About 50% of individuals ages 6–17 years old in the United States play an organized sport.1 Athletic trainers that work with this population have self-reported that overuse injuries comprised about 50%–54% of the injuries they encountered.2,3 Despite these reports, historical epidemiological evidence on overuse injuries in high school-aged athletes (generally between the ages 13 and 18 years old) demonstrated overuse injury percentages ranging from 3% to 30%.4–8 Roos and Marshall produced a seminal systematic review on collegiate and high school sport epidemiology in the United States which found extreme variations in the amount of overuse injuries and the operational definition of the term “overuse injury” from study to study.9 In the systematic review, some studies provided no definition for overuse injuries. Furthermore, for the studies that did have a definition, some defined “overuse injuries” as a product of the mechanisms of injuries, diagnoses of specific injury, or both.9 Roos and Marshall identified this as a limitation to the ability to properly track the number of overuse injuries.9 In the authors’ discussion, they recommend that the term “overuse injury” be used to define an injury that arises from a specific mechanism of injury.9 Roos and Marshall then recognized that one paper in their review provided a clear overuse injury definition which states an overuse injury as, “a gradual-onset injury caused by repeated microtrauma without a single identifiable event responsible for that injury.”9,10 This definition requires that overuse injuries should be distinct from noncontact injuries as some noncontact injuries can be from acute mechanisms.9 Since Roos and Marshall’s publication in 2014, several articles have proposed a definition for overuse injuries. These articles consistently define overuse injuries as resulting from a mechanism of repetitive movements that cause microtrauma which compounds over time and can progress in the severity of damage.2,11,12 Therefore, overuse injuries should have a mechanism of repetitive movement that compounds over time (i.e., gradual onset) that is distinct from noncontact injuries. Using a consistent definition, and one that is supported by previous research, can help researchers and clinicians understand the true burden and number of overuse injuries.
Overuse injury documentation in high school-aged athletes is of particular importance. The recent emergence of sport specialization in youth athletes has been found to be associated with an increased risk of overuse injuries.13,14 Though the cost and burden of injuries related to sport specialization have been estimated,15 the true burden of overuse injuries in high school-aged populations is not well established. Anecdotally, athletic trainers question the current overuse injury rate as they perceive that the burden has increased with the rise of sport specialization. Though we cannot imply that sport specialization is specifically causing an increase in overuse injuries in recent epidemiology publications, there is a need to understand whether current overuse injury rates are different from previously published rates. Roos and Marshall’s systematic review demonstrated that overuse injury definitions provided by epidemiological studies can impact the overall overuse injury rates observed. Therefore, the purpose of this critically appraised topic is to determine (a) whether a specific definition of “overuse injury” was given, (b) whether overuse injuries were characterized by their mechanism of injury, and (c) whether “overuse injuries” were differentiated from noncontact injuries in high school-aged athlete epidemiology studies. Another purpose was to explore whether overuse injury rates are greater than the high school-aged athlete studies reviewed by Roos and Marshall’s systematic review.
Focused Clinical Question
Is there more consistency in how the term “overuse injury” is being used, and has the rate of overuse injuries in high school-aged athletes’ epidemiology studies changed since Roos and Marshall’s 2014 systematic review on overuse injury definitions?
Search Strategy
The complete search was conducted through SPORTDiscus and Google Scholar. The Boolean phrase used on SPORTDiscus and MEDLINE was “overuse injur*” AND “athlet*” AND “epidemiology.” The Boolean phrase “overuse injury” AND “athletes” AND “intitle:epidemiology” was used to search on Google Scholar.
Inclusion Criteria
- a.Participants had to be athletes in a secondary school or high school setting
- b.Study time longer than 1 year
- c.In the United States
- d.Epidemiology study
- e.Studies published between August 23, 2018 and August 23, 2023 (last 5 years of literature from the date of the literature review)
Exclusion Criteria
- a.Overuse injury not a main outcome or not defined
- b.Overuse injuries only recorded for a specific body region or joint (e.g., shoulder overuse injuries)
- c.Did not record athlete exposure data
Evidence Quality Assessment
Studies were assessed for validity using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for observational studies for sport-related conditions.16 For all the qualifying studies, two researchers scored each article independently, then collaborated to achieve one overall score.
