Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Musculoskeletal injury in children and skeletally immature adolescents: Overview of treatment principles for nonoperative injuries

Gabriel P Brooks, PT, DPT, SCS, MTC
Albert C Hergenroeder, MD
Section Editor
Joseph Chorley, MD
Deputy Editor
James F Wiley, II, MD, MPH


This topic provides an overview of the basic principles of and modalities used in the treatment of nonoperative musculoskeletal injuries in young athletes. Rehabilitation of musculoskeletal injuries, with an emphasis on the physical therapy program, is discussed separately. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries".)

The discussion that follows assumes that fractures and joint instability have been excluded. The evaluation of musculoskeletal trauma and the management of fractures and unstable joints are discussed separately (refer to UpToDate topics on the specific bone or joint in which fracture or dislocation is suspected)


Approximately 60 million US youth aged 6 through 18 years participate in organized sports each year [1]. Analysis of sports and recreation related injury episodes in the United States has shown an average annual estimate of 8.6 million injury episodes with an age-adjusted rate of 34.1 per 1000 population [2]. Overall, injury rates are higher among males and children between the ages of 5 to 14 years. Approximately 50 percent of injuries require medical attention. Injuries to the lower extremities are most common (42 percent) followed the upper extremities (30 percent), and head and neck (16 percent).

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases report there are more than 2.6 million children younger than 19 years of age who were treated in emergency departments for musculoskeletal injuries due to sport participation [3]. Musculoskeletal injuries are also the most common reason for injury-related visits to primary care physicians. Sprains and strains, growth plate injuries, and repetitive motion injuries account for the majority of injuries.

