Pediatric Annals

CME Article 

Non-Contact Sports: Running, Swimming, and Dance — Identifying Common Injuries

Amanda Weiss Kelly, MD


Physical activity can play an important role in disease prevention, including cardiovascular disease, cancer, obesity, osteoporosis, and depression. Introducing children to participate in non-contact sports lead to the development of healthy habits that may affect long-term health positively.


Physical activity can play an important role in disease prevention, including cardiovascular disease, cancer, obesity, osteoporosis, and depression. Introducing children to participate in non-contact sports lead to the development of healthy habits that may affect long-term health positively.

Amanda Weiss Kelly, MD, is Assistant Professor, Case Western Reserve University, and Director Pediatric Sports Medicine, Rainbow Babies and Children’s Hospital.

Dr. Weiss Kelly has disclosed no relevant financial information.

Address correspondence to: Amanda Weiss Kelly, MD, Pediatric Orthopedics, 11100 Euclid Ave., Cleveland, OH 44106; e-mail:

Physical activity can play an important role in disease prevention, including cardiovascular disease, cancer, obesity, osteoporosis, and depression. Introducing children to participate in non-contact sports lead to the development of healthy habits that may affect long-term health positively.

Although non-contact sports may present a lower risk for injury, especially for acute and catastrophic injury, they are not risk-free. An understanding of the common injuries associated with non-contact sport participation can allow early recognition, treatment, and prevention of injury, making participation safer and more fun.


Injury in young runners is common, with 26% to 47% of high-school cross-country runners sustaining injuries each season.1 Most injuries are relatively minor, leading to less than 4 days of missed training.1 Knee, leg, and ankle injuries are most common, and only 20% of running injuries occur above the knee.2 Most running injuries are caused by overuse, although acute injuries, such as ankle sprains, do occur. Therefore, it is important to remember to obtain a training history in young runners to identify training errors that could predispose to overuse injury.

Case #1

A 15-year-old high school freshman cross-country runner presents with complaints of gradually increasing pain over the lateral aspect of his knee for 3 weeks. He cannot recall any specific injury. The pain does not prevent him from running, but he feels it affects his performance. He denies locking, catching, and swelling.

He ran cross-country in middle school but reports that he is running almost twice the distance this year that he did last year. In addition, he is now running more speed and hill workouts than before.

On physical exam, there is no evidence of swelling. He has pain with palpation of the distal iliotibial band (ITB) at the lateral femoral condyle and mild pain at the attachment of the ITB at Gerdy’s tubercle, a lateral tubercle of the tibia, located where the fascia lata inserts. He has decreased hip adduction strength in comparison with adduction strength. When performing single-leg squats, he has valgus at the knee, and this maneuver reproduces his pain in the distal iliotibial band. He has decreased flexibility of the ITB noted with Ober’s testing.

This case demonstrates a typical presentation for distal iliotibial band syndrome (ITBS), caused by friction of the ITB over the lateral femoral condyle. The knee is the most common site for a running-related injury, and ITBS is the second most common injury, with patellofemoral pain syndrome (PFPS), discussed in the overuse article in this issue (see page 286), being the most common. ITBS is the most common cause of lateral knee pain in runners and can also cause pain proximally where the ITB rubs over the greater trochanter.3

Pain with palpation over the greater trochanter, lateral femoral condyle, and/or Gerdy’s tubercle is typical in ITBS. Poor ITB flexibility may be noted on Ober’s testing. Weak hip abductor and external rotator strength, as noted in this case, have been identified as risk factors for ITBS and PFPS.

Treatment is aimed at alleviating pain, addressing strength and flexibility deficits, and addressing training errors. Pain can be relieved with modalities, including ice, ultrasound, and massage. Some modification of training schedule may be needed to eliminate pain, but most athletes can continue to participate in some running during rehabilitation. Cross-training with other non-painful activities, such as aqua running or biking, can help maintain optimal fitness while running distance is limited. Flexibility and strength deficits are also addressed during rehabilitation. Prospective investigations have demonstrated that physical therapy protocols aimed at improving hip abductor, flexor, and external rotator strength can improve symptoms of ITBS and PFPS symptoms.4,5

Most running injuries, including ITBS, are caused by overuse, and training error is the most commonly identified risk factor for these overuse injuries.2 Typical training errors include excessive distance or training intensity, or increasing distance or intensity too quickly. In this case, the athlete was not prepared for the significant increase in distance or difficulty of running, including speed and hill workouts, associated with high school running.