Results of Search
Overall, the search yielded 158 results from SPORTDiscus, 159 results from Google Scholar, and 463 from MEDLINE (total = 780). A full explanation of how studies were screened is provided in Figure 1. Table 1 outlines the articles that met all inclusion criteria and their main results. Every study recognized that “overuse injuries” arise from an overuse mechanism of injury. However, not every study provided a specific definition of “overuse injury” or differentiated overuse injuries from noncontact injuries. To keep a consistent metric of overuse injury rates, the authors reported or calculated the overuse injury rate per 1,000 athlete exposures. These calculations are reviewable in Supplementary Table S1 (available online). The overuse injury rate ranged from 0.07 per 1,000 athlete exposures to 0.66 per 1,000 athlete exposures.
—Process for reviewing articles and final number of studies in the review.
Citation: International Journal of Athletic Therapy and Training 29, 3; 10.1123/ijatt.2023-0073
Review of the Studies
| Post et al.22 | Allen et al.23 | Belilos et al.17 | Wasserman et al.18 | Wasserman et al.19 | Pierpoint et al.21 | Ritzer et al.20 | |
|---|---|---|---|---|---|---|---|
| Study title | Epidemiology of Overuse Injuries in US Secondary School Athletics from 2014–2015 to 2018–2019 using the National Athletic Treatment, Injury and Outcomes Network Surveillance Program | Epidemiology of Secondary School Boys’ and Girls’ Basketball Injuries: National Athletic Treatment, Injury and Outcomes Network | Descriptive Epidemiology of High School Swimming and Diving Injuries | The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys’ Baseball (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Men’s Baseball (2004–2005 Through 2013–2014) | The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls’ Softball (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Women’s Softball (2004–2005 Through 2013–2014) | The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls’ Lacrosse (2008–2009 Through 2013–2014) and National Collegiate Athletic Association Women’s Lacrosse (2004–2005 Through 2013–2014) | An Epidemiologic Comparison of Acute and Overuse Injuries in High School Sports |
| Participants | Athletes who participated in secondary school-sponsored boys’ or girls’ sports | Athletes participating in secondary school-sponsored boys’ or girls’ basketball | High school boy and girl swimmers and divers (aged about 14–18 years) | Boys’ baseball players who participated in practices and competitions during the 2005–2006 through 2013–2014 academic years in high school | Girls’ softball players who participated in practices and competitions during the 2005–2006 through 2013–2014 academic years in high school | Female lacrosse players who participated in practices or competitions during the 2008–2009 through 2013–2014 academic years for high school | Athletes who participated in secondary school-sponsored boys’ or girls’ sports |
| Overuse injury ratesa | Overall overuse injury rate = 0.66 per 1,000 athlete exposures | Overall overuse injury rate = 0.07 per 1,000 athlete exposures. Overall noncontact injury rate = 0.46 per 1,000 athlete exposures | Overall overuse injury rate = 0.13 per 1,000 athlete exposures | Overall overuse injury rate = 0.12 per 1,000 athlete exposures Overall noncontact injury rate = 0.63 per 1,000 athlete exposures | Overall overuse injury rate = 0.21 per 1,000 athlete exposures Overall noncontact injury rate = 0.13 per 1,000 athlete exposures | Overall overuse injury rate = 0.16 per 1,000 athlete exposures. Overall noncontact injury rate = 0.44 per 1,000 athlete exposures | Overall overuse injury rate = 0.15 per 1,000 athlete exposures |
| Provided a complete definition of “overuse injury” | Yes—“We defined overuse injuries as injuries for which the mechanism was recorded by the AT as overuse/gradual onset. We then used that definition to include/exclude injuries that may not have been accurately recorded as overuse due to the limitation of the NATION reporting system.” | No—overuse injuries are referenced within the mechanism of injury portion of the “Methods” section: “Mechanisms of injury were categorized as player contact, surface contact, ball contact, contact with other equipment, out-of-bounds contact, noncontact, overuse, illness or infection, other, or unknown.” | No—overuse injuries are referenced as a mechanism of injury