Review Article

Epidemiology of sports-related musculoskeletal injuries in young

athletes in United States
Dilip R. Patel, Ai Yamasaki, Kelly Brown

Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All
authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII)
Final approval of manuscript: All authors.
Correspondence to: Dilip R. Patel. Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008,
USA. Email: [email protected].

Abstract: Over the past several decades there has been increased participation in sports by children and
adolescents at earlier ages in the United States, as well as more intense participation and specialization in
sports at very early ages. This trend has also partly contributed to the patterns of injuries seen in young
athletes, and especially in recent years, injuries previously seen in mature athletes are being seen in young
athletes. Overall, the vast majority of sport-related musculoskeletal injuries in children and adolescents are
due to repetitive overuse and acute macrotrauma is less frequently seen in young athletes. Epidemiological
data on sports injuries are provided by several national surveys. Investigators have used different methods to
define sports injuries and the most widely used definition is based on athlete-exposure time. Certain aspects
related to adolescent growth and development modulate the pattern of injuries. This article provides an
overview of the epidemiology of sports-related musculoskeletal injuries seen in children and adolescents.

Keywords: Epidemiology; athlete-exposure; overuse injury

Submitted Mar 21, 2017. Accepted for publication Apr 03, 2017.
doi: 10.21037/tp.2017.04.08
View this article at: http://dx.doi.org/10.21037/tp.2017.04.08

Introduction an organized high school athletic practice or competition,

(II) requiring medical attention from a certified athletic
Studies regarding the epidemiology of sports injuries in
trainer or a physician, and (III) restricting the athlete’s
youth sports are often difficult to compare as the definition
participation for 1 or more days beyond the day of injury (1).
of a sport-related injury varies across studies (1-8). However,
An athlete exposure was defined as one athlete participating
most definitions include one or more of the following in one practice or competition during which the athlete was
descriptors: time loss from practice or game, decreased exposed to the possibility of athletic injury (1).
level of activity, and the need for medical attention (7). Time loss from game or practice is a commonly used
Limitations of some studies include reliability of the indicator for severity of injury (2). For example: non-
collected data, self-report recall bias, presence or absence reportable, no time lost, 1–7 days lost (minor), 8–21 days
of an athletic trained or other qualified professional to lost (moderate), more than 21 days lost, and severe injury
record the injury, difficulty in determining the denominator resulting in permanent disability (2). In addition to the
(population at risk), and insufficient information on actual number of days lost, other factors have been considered in
time the athlete was exposed to the risk (7). determining the severity of injury. These factors include the
According to a study conducted by the Centers for nature of the injury, duration of treatment, absence from
Disease Control and Prevention (CDC), sports injuries school, and cost of treatment (2). Cumulative incidence of
were defined as those (I) resulting from participation in injuries refers to the number of injuries among a specific

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Translational Pediatrics, Vol 6, No 3 July 2017 161

Table 1 Factors of specific significance in adolescent athletes

Factor Comments

Height and weight Increase in rate of height and weight during adolescence contribute to increase in momentum and force during
collision with another athlete; increased weight also increases stress and load to skeletal structures

Muscle growth and There is increased muscle hypertrophy and associated increase in strength during adolescence. This is relatively
strength more pronounced in males compared to females

Motor skills and Motor skills generally improve during adolescence. This is associated with improved motor performance and may
performance contribute to improved sport-specific task performance. Males and females follow a different trajectory in motor
skills development

Body composition There are inherent differences between males and females described in terms of fat mass and fat-free mass as
well as body fat distribution. Some athletes may engage in unhealthy measures to manipulate body fat mass

Flexibility There is a relative period of decreased overall musculotendinous flexibility during adolescent growth spurt.
Generally females are more flexible when compared to males

Growth cartilage The immature growth plate is vulnerable to stress injury

Bone structure There is increased risk for tendon or ligamentous injury and bony avulsions because of relative weakness of
growing bones