Because most running injuries can be attributed to training error, it stands to reason that the elimination of training error could prevent many injuries in young runners. A common recommendation is to increase running distance or intensity no more than 10% each week.2 To attain this goal, the runner must understand what distance and intensity will be expected at the start of the season. Using this information, the athlete can begin preparation 6 to 8 weeks before the season begins, allowing time to increase the duration and intensity of running gradually.

Other measures that may prevent common knee injuries such as PFPS and ITBS in young runners include the development of a program to enhance lower extremity strength, specifically hip abduction and external rotation strength.4,5

Because prior injury to a body site significantly increases risk for re-injury to the same site, appropriate rehabilitation, addressing training error and strength and flexibility deficits, is essential for the prevention of recurrent injury.1

Other common injuries in runners include stress fractures and shin splints; both are addressed in the overuse article of this journal (see page 286).


Swimming is a demanding sport in which training to increase endurance is emphasized, leading to long workouts and predisposing swimmers to overuse injury.6 The shoulder is particularly at risk, since 90% of forward propulsion in swimming comes from the upper extremity.6,7

Case #2

A 15-year-old high school freshman complains of bilateral shoulder pain for 6 weeks. This is her first year swimming with the high school team, and she reports that the training distance and intensity are significantly greater than what she has done in the past. She has had mild shoulder pain before, but it was only occasional and resolved quickly after practice. She now has pain with every practice. She said she notices that her shoulder pops as she brings her arm overhead, and she feels like the shoulder is “popping out of place.” She has the most pain with butterfly, but freestyle is also painful after 10 to 15 minutes of continuous swimming. Backstroke and breaststroke are non-painful.

Physical exam reveals poor posture with forward slumping of the shoulders. She has pain with palpation of the biceps tendon but is otherwise non-tender with palpation. She has a positive sulcus sign and increased translation of the humeral head anteriorly and posteriorly with load and shift testing (see Figure 1). She has pain with passive abduction and external rotation (apprehension testing; see Figure 2). Relocation testing decreases her level of pain (performing the apprehension test with anterior stabilizing force). Impingement testing is painful. She has poor rotator cuff muscle strength and scapular winging with wall push-ups and range of motion of the shoulders (see Figure 3). Her pectoralis and latissimus dorsi (internal rotation and adduction) strength are excellent. She has 5 degrees of elbow hyperextension and can oppose her thumb to her forearm. She denies neck pain, numbness, tingling, and radiating pain. Plain X-rays are normal.

Load and Shift Testing.

Figure 1: Load and Shift Testing.

Pain with Passive Abduction and External Rotation (apprehension Testing).

Figure 2: Pain with Passive Abduction and External Rotation (apprehension Testing).

Scapular Winging on the Right with Wall Pushups and Range of Motion of the Shoulders.

Figure 3: Scapular Winging on the Right with Wall Pushups and Range of Motion of the Shoulders.

The swimmer in this case has a history and physical exam typical of swimmer’s shoulder, with an increase in level of activity, increased shoulder range of motion and laxity, and inadequate rotator cuff strength and scapular stabilizer strength. Although increased shoulder range of motion and laxity are related to improved swimming performance, they can reduce stability of the shoulder and cause pain.6,8 Muscle strength imbalance in swimmers with good internal rotation and abduction strength but poor rotator cuff and scapular stabilizer strength, as seen in this case, is common. Swimmers, especially those with swimmer’s shoulder, tend to have excellent pectoralis and latissimus strength and inadequate strength and endurance of the rotator cuff and scapular stabilizer muscles responsible for shoulder stability by compressing the humeral head into the glenoid and positioning the glenoid beneath the humeral head. The pain associated with swimmer’s shoulder is due to subluxation of the shoulder, which occurs when the rotator cuff and scapular stabilizer muscles, responsible for shoulder stability, fatigue during long workouts.6

The shoulder is the most common site of injury in swimmers, with 47% to 73% of swimmers reporting a history of shoulder pain and 10% to 26% reporting current shoulder pain severe enough to interfere with performance.9 The demands placed on the swimmer’s shoulder are extreme: The average collegiate swimmer performs more than 1 million strokes each year.10 The highly repetitive nature of swim training contributes to the occurrence of overuse injury in these athletes. The exact cause of pain in swimmer’s shoulder is varied and includes instability secondary to muscle dysfunction or laxity, as in this case, biceps tendinosis, supraspinatus tendinosis or impingement syndrome.6 A swimmer with shoulder pain may have one or more of these specific diagnoses.

