Overuse injuries in athletes

Mar 20, 2024

What are they?

Overuse injuries are those that occur in the absence of one, identifiable traumatic cause. They occur over a period where excessive training load, insufficient recovery, and other intrinsic and extrinsic factors contribute to cumulative tissue damage that comes from repetitive microtrauma.

Overuse injuries can affect the muscles, tendons, and bones.


What does the research suggest?

Interestingly, athletes in individual sports are at a higher risk of overuse injuries than their peers who compete in team sports. It is estimated that the prevalence of injury in individual athletes is 42% whereas in team sport athletes it’s 33%. This can be explained by considering the nature of individual sports where all the demand is concentrated on one individual.

In addition, the nature of the sport also needs to be considered. On average, professional soccer players experience two injuries per season, causing them to miss 37 days in an average 300-day season. Handball players have 39% prevalence of overuse injuries in areas such as the shoulder (17%), knee (14%) and lumbar spine (12%). This high incidence of shoulder overuse injuries can be attributed to the repeated overhead motion of the shoulder at high speeds.


Contributing/risk factors

Repeated movements, even when biomechanics and movement patterns are efficient, are still a leading cause of overuse injuries. In addition, an increased training load above what the athlete is conditioned for, together with insufficient recovery (time/modality) creates a recipe for chronic overuse injuries.

Pre-season is the most common time of year when athletes notice ‘niggles.’ They’re coming back into training for their sports and often their readiness from a physical conditioning standpoint can be overestimated. This leads to sessions involving greater load being placed on the athlete’s body than what their body can cope with and they, as a result, ‘break down.’ Furthermore, in the early phases of pre-season training, recovery time may need to be extended between training sessions to allow their bodies to adapt.

Another high-risk time for overuse injuries is when an athlete is returning to play from a previous injury. If the athlete returns too quickly, or is introduced to too much load on return, they can reinjure or experience the onset of an overuse injury.


Common overuse injuries


Inflammatory changes and excessive use may lead to a condition known as tendinitis. All tendons are at risk of developing tendinopathy and the common injury sites include supraspinatus, patella and the Achilles tendon. Elite athletes and recreational athletes are at risk of developing tendinopathies related to overuse. Diagnosis of tendinopathy requireds clinical examination and diagnostic imaging such as an ultrasound or MRI scan. Pain is usually the first obvious symptom of an overuse injury and it can be felt at the beginning of physical activity or shortly after cessation of physical activity. If the injury is not reported and the athlete continues to train and compete as normal, pain may become evident throughout the entire session of physical activity. In addition to pain, tendon overuse injuries may present swelling and impaired performance.

The common tendon overuse injuries include:

  • Lateral Epicondylitis (Tennis Elbow)
  • Medial Epicondylitis (Golfers Elbow)
  • Rotator Cuff injury
  • Patellofemoral pain syndrome (Runner’s knee)
  • Achilles Tendinitis

Stress fracture

Stress fractures can be categorised as fatigue or insufficiency fractures.

Fatigue fractures occur in individuals who have a normal bone mineral density (BMD) and results from repetitive overuse. The cause of a stress fracture is an imbalance in the ability of the bones to repair from excessive bone strain. With excessive repetition and loading, microdamage to the bone accumulates.

Insufficiency fractures occur in those with low bone mineral density (BMD). Athletes who experience insufficiency fractures are more likely to be women with the female athlete triad, and runners.

Stress fractures can be attributed to primary external risk factors such as an increase in training frequency, intensity or load and the surface’s type or condition (e.g. hard surfaces). Footwear also plays a vital role and it is suggested that shoes older than 6 months may be a contributing factor.

Stress fractures can also result from internal risk factors such as muscle mass, particularly in the calf area for lower limb fractures. Biomechanics and poor mobility and movement patterns also contribute as internal risk factors.

Signs and symptoms of stress fractures include pain, swelling, and warmth in and around the area. Clinical diagnoses of stress fractures can be made through MRI and CT scans.

The common areas for stress fractures include:

  • Weight bearing bones (femur, tibia, fibula and foot bones)
  • Spine

Juvenile Osteochondritis Dissecans (JOCD)

JOCD results from repetitive microtrauma, such as overuse. It is a cause of knee pain in adolescent athletes and non-athletes, and the incidence of JOCD is higher among adolescent boys than girls. JOCD involves the separation and premature death of the articular cartilage of the subchondral bone (layer of bone just underneath the cartilage), most commonly affecting the medial femoral condyle.

Very active adolescents commonly present with a history of aching and onset of pain over time (days-weeks) that gets worse during physical activity.

Early diagnosis is essential to ensuring that the condition does not progress and get worse over time. Clinical diagnoses involves an X-ray or MRI scan. Adolescents who are diagnosed with JOCD should restrict their physical activity and allow for healing to occur.



Management of a suspected overuse injury begins with stopping the athletes from participating in any movements or activities that cause pain and discomfort (STOP principle). In the early stages of injury management, the athlete can follow the RICER protocol. Referral of the athlete to an allied health professional with musculoskeletal knowledge is critical so they can be assessed, diagnosed, and an injury management plan put into place to manage their return to sport.

It’s essential for sports trainers to build healthy, respectful and open relationships with their athletes. Doing this will provide the necessary safe environment for athletes to voice their concerns about how they are feeling and if they are concerned about any potential new injuries.



Franco, M. F., Madaleno, F. O., de Paula, T. M. N., Ferreira, T. V., Pinto, R. Z., & Resende, R. A. (2021). Prevalence of overuse injuries in athletes from individual and team sports: a systematic review with meta-analysis and grade recommendations. Brazilian Journal of Physical Therapy, 25(5), 500–513.

Weisskopf, L., Hesse, T., Sokolowski, M., Hirschmüller, A. (2022). Tendons and Jumping: Anatomy and Pathomechanics of Tendon Injuries. In: Canata, G.L., D’Hooghe, P., Hunt, K.J., M. M. J. Kerkhoffs, G., Longo, U.G. (eds) Management of Track and Field Injuries. Springer, Cham.

Winter SC, Gordon S, Brice SM, Lindsay D, Barrs S. A Multifactorial Approach to Overuse Running Injuries: A 1-Year Prospective Study. Sports Health. 2020 May/Jun;12(3):296-303. doi: 10.1177/1941738119888504. Epub 2020 Jan 29. PMID: 31994970; PMCID: PMC7222667.

Sports Injuries – Acute, Chronic & Common Injuries | NIAMS (