Psychological maturity Psychosocial factors and development play an important role in how adolescents view participation in sports. This
has direct implications for adherence to treatment recommendations and how they cope with injuries

group of athletes followed for a defined period (2,4,7). Epidemiology

Cumulative incidence is an indicator for an individual
The CDC High School Sports-Related Injury Surveillance
athlete’s risk for injury; whereas, the incidence of first injury
Study was conducted in June 2005 (1). There were
is an indicator of any one athlete being injured (2,4,7).
7.2 million students who participated in high school sports
A widely accepted definition of sport-related injury
in June 2005 (1). It is estimated that high school sports
considers athlete-exposure time. An injury, for example,
account for 2 million injuries, 500,000 doctor visits, and
may be reported as rate per 1,000 athlete-exposures. This
30,000 hospitalizations every year (1).
is considered to be a more accurate measure to define
an injury. An athlete-exposure is defined as one athlete Based on the CDC study, the overall injury rate in all
participating in one practice or game, in which there is the high school sports combined was 2.44 injuries per 1,000
possibility of sustaining an injury (1,4,7). athlete exposures. American football has the highest injury
rate at 4.36 injuries per 1,000 athlete exposures. In each of
the nine sports for which data were collected, approximately
Special considerations in adolescent athletes 80% of the injuries reported were new injuries. Overall
The risk for sport-related musculoskeletal injuries is the injury rates were higher for competition compared to
modulated to some extent in adolescents by certain aspects practice. About 50% of injuries resulted in less than 7 days
related to growth and development. These factors are of time lost from participation. No deaths were reported in
summarized in Table 1 (7). the study.
Catastrophic and acute macrotrauma are relatively less Sheu et al. (2016) reported on sports and recreation
frequent injuries seen in children and adolescents. The vast related injury episodes in the United States for the period
majority of injuries seen in clinical practice are overuse of time between 2011 and 2014 (9). Their analysis showed
injuries (Table 2) (2,7-12). An overuse injury is a result an average annual estimate of 8.6 million sports and
of repetitive and excessive stress from physical activity recreational related injury episodes with an age-adjusted
applied to normal musculoskeletal tissues and failure of rate of 34.1 per 1,000 population. Male and individuals
normal adaptation of the tissue. Several factors have been between 5 and 24 years of age accounted for greater than
identified that contribute to risk for overuse injuries (Table 3) 50% of all injury episodes. Overall, injury rates were higher
(7,8,13,14). among males and children between the ages of 5–14 years.

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162 Patel et al. Epidemiology of sports injuries

Table 2 Spectrum of overuse musculoskeletal injuries in young

Table 2 (continued)
athletes
Structure affected Injuries
Structure affected Injuries
Tendons Rotator cuff tendonitis
Articular cartilage Juvenile osteochondritis dissecans
and subchondral De Quervain tenosynovitis
Medial condyle of the femur
bone
Popliteus tendonitis
Patella
Iliotibial band friction syndrome
Talus
Patellar tendonitis
Capitellum
Achilles tendonitis
Apophysis Osgood-Schlatter disease (tibial tubercle)
Other Medial and lateral epicondylitis
Severe disease (posterior calcaneus)
Osteitis pubis (affecting symphysis pubis)
Iselin disease (fifth metatarsal)
Scheuermann disease (affecting vertebral
Iliac crest
endplates)
Bone Low-risk stress fractures
Idiopathic anterior knee pain (patella
Medial tibia femoral pain syndrome)

Fibula Sinding-Larsen-Johansson syndrome

(affecting distal pole of patella)
Ribs
Chronic exertional compartment
Radius
syndromes of the leg
Second and third metatarsals
Medial tibial stress syndrome (shin splints)
High risk stress fractures

Femoral neck

Midanterior tibia Approximately 50% of injuries required medical attention.

General exercise was the most frequently reported activity
Patella
associated with sports or recreation related injuries. Injuries
Medial malleolus
to the lower extremities were most common (42%) followed
Talus by those of upper extremities (30%), and head and neck
Tarsal navicular region (16%).
Another study conducted by Comstock et al., analyzed
Fifth metatarsal
high-school sports related injuries for the years 2015–2016
Pars interarticularis (spondylolysis) (Table 4,5) (10).
Bursa Subacromial bursitis According to the National Institute of Arthritis and
Olecranon bursitis
Musculoskeletal and Skin Diseases report there were more
than 2.6 million children younger than 19 years of age who
Iliopectineal bursitis
were treated in emergency departments for musculoskeletal
Trochanteric bursitis injuries due to sport participation (11). Musculoskeletal
Prepatellar bursitis injuries were also the most common reason for injury-
related visits to primary care physicians. The most common
Pes anserine bursitis
injuries were sprains and strains, growth plate injuries, and
Physis or growth Distal radius phyis
repetitive motion injuries. Most injuries were reported in
plate
Proximal humeral physis basketball followed by track and field, American football,
Table 2 (continued) baseball, softball, soccer and gymnastics.