Treatment is based on decreasing pain and improving rotator cuff and scapular stabilizer muscle strength and endurance. Swimming below the pain threshold is permitted during rehabilitation, but a significant reduction in activity is usually necessary. As pain resolves, a very gradual increase in activity is permitted; as described above in runners, the 10% rule is reasonable. Return to swimming should be monitored carefully by qualified coaches who can help the athlete address any technique errors that could contribute to shoulder pain. It is important for swimmers to understand the importance of maintaining a rotator cuff and scapular stabilizer strengthening program indefinitely.

Case #3

A 16-year-old high school swimmer presents with complaints of gradually increasing knee pain for the past 8 weeks. She is a breaststroke specialist and has had pain in her knees in previous seasons. She said this season seems worse, and her breaststroke performance is now suffering.

She cannot recall any specific injury. She has had no swelling, locking, or catching.

Her physical exam reveals pain with palpation over the medial collateral ligament and medial patellar facets. She has mild laxity and pain with valgus stress testing of the knees bilaterally.

Breaststroker’s knee is a common ailment among breaststroke specialists, with 73% to 86% of breaststrokers complaining of medial knee pain. The whip kick motion used in the breaststroke places large valgus loads on the knee, leading to medial sided knee stress and pain.11 Knee pain in breaststroker’s knee has been associated with chronic medial collateral ligament sprain, inferior-medial patella facet pain/chondral damage, and medial plica irritation.12,13 Several risk factors have been identified for breaststroker’s knee, including hip abduction angle at the kick initiation of less than 37° or more than 42°, older age, more years in competitive swimming, inadequate warm-up, and swimming greater distances of the breaststroke.12,13

Rehabilitation includes an initial significant reduction or elimination of breaststroke training; however, other non-painful strokes may be performed. Changing kick technique to initiate the kick at a more favorable hip position may be helpful.

Prevention efforts should include gradually increasing the amount of breaststroke performed each season and an assessment of whip kick form early in the season so that technique errors can be corrected before the onset of pain.


Dance is an intense sport requiring high levels of aerobic power and muscle strength, endurance, and flexibility. Injury is common in young dancers, and 20% to 57% may suffer injury each year.14,15 Because of the extensive amount of time that dancers spend practicing and performing their sport each week, overuse injuries are more common than acute injuries. Young dancers frequently train 5 to 20 hours each week to obtain instruction in multiple styles of dance, including ballet, jazz, modern, lyrical, and hip-hop, each placing unique demands on the body. Age-based differences in injury pattern have been noted, with low back and hip injuries being more common among young dancers, whereas foot, ankle, and leg injuries are more common in mature dancers.16 Acute injuries such as fractures and sprains are also more common in young dancers than in mature dancers.17

Case #4

A 13-year-old dancer participating in ballet, tap, and jazz for a total of 10 hours of dance each week complains of low back pain for 6 months. She cannot recall any specific injury, but the pain has been gradually increasing. Initially, she had pain primarily with back extension activities. Her pain has progressed, and she now has pain with sitting or standing for prolonged periods of time. She denies radicular symptoms, numbness, tingling, or bowel/bladder problems.

On physical exam, she has pain with palpation of the lumbar spine at L5–S1 in the midline and diffuse paraspinal muscle tenderness throughout the lumbar spine. She has pain with back extension and Stork test (one-legged hyperextension). She had no neurological symptoms.

Lumbar spine series with oblique views revealed bilateral pars defect at L5–S1.

