, some apophyseal injuries, and effort thrombosis.

* Physeal stress injuries can occur at the proximal humerus, distal radius, distal femur, and the proximal tibia.

BURNOUT

* Burnout is part of a spectrum of conditions that includes overreaching and overtraining.

* It has been defined to occur as a result of chronic stress that causes a young athlete to cease participation in a previously enjoyable activity.

* Sport specialisation may be a factor.

∘ Data suggest that athletes who had early specialised training withdrew from their sport either due to injury or burnout from the sport.

* However, not all young athletes who drop out of sports are burned out.

∘ Most youth who discontinue a sport do so as a result of time conflicts and interest in other activities.

∘ Some may re-enter the same sport or participate in a different sport in the future.

* In children there appears to be more of a psychological component related to burnout and attrition with adult supervised activities.

PREVENTION

* Limiting weekly and yearly participation time, limits on sport-specific repetitive movements (eg, bowling limits in cricket), and scheduled rest periods are recommended.

* Such modifications need to be individualised based upon the sport and the athlete's age, growth rate, readiness, and injury history.

* Careful monitoring of training workload during the adolescent growth spurt is recommended, as injury risk seems to be greater during this phase.

* Preseason conditioning programs can reduce injury rates in young athletes.

* Pre-practice neuromuscular training can reduce lower extremity injuries.

* Given the altered biomechanics that may occur with ill-fitting equipment, proper sizing and resizing of equipment is recommended, although data are lacking that demonstrate a link to injury.

* To reduce the likelihood of burnout, an emphasis should be placed on skill development more than competition and winning.

SUMMARY FINDINGS AND RECOMMENDATIONS

* Overuse injuries are underreported in the current literature because most injury definitions have focused on time loss from sport.

* Pre-participation exams may identify prior injury patterns and provide an opportunity to assess sport readiness.

* A history of prior injury is an established risk factor for overuse injuries that should be noted as part of each injury assessment.

* Adolescent female athletes should be assessed for menstrual dysfunction as a predisposing factor to overuse injury.

* Parents and coaches should be educated regarding the concept of sport readiness. Variations in cognitive development, as well as motor skills, should be considered when setting goals and expectations.

* Early sport specialisation may not lead to long-term success in sports and may increase risk for overuse injury and burnout.  With the possible exception of early entry sports such as gymnastics, figure skating, and swimming/diving, sport diversification should be encouraged at younger ages.

* When an overuse injury is diagnosed, it is essential to address the underlying cause. The athlete, parents, and coaches should be involved in reviewing all risk factors and developing a strategy to attempt to avoid recurrent injury.

Research conducted by the American Journal of Sports Medicine