in the “Statistical Analysis” section: “Descriptive analysis was also conducted to summarize the distribution of injuries by demographic characteristics (i.e., gender and year in school), anatomic location (i.e., shoulder and knee), and mechanism of injury (i.e., overuse and contact with board).” | No—overuse injuries are referred to as just a mechanism of injury and the term is first introduced in the “Results” section: “Other frequent mechanisms of injury were overuse/chronic ....” | No—overuse injuries are referred to as just a mechanism of injury and the term is first introduced in the “Results” section: “The most frequent mechanism of injury during practices were no contact (22.9%) and overuse/chronic ....” | No—overuse injuries are first referenced in Table 6: “Number of Injuries and Injury Rates by Mechanism of Injury and Type ....” | Yes—“Overuse injury has been previously characterized by (1) a mechanism of gradual onset, and (2) an underlying pathogenesis of repetitive microtrauma (Roos et al., 2014). In the current study, overuse injuries included those resulting from repetitive exposure or an overuse/chronic mechanism” |
| Identified “overuse injury” as needing a specific mechanism of injury | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Had a category for “noncontact injuries” as a mechanism of injury | No | Yes | No | Yes | Yes | Yes | No |
| Reported a method for how the authors differentiated between noncontact overuse injuries and noncontact acute injuries | Yes—“For example, to capture overuse injuries that might have been missed due to this singular inclusion criterion, we also included injuries that listed no apparent contact as the injury mechanism and had an injury diagnosis that was chronic in nature ....” | No—“Mechanisms of injury were categorized as player contact, surface contact, ball contact, contact with other equipment, out-of-bounds contact, noncontact, overuse, illness or infection, other, or unknown” | No—no “noncontact” injury mechanism reported | No—“We examined injury counts, national estimates, and distributions by event type (practice, competition), time in season (preseason, regular season, and postseason), time loss (1–6 days; 7–21 days; .21 days, including injuries resulting in a premature end to the season), body part injured, diagnosis, mechanism of injury, activity during injury, and position.” | No—“We examined injury counts, national estimates, and distributions by event type (practice, competition), time in season (preseason, regular season, and postseason), time loss (1–6 days; 7–21 days; .21 days, including injuries resulting in a premature end to the season), body part injured, diagnosis, mechanism of injury, activity during injury, and position.” | No—“We examined injury counts, national estimates, and distributions by event type (practice, competition), time in season (preseason, regular season, and postseason), time loss (1–6 days; 7–21 days; .21 days, including injuries resulting in a premature end to the season), body part injured, diagnosis, mechanism of injury, activity during injury, and position.” | Unknown—“In the current study, overuse injuries included those resulting from repetitive exposure or an overuse/chronic mechanism, and acute injuries included those caused immediately by a specific event. Injuries were first categorized as overuse or acute based on reported injury diagnosis. Any injury that was reported by an AT as being due to an overuse/chronic mechanism was categorized as overuse. If an injury had a diagnosis that initially was considered to be in the acute injury category but was reported to have an overuse/chronic mechanism, then it was recategorized as an overuse injury.” |
| STROBE score (out of 22 points) | 17 | 16 | 19 | 19 | 19 | 19 | 19 |
| Supports clinical question | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
Note. AT = athletic trainer; NATION = National Athletic Treatment, Injury and Outcomes Network.
aThe calculations for injury rates for each study can be found in Supplementary Table S1 (available online).
Results of Evidence Assessment
All articles were evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. The Belilos et al.,17 Wasserman et al. (baseball),18 Wasserman et al. (softball),19 Ritzer et al.,20 and Pierpoint et al.21 studies all received a score of 19/22. Post et al.’s22 article received a score of 17/22, Allen et al.23 received a score of 16/22.