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Translational Pediatrics, Vol 6, No 3 July 2017 163

Table 3 Factors contributing to overuse musculoskeletal injuries

Relatively more consistently associated factors Relatively less consistently associated factors

Sudden increase in the intensity, duration, and volume of Anatomic variations, especially in lower extremities
physical activity

Poor conditioning Hard playing surfaces

Insufficient sport-specific training Stress to the growth cartilage

Poor training techniques Differential growth between bones and musculotendinous structures

Inappropriate equipment for the sport Decreased musculotendinous flexibility

Presence of associated neuromuscular conditions

Table 4 Injury rates by sport, High School Sports-Related Injury day were seen in emergency departments for sports-related
Surveillance Study, United States, 2015–2016 school year (only injuries, including musculoskeletal and other injuries.
includes injuries resulting in more than 1 day of time loss)
According to this report, the highest rate of sports-related
Sport Injury rate per 1,000 athlete-exposures injury occurred in teens between the ages of 15–17 years, in
Overall total 2.32 remote rural settings, playing American football, and during
Boys’ American football 4.08 practice. A history of previous injury was a risk factor for
subsequent injury. In 2011, sport-related traumatic brain
Boys’ soccer 1.87
injury accounted for 15% of all injuries in high school
Girls’ soccer 2.59 athletes. Other significant reasons for athletes to seek
Girls’ volleyball 1.19 medical attention included exercise-induced asthma, heat
Boys’ basketball 1.48
illness, exertional sickling, and infrequently spinal cord
injury.
Girls’ basketball 2.14
Analysis by Rosendahl and Strouse (2016) of sports-
Boys’ wrestling 2.23 related injuries showed that factors influencing the
Boys’ baseball 0.84 distribution of musculoskeletal injuries were age, sex, type
of sport, intensity of participation, position played, and
Girls’ softball 1.30
underlying congenital conditions (13). They reported a
sports injury incidence of 1 in 10 children per year with
higher overall incidence and greater severity of injury in
Table 5 Injury diagnosis by type of exposure, High School Sports-
boys. The report noted that younger athletes sustained
Related Injury Surveillance Study, United States, 2015–2016 school
year relatively milder non-specific injuries compared to older
athletes. The highest incidence of musculoskeletal injuries
Type of injury During game (%) During practice (%)
was reported in contact and jumping sports that included
Sprain or strain 39 43
American football, wrestling, basketball, soccer, baseball,
Contusion 11 7 skiing and snowboarding. Children under the age of
Fracture 9 9 10 years were most likely to have contusions, mild sprains,
and injury to growth plates. During pre-pubertal years acute
Concussion 28 20
or repetitive stress fractures were reported more frequently.
Other 14 22 Ligamentous injuries were more likely after skeletal
maturity was attained. Sport-related musculoskeletal
injuries by location reported by Rosendahl and Strouse are
According to the Youth Sports Safety Statistics report listed in Table 6.
of the National Athletic Trainers’ Association there were In a retrospective review, Stracciolini, et al. (2014)
39 sports-participation-related deaths in young athletes in analyzed athletes aged 5–17 years old who presented to a
2011 (12). Nationally, approximately 8,000 children per sports medicine clinic over a period of 10 years (15). Results

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164 Patel et al. Epidemiology of sports injuries

Table 6 Sports-related MSK injuries by location

Location Injuries

Shoulder Most common in older youth from contact sports (wrestling, football, hockey); clavicular fracture occurs at all ages

Elbow Supracondylar/lateral condylar fractures; throwing athletes prone to osteochondritis dissecans, stress injury, flexor
tendinopathy, ulnar collateral ligament injury; note that dislocations are very rare

Wrist and hands Salter-Harris type fractures of growth plates/plastic fractures of distal radial physis and metaphysis are most
common, but if inciting activity is not decreased, premature physeal fusion or carpal impingement can occur;
carpal bone injuries are rare

Pelvis and hips Avulsion of apophyseal growth centers, especially at anterior superior iliac spine (kicking) and ischial apophysis
(hurdling); slipped capital femoral epiphysis; femoral acetabular impingement

Knee Physeal fracture at distal femur or proximal tibia are seen in younger children, whereas cruciate/collateral ligament
and meniscal injury are more common after skeletal maturity is reached; extensor mechanism injury is also
common in older adolescents