Although most children and adolescents with musculoskeletal complaints can be managed by primary care providers with appropriate training, such children often are referred to specialists [4]. Primary care providers (including pediatricians, family physicians, and internists) and providers trained in physical medicine and rehabilitation frequently report a lack of confidence and/or training in the management of musculoskeletal problems [5-8].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Sep 05, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Brenner JS, COUNCIL ON SPORTS MEDICINE AND FITNESS. Sports Specialization and Intensive Training in Young Athletes. Pediatrics 2016; 138.
  2. Patel DR, Yamasaki A, Brown K. Epidemiology of sports-related musculoskeletal injuries in young athletes in United States. Transl Pediatr 2017; 6:160.
  3. National Institute of Arthritis and Musculoskeletal and Skin Diseases: Preventing musculoskeletal sports injuries in youth: a guide for parents. https://www.niams.nih.gov/Health_Info/Sports_Injuries/child_sports_injuries.asp (Accessed on August 28, 2017).
  4. Stirling JM, Landry GL. Sports medicine training during pediatric residency. Arch Pediatr Adolesc Med 1996; 150:211.
  5. Taras HL, Nader PR. Ten years of graduates evaluate a pediatric residency program. Am J Dis Child 1990; 144:1102.
  6. Anderson JM, Felsenthal G. Residency training in physical medicine and rehabilitation. I: Clinical and didactic experience. Arch Phys Med Rehabil 1990; 71:372.
  7. Glazier RH, Dalby DM, Badley EM, et al. Determinants of physician confidence in the primary care management of musculoskeletal disorders. J Rheumatol 1996; 23:351.
  8. Glazier RH, Dalby DM, Badley EM, et al. Management of common musculoskeletal problems: a survey of Ontario primary care physicians. CMAJ 1998; 158:1037.
  9. Reid DC. Sports Injury Assessment and Rehabilitation, Churchill Livingstone, New York 1992.
  10. Magee DL, Quillen WS, Zachazewski JE. Athletic Injuries and Rehabilitation, 1st ed, WB Saunders Company, Philadelphia 1996.
  11. Anderson SJ. Principles of Rehabilitation. In: Care of the Young Athlete, 2nd edition, Anderson SJ, Harris SS (Eds), American Academy of Orthopaedic Surgeons: American Academy of Pediatrics, Elk Grove Park, IL 2010. p.263.
  12. Ernst E, Fialka V. Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. J Pain Symptom Manage 1994; 9:56.
  13. Hergenroeder A. Acute shoulder, knee, and ankle injuries part 2: Rehabilitation. Adolescent Health Update 1996; 0:8.
  14. Mac Auley DC. Ice therapy: how good is the evidence? Int J Sports Med 2001; 22:379.
  15. Lievens P, Leduc A. Cryotherapy and sports. Int J Sports Med 1984; 5(Suppl):37.
  16. Janwantanakul P. The effect of quantity of ice and size of contact area on ice pack/skin interface temperature. Physiotherapy 2009; 95:120.
  17. Tomchuk D, Rubley MD, Holcomb WR, et al. The magnitude of tissue cooling during cryotherapy with varied types of compression. J Athl Train 2010; 45:230.
  18. Hocutt JE Jr, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. Am J Sports Med 1982; 10:316.
  19. Hobbs KT. Results of intramuscular temperature changes at various levels after the application of ice. Sport Health 1983; 1:15.
  20. Myrer JW, Measom G, Durrant E, Fellingham GW. Cold- and hot-pack contrast therapy: subcutaneous and intramuscular temperature change. J Athl Train 1997; 32:238.
  21. Zemke JE, Andersen JC, Guion WK, et al. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Orthop Sports Phys Ther 1998; 27:301.
  22. Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Athl Train 1993; 28:236.
  23. Sloan JP, Gidding P, Hain R. Effects of cold and compression on edema. The Physician and Sports Medicine 1988; 16:116.
  24. Quillen WS, Rouillier LH. Initial management of acute ankle sprains with rapid pulsed pneumatic compression and cold. J Orthop Sports Phys Ther 1982; 4:39.
  25. Bugaj R. The cooling, analgesic, and rewarming effects of ice massage on localized skin. Phys Ther 1975; 55:11.
  26. Waylonis GW. The physiologic effects of ice massage. Arch Phys Med Rehabil 1967; 48:37.
  27. Herrera E, Sandoval MC, Camargo DM, Salvini TF. Motor and sensory nerve conduction are affected differently by ice pack, ice massage, and cold water immersion. Phys Ther 2010; 90:581.
  28. Drez D, Faust DC, Evans JP. Cryotherapy and nerve palsy. Am J Sports Med 1981; 9:256.
  29. Cross KM, Wilson RW, Perrin DH. Functional performance following an ice immersion to the lower extremity. J Athl Train 1996; 31:113.
  30. Meeusen R, Lievens P. The use of cryotherapy in sports injuries. Sports Med 1986; 3:398.
  31. Uchio Y, Ochi M, Fujihara A, et al. Cryotherapy influences joint laxity and position sense of the healthy knee joint. Arch Phys Med Rehabil 2003; 84:131.
  32. LaRiviere J. The effect of ice immersion on joint position sense. J Sport Rehabil 1994; 3:58.
  33. Hopper D, Whittington D, Davies J. Does ice immersion influence ankle joint position sense? Physiother Res Int 1997; 2:223.
  34. Dover G, Powers ME. Cryotherapy does not impair shoulder joint position sense. Arch Phys Med Rehabil 2004; 85:1241.
  35. Costello JT, Donnelly AE. Effects of cold water immersion on knee joint position sense in healthy volunteers. J Sports Sci 2011; 29:449.
  36. Oliveira R, Ribeiro F, Oliveira J. Cryotherapy impairs knee joint position sense. Int J Sports Med 2010; 31:198.
  37. Grassi Dde O, de Souza MZ, Ferrareto SB, et al. Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint. Man Ther 2011; 16:495.
  38. Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther 2010; 90:1239.
  39. Tate AR, McClure PW, Young IA, et al. Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series. J Orthop Sports Phys Ther 2010; 40:474.
  40. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J Orthop Sports Phys Ther 2005; 35:409.