Clinical Bottom Line
Since Roos and Marshall’s 2014 systematic review, more studies are beginning to consistently define “overuse injury”; still, more progress and consistency are needed. Importantly, all studies recognized that overuse injuries must have a specific mechanism of injury; however, not every study was explicit about what an “overuse” mechanism of injury was. Still, recognizing that overuse injuries require a specific mechanism is an improvement from Roos and Marshall’s systematic review and is in line with recent articles published on best practices for defining overuse injuries.2,11,12 Not every study addressed how noncontact and overuse injuries were differentiated. Methodological consistency for differentiating overuse injuries from noncontact injury is paramount as it will help eliminate confusion on the definition of an overuse injury. Overuse injury rates ranged from 0.07 per 1,000 athlete exposures in boys’ and girls’ basketball23 to 0.66 per 1,000 athlete exposures in a wide range of boys’ and girls’ high school sports.22 These studies were mixed in whether overuse injuries were more or less common than other injury mechanism, and the rate of overuse injuries appears to be sport dependent with softball and swimming and diving reporting overuse injuries as the most common mechanism of injury.17,19,20
Implications for Practice, Education, and Future Research
Epidemiology studies in high school-aged athletes from August 23, 2018 to August 23, 2023, have consistently recognized overuse injuries as needing a specific mechanism of injury. Though this is an encouraging result, there is still a lack of consistency in providing a specific overuse injury definition. Only two studies in this review provided a specific definition of an overuse injury.20,22 It is important to note that the main objective of both studies was to report on overuse injuries.20,22 In contrast, the other five studies only referenced “overuse” or “overuse/chronic” as a mechanism of injury without a formal definition.18,19,21 Therefore, future epidemiology studies should provide precise definitions so that adequate comparisons between studies can be made. One area where researchers can better define overuse injuries is by clarifying whether a “noncontact” injury is an acute or overuse injury. Post et al.22 were the only study to clarify how overuse injuries and “noncontact” injuries were differentiated. Post et al.22 reviewed injuries with a noncontact mechanism of injury that had pathophysiology of an overuse mechanism (e.g., chronic dislocation, compartment syndrome, and stress fracture). This methodology may be one reason that Post et al. had the highest overuse injury rate of all the studies examined. It is possible that this method was able to correctly reclassify “noncontact” injuries as overuse injuries. Therefore, the current authors decided to also include the noncontact injury rates for the currently reviewed studies that reported noncontact injuries. Though speculative, it is possible that overuse injury rates reported by Allen et al.23 Wasserman et al. (baseball),18 Wasserman et al. (softball),19 and Pierpoint et al.21 would have been higher if they used similar methods as Post et al. If the previously mentioned studies used Post et al.’s methods, some noncontact injuries in those studies may have been reclassified as an overuse injury based on the mechanism reported and would have aligned better with current recommendations. Unfortunately, it is unclear to the authors how Ritzer et al. managed noncontact injuries. Ritzer et al.20 used High School Reporting Information Online data similar to other studies in this review.18,19,21 It appears Ritzer et al.20 had the most similar methodology to Post et al.22 but still had a noticeably lower overuse injury rate than Post et al. These findings highlight that more consistency is needed in how overuse injuries are differentiated from noncontact injuries in future studies. These studies demonstrate that it may be beneficial to create subcategories for injuries. It appears that two subcategories could be attributed to every injury: “acute or overuse” and “contact or noncontact.” For example, secondary myositis ossificans requires an overuse, contact mechanism with an object forcefully hitting the same area repeatedly.24 Conversely, shoulder impingement requires an overuse, noncontact mechanism as the arm goes through overhead movements repeatedly and most likely with some form of scapular dyskinesis.25 These subcategories may help clinicians and researchers better define what mechanisms led to a specific injury. This grouping system of different types of mechanisms of injury can also inform the clinician about appropriate treatment or preventative strategies. For example, overuse, noncontact injuries can be treated and prevented with proper biomechanical training of the patient.26,27 Future studies and clinicians should define overuse injuries as an injury with a gradual onset due to repetitive microtraumas and should look to differentiate the mechanism of overuse injuries between “contact” and “noncontact” injuries. The more precise the language surrounding overuse injuries, the better understanding clinicians and researchers will have of the true impact of overuse injuries on high school-aged athletes.