Ankle and foot Juvenile Tillaux (Salter III) and triplane fractures in partially fused physes; ligamentous injury typically in skeletally
mature athletes; tarsal coalition; posterior ankle impingement in dancers; avulsion fractures

Spine Mostly from high-risk sports (football, diving, skiing, gymnastics); intervertebral disk herniation at L4/L5/
S1; Scheuermann disease (gymnastics, rowing, weightlifting); spondylolysis and spondylolisthesis at L5/S1
(gymnastics, dance, cheerleading, football, weightlifting, running); all spine injuries are generally more common in
older adolescent athletes
MSK, musculoskeletal.

showed higher incidence of overuse injuries compared to overuse injuries are not inherently benign, for example,
acute traumatic injuries in females, and the opposite in high-risk injuries include stress fractures of the femoral
males. Females tended to injure the lower extremity and neck/tarsal navicular/anterior tibial physis, as well as effort
spine more frequently, whereas males tended to injure the thrombosis.
upper extremity. Hip/pelvic injury tended to be overuse Lykissas et al. (2013) conducted a cross-sectional
or soft tissue injury in females, as opposed to traumatic or epidemiological study of pediatric injuries presenting to
bony injury in males. Females were more likely to suffer the emergency department, using data collected from
from patellofemoral knee pain, but males were more the National Electronic Injury Surveillance System
likely to develop osteochondritis dissecans and fractures. database (16). It compares reports of sports and recreational
Anterior cruciate ligament sprains were equal among injuries in children in the years 2000, 2005, and 2010,
sexes. Differences between sexes may be due to differential to determine the trends in the top eight causes of these
movement patterns, sport participation, strength, flexibility, injuries. The top eight causes of injury for children ages
physiologic and anatomic factors (biomechanics of growing 5–14 years were bicycling, football, roller sports, playground
joints etc.). equipment, baseball/softball, soccer, and trampoline.
DiFiori et al. (2014) conducted a systematic review of The study found that the incidence of all musculoskeletal
trends in competitive youth sports with regards to overuse injuries decreased over time for all eight activities (16.4 to
injury and burnout (14). Overuse injury is often variable 14.4/1,000 person-years); and sports-specific injuries were
with the sport, ranging from 15% in soccer players up found to have decreased in 6 out of 8 activities. Maximal
to 68% in running. Authors noted that the incidence of decrease was seen in bicycling, with a smaller decrease in
such injury is still underreported. Most define injury as football and soccer. Older children (10–14 years of age)
loss of time from sports participation and many cases of sustained a greater proportion of injuries. This study
overuse injury do not cause the athlete to miss playing time. concludes that although injury severity or overuse injury
Overuse injury also varies by age: younger athletes suffer prevalence may have increased, the total incidence of acute
more growth-related conditions (apophysitis, physeal stress sports/recreation-related injuries has been decreasing over
injury) as opposed to older skeletally mature athletes. All the last decade.

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Translational Pediatrics, Vol 6, No 3 July 2017 165

Stracciolini et al. (2013) conducted a retrospective review Individual studies highlight the variability in injuries, but
of sports injuries in younger children (5–12 years of age) in general, boys are more likely than girls to sustain injury
versus older children (13–17 years of age), to determine during sports, lower extremity injuries are more common
whether there was variation in location, severity, and overall, and prior injury is a strong risk factor for future
diagnosis depending on age (17). The authors collected injury. It remains important for practitioners to understand
retrospective data from a sports medicine clinic over the epidemiology and variance of injury for their patient
10 years and found definitive differences between the populations.
age groups. Forty percent of the total cohort underwent
surgery, which was disproportionately in older children.
Acknowledgments
Younger children sustained more acute traumatic bony
injuries of upper extremities. Older children sustained more None.
overuse, soft tissue injuries of back and lower extremities.
To classify sports injuries by sex and sport, Schroeder
Footnote
et al. (2015) conducted a retrospective cohort study that
focused on older children (approximately 14–18 years of Conflicts of Interest: The authors have no conflicts of interest
age) with overuse injuries (18). The authors collected data to declare.
from the High School Reporting Information Online study
generated in the 2006–2007 and 2011–2012 school years
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Cite this article as: Patel DR, Yamasaki A, Brown K.

Epidemiology of sports-related musculoskeletal injuries in
young athletes in United States. Transl Pediatr 2017;6(3):160-166.
doi: 10.21037/tp.2017.04.08

© Translational Pediatrics. All rights reserved. tp.amegroups.com Transl Pediatr 2017;6(3):160-166