Spondylolysis (see Figure 4) is a common overuse injury among young athletes. In fact, it was the most common diagnosis found in adolescents presenting to a sports medicine clinic with low back pain.18 Young dancers place significant stress on the low back with repetitive hyperextension maneuvers. Also, dancers with inadequate turnout (external rotation at the hip) may compensate by increasing pelvic tilt and lumbar lordosis, leading to strain in the lower back.19

Spondylolysis with Grade 1 Anterolisthesis.

Figure 4: Spondylolysis with Grade 1 Anterolisthesis.

In this case, spondylolisthesis, slippage of the vertebra, had not occurred. However, concurrent spondylolisthesis occurs in about 50% of cases.20 In cases of spondylolysis associated with spondylolisthesis, significant progression of the slip is unusual, and sports participation is not likely to increase the risk for significant slippage.21 However, if slippage does occur, it is most likely to do so during the adolescent growth spurt, so radiographic monitoring is recommended until growth is complete.22 When slippage does occur, it is typically asymptomatic.

In this case, the diagnosis was made on plain film. However, if suspicion is high and plain X-rays are normal, magnetic resonance imaging (MRI), computerized tomography (CT), or radionuclide imaging may be used to aid in making the diagnosis.

The treatment of spondylolysis is controversial, with some experts recommending immobilization in a lumbosacral orthosis for 23 hours/day for 4 to 16 weeks, until pain-free with extension on physical exam. Others simply recommend the elimination of all painful activities for a similar time period. Regardless of the treatment regimen, the athlete should not be permitted to return to the activity that caused pain until completely pain-free with extension on physical exam, which usually takes 2 to 4 months.22 The return to full activity should be gradual, typically over a 2- to 4-month period.22 During the period of immobilization/rest, the athlete should be involved in physical therapy to maximize hamstring and hip flexor flexibility and lower back, pelvic, and abdominal strength. Pain-free activities such as biking, swimming, and water aerobics should be encouraged to maintain fitness during rehabilitation.

Case #5

A 14-year-old dancer complains of painful popping and snapping in her hips, bilaterally, right worse than left. She has had a popping sensation for at least 1 year, but she began to notice pain about 4 weeks ago. She cannot recall any specific injury. Early in class, she does not have pain, but as class goes on, the repetitive popping eventually causes pain. She usually notices pain in her gesturing (non-weight-bearing) leg when performing high kicks to the side or circling the leg from front to back.

On physical exam, she has mild pain with palpation over the anterior aspect of the hip with deep palpation. She has excellent adductor strength, but decreased abductor strength in comparison. She has mild pain and decreased strength with hip flexion on the right compared with the left. She has decreased hip flexor flexibility and excellent hamstring flexibility. She can voluntarily reproduce snapping on exam, and a palpable click is noted in the anterior hip with repetitive abduction of the leg.

This case is a typical presentation for “snapping hip syndrome,” a common problem among young dancers. In this case, the snapping sensation and pain were noted in the gesturing leg as she circled the leg from the front of the torso to the back or performed high kicks to the side. This type of snapping hip syndrome is referred to as internal or medial snapping hip syndrome, and is typically noted in the non-weight-bearing leg. The iliopsoas tendon creates the snapping as it moves across either the femoral head or the iliotibial eminence.

Another type of snapping hip, external or lateral snapping hip, is usually associated with snapping and pain in the supporting (weight-bearing) leg during rotation movements or landing from jumps as the leg moves from flexion to extension. Here, the snapping sensation is caused by the ITB snapping back and forth across the greater trochanter.

As many as 90% of dancers report snapping of the hip while dancing.23 However, only 58% of dancers have pain with snapping, and only 7% have had severe enough pain to take time off as a result of the injury.23 Most dancers can reproduce the snapping sensation voluntarily during the clinic visit, aiding in the diagnosis.

Initial treatment is intended to decrease pain and can include ice, ultrasound, electrical stimulation, and analgesic medications. A brief period of rest from dance activities that lead to pain may be needed. Rehabilitation is aimed at improving flexibility and strength of the iliopsoas, ITB, and other pelvic muscles and correction of postural and technique errors.

It is important to distinguish these extra-articular causes of snapping hip from intra-articular pathologies that can also cause snapping such as labral tears, loose bodies, and osteochondral fractures. These conditions are almost always painful and may cause mechanical symptoms, such as locking and catching, in addition to popping.