To consistently compare overuse injury rates between studies, overuse injury rate per 1,000 athlete exposures was calculated for each study reviewed (Supplementary Table S1 [available online]) and for as many studies as was appropriate in the Roos and Marshall 2014 systematic review. In the reviewed studies that reported other mechanisms of injuries, these studies generally found that other mechanisms produced higher injury rates than overuse injury mechanisms,18,21,23 except for in high school swimming and diving and softball.17,19 Supplementary Table S2 (available online) outlines the rationale for which studies from Roos and Marshall’s systematic review could be used to calculate an overuse injury rate per 1,000 athlete exposures. For the selected studies, Supplementary Table S2 (available online) also outlines the calculations used to report the overuse injury rate per 1,000 athlete exposures in high school-aged athletes.9 Only two studies reported by Roos and Marshall could be used to calculate the overuse injury rate per 1,000 athlete exposures.4,6 Collins et al. reported “no-contact (e.g., pulled muscle or overuse)” injuries in baseball players,4 and Hinton et al. reported overuse injuries in high school girls’ and boys’ lacrosse.6 Collins et al.’s “no-contact (e.g., pulled muscle or overuse)” injury rate was 0.38 per 1,000 athlete exposures, and Hinton et al.’s overuse injury rate was 0.29 per 1,000 athlete exposures. Interestingly, Wasserman et al. (baseball, 0.12 overuse injuries per 1,000 athlete exposures) and Pierpoint et al. (lacrosse, 0.16 overuse injuries per 1,000 athlete exposures) reported lower overuse injury rate than their historical counterparts. As presented earlier in this discussion, this discrepancy could be due to differences in methodology and definition of overuse injuries. Furthermore, many of the currently reviewed studies had noncontact injury rates (Table 1), which could have accounted for more overuse injuries if methods employed by Post et al. were used. This suggestion may provide further support for future studies to adopt Post et al.’s methodology for operationally defining overuse injuries. Though a thorough statistical analysis would be needed to definitively answer part of the authors’ clinical questions, the current review does not appear to support the idea that overuse injury rates in high school-aged athletes have drastically increased when compared with the studies reviewed by Roos and Marshall. However, the review does outline that more thorough and consistent definitions of overuse injuries in future studies would allow for a more definitive claim of how the overuse injury rate in high school-aged athletes is changing over time.
There are several limitations to the reviewed studies. First, though all studies recognized “overuse injuries” as needing a specific mechanism of injury, not all studies had a consistent operational definition of an overuse injury. Similarly, there were three different surveillance systems used between the six studies. The surveillance systems used were the National Athletic Treatment, Injury and Outcomes Network22,23; the High School Reporting Information Online18–21; and a study-specific prospective cohort design.17 The methodological differences in these surveillance systems may impact the results reported in this review. Last, only two studies from Roos and Marshall’s systematic review could be analyzed for overuse injury rates in high school-aged athletes. However, those two studies were at least in sports that were also reported in the current review allowing for some historical context to be explored.
Each of the reviewed studies defined overuse injuries as needing a specific mechanism of injury which follows the recommendation proposed by Roos and Marshall as well as other previous articles.2,9,11 Though a limited review, it appears that the current overuse injury rates are not drastically higher than some of the studies presented in Roos and Marshall’s systematic review. This critically appraised topic demonstrates that overuse injury epidemiological studies are more consistent with their definition of overuse injuries than previous studies; however, current injury surveillance systems and future studies must better differentiate between an “overuse/gradual” mechanism of injury and a “noncontact” injury as well as provide a standardized operational definition of overuse injury to allow for the best understanding of the impact that overuse injuries are having on high school-aged athletes. This topic should be revisited in 5 years (August 23, 2028) or as additional research is published.
CAT Kill Date: May 2026
CATs have a limited life span and should be revisited approximately 2 years after publication or as new evidence becomes available in that time frame (see
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