Dancers who have sustained an apophyseal avulsion fracture may also report a single, large, painful pop at the time of injury. This type of hip popping is easily distinguished from snapping hip syndrome by its acute and very painful nature. The athlete may be unable to bear weight at the time of injury, and the physical exam will reveal significant tenderness over the affected apophysis and weakness of the muscle group that attaches at the site. These injuries are sustained when an apophysis is pulled away from the pelvis by a strong muscle contraction. Common sites include avulsion of the anterior superior iliac spine by the sartorius muscle, avulsion of the anterior inferior iliac spine by the rectus muscle, and avulsion of the ischial tuberosity by the hamstring muscle.

Case #6

A 12-year-old dancer was on demipointe (standing with the ankle in full plantar flexion and the metatarsal phalangeal joints flexed at 90 degrees), and as she attempted to turn, she inverted the foot and ankle and fell. She felt a pop in her lateral foot as she fell and had immediate pain. She was unable to continue with class and immediately applied ice. She was able to bear a little bit of weight, but her parents needed to help her to the car and into the house that evening. When the foot was still painful and swollen the next day, she was seen in sports clinic.

At sports clinic, she had swelling and ecchymosis on the lateral border of her foot extending from the base of her fifth metatarsal to her toes. She was very tender to palpation at the base of the fifth metatarsal and had severe pain at the base of the fifth metatarsal with attempts to perform resisted eversion of the ankle.

X-rays revealed an avulsion fracture of the base of the fifth metatarsal (see Figure 5, page 283).

Avulsion Fracture at the Base of the Fifth Metatarsal.

Figure 5: Avulsion Fracture at the Base of the Fifth Metatarsal.

She was treated with a removable boot cast for 3 weeks, at which time she began a gradual return to dance, starting with barre work (exercises done while holding a bar), and gradually progressing to center work and leaps over 3 weeks. She also performed physical therapy to regain peroneal muscle strength and balance one to two times each week for 6 weeks. She had access to an indoor pool and did water-based activities during her rehabilitation as well.

Inversion injuries such as these are commonly associated with fractures of the fifth metatarsal; another common mechanism is inversion when landing from a jump. In this case, the dancer had an avulsion fracture at the base of the fifth metatarsal that healed quickly, allowing the dancer to return to sport relatively quickly. Care must be taken to distinguish this type of fracture from those at the metaphyseal/diaphyseal junction of the fifth metatarsal, a relatively avascular area that does not heal well. This fracture requires 6 to 8 weeks of non-weight-bearing immobilization and can require surgical intervention if healing does not occur with conservative treatment.

Ankle sprains, typically the anterior talofibular ligament, are the most common acute injury in dancers and have a similar mechanism of injury. Special care must be taken in the rehabilitation of dancers after ankle sprains. The sport of dance requires exceptional proprioceptive skills, and impairments in proprioception after sprain is common. Without appropriate attention to regaining proprioceptive skills during rehabilitation, the dancer will be at increased risk for re-injury. In addition, special attention to peroneal muscle strengthening will help stabilize the ankle when the dancer is bearing weight with the ankle in plantarflexion, such as the demipointe and pointe positions.24

Regardless of the injury, it is important to help the dancer find safe ways to maintain cardiovascular fitness during the rehabilitation period. This can often be achieved with water-based aerobics or running. Pilates is a form of exercise that is very familiar to most dancers and can help maintain strength and improve balance during rehabilitation. Also, with some injuries, limited participation in dance class may be possible, such as performing barre activities or by simply eliminating all painful dance activities but allowing non-painful activities during the rehabilitation process.


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CME Educational Objectives

  1. Identify the common injuries associated with non-contact sports participation in children and adolescents.

  2. Identify and discuss the assessment of commonly associated injuries in children and adolescents who participate in non-contact sports.

  3. Determine the best rehabilitation program for each of the identified injuries discussed.


Amanda Weiss Kelly, MD, is Assistant Professor, Case Western Reserve University, and Director Pediatric Sports Medicine, Rainbow Babies and Children’s Hospital.

Dr. Weiss Kelly has disclosed no relevant financial information.

Address correspondence to: Amanda Weiss Kelly, MD, Pediatric Orthopedics, 11100 Euclid Ave., Cleveland, OH 44106; e-mail:


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