Tuesday, December 1, 2015

Minimalist vs Traditionalist

Minimalist vs. Traditionalist
 Paul Jenkins, PT

During fall, Cross country season moves into full swing and concern for running injuries grows. Questions continue as to if different shoes can prevent these injuries. 40,000,000 athletes are reported to run regularly in the United States.  With that impressive number, injury rates among runners are uncertain.  Research is scattered with reports ranging from 7% to 79% of runners will be injured each year. Reasons for the wide range include: injuries that are recorded, level of severity, and different levels of runners—novice to ultra-marathoners.   One study looked specifically at high school cross country runners.  Impacting factors included age, gender, body mass and shoes. Debate rages over which type of shoes are best for avoiding injuries and improving performance. Current medical science does not make this any clearer.

Before the development of modern “traditional” running shoes in the 1970’s, minimalist shoes were all that existed. Running shoes were developed to prevent injuries and improve performance. Now the minimalist movement is making the same claims. However, having less research on minimalist runner injuries makes a true comparison impossible. Simple injuries such as sprains and strains will occur with either shoe types and seems to be more based on volume of training.
Traditional running shoe pictured on the left with example of a minimal type shoe on the right
Although when comparing shoe types, scientific research has shown differences in muscle activation, joint angle, and impact forces. It is difficult to determine if this is truly related to the shoes or the running style associated with the shoes.  Typically runners in minimalist shoes will have a forefoot strike pattern unlike traditional running shoes which have a rear-foot strike pattern. The forefront pattern will land on the front of the foot, with the heel hitting later, if at all, versus the rear-foot pattern the heel hits first, taking advantage of the cushioning of the shoe.  Runners who have a rear-foot strike pattern will not likely do as well in minimalist shoes if they do not change their running style.
If you are having pain in your current footwear you may consider changing shoes, if your running style matches the other shoe.  Otherwise keep on running the way you enjoy and wear the shoes you like best.  Personally I enjoy training in both, but I do run differently in different shoes

Thursday, November 5, 2015

Pediatric Imaging Services at the Young Athlete Center

by Eric Eutsler, MD
Pediatric Musculoskeletal Radiologist
           High quality medical imaging is crucial to any orthopedic practice. At the Young Athlete Center, our imaging technologists and radiologists work closely with the orthopedic doctors to optimize the imaging tests that are performed. The Young Athlete Center is staffed every weekday by a pediatric radiologist from the Mallinckrodt Institute of Radiology (which is part of Washington University). We have on-site x-ray, ultrasound, and MRI available at the Children’s Specialty Care Center in West County.

            X-rays are primarily used to evaluate bones. When a sports-related injury occurs, an x-ray is almost always the first imaging test that is obtained. X-rays use ionizing radiation (photons) to take an image of the injured body part. It is important to limit radiation exposure in all patients, but especially in young patients whose bodies are still growing. At the Young Athlete Center, our carefully calibrated x-ray equipment ensures that our patients’ x-rays are obtained at the lowest radiation dose possible while still maintaining excellent image quality.

An X-ray of the forearm demonstrating fractures of the radius and ulna

            Ultrasound is primarily used to evaluate the soft tissues. This type of imaging uses sound waves to generate a picture, and there is no ionizing radiation involved. It is especially helpful for looking at the superficial soft tissues (close to the skin), such as certain muscles, tendons, and ligaments, as well as other “lumps and bumps” related to acute or chronic injuries.
An ultrasound image showing the normal patellar tendon which is close to the skin surface and connects the kneecap (or patella, arrow) to the tibia (curved arrow)

            Magnetic Resonance Imaging (or ‘MRI’) can be used to evaluate both the bones and soft tissues, including structures deep inside joints. MRI pictures are created using a powerful magnet, and no ionizing radiation is involved. Most MRI examinations for sports injuries do not require injection of contrast material (no needles!). However, a special type of MRI called an MR Arthrogram (or ‘MRA’) does help diagnose many types of sports injuries, including labral tears of the shoulder, ulnar collateral ligament tears of the elbow, various ligament injuries of the wrist, and labral tears of the hip. In this procedure, our pediatric musculoskeletal radiologist Dr. Eric Eutsler uses pulses of low-dose x-rays to guide a needle into the joint and fills the joint with contrast fluid. After that, the patient is immediately escorted down the hall to our state-of-the-art MRI machine and an MRI is performed. The Young Athlete Center currently offers appointments for MR arthrograms every Wednesday at the Children’s Specialty Care Center in West County, and will offer MR arthrogram appointments at St. Louis Children’s Hospital in the near future.

An MR image of the knee demonstrating the anterior cruciate ligament (or 'ACL', arrow)

Monday, October 26, 2015

What It Means To Be Pediatric Sports Medicine Surgeon

By: Jeffrey J. Nepple
Washington University Orthopedics

Over 3.5 million injuries occur in youth sports every year. It takes many types of individuals to care for all aspects of the health of these injured young athletes. Pediatric sports medicine surgeons are one part of this team and are orthopedic surgeons who specialize in the treatment of musculoskeletal injuries in these young athletes. Pediatric sports medicine surgeons have overlap with other orthopedic subspecialties including pediatric orthopedics (caring for general musculoskeletal conditions in children) and sports medicine surgeons (caring for sports injuries in adolescents and adults).  Pediatric sports medicine surgeons focus on the injuries in the growing child and adolescent (skeletally immature meaning still growing). Many surgeons in this field have dedicated fellowship training in both pediatric orthopedics and sports medicine. The unique period of rapid growth and development make young athletes at risk for a variety of injuries not seen in adults, particularly injuries involving the growth plate (called physis).  Similarly, surgical treatment of injuries in these athletes may be different than adults and require adjustment due to the open growth plate. My practice includes 4 main areas:  (1)  Nonoperative care, (2) Surgical care, (3) Team coverage, and (4) Research.

As a pediatric sports medicine surgeon, I care for a variety of conditions that will never require surgery and can be successfully treated with nonoperative measures (including rest, physical therapy, bracing/casting, and medications). This is similar to nonoperative pediatric sports medicine physicians caring for these athletes. With nearly half of all youth sports injuries occurring secondary to overuse, overuse is a common source of many of these injuries. This is particularly true for athletes playing a single sport year-round. Some common conditions include Osgood-Schlatter’s disease, patellofemoral pain, and Little Leaguer’s elbow.

As a pediatric sports medicine surgeon, I specialize in performing surgery on young athletes with injuries that can’t be managed by nonoperative measures alone.  Often these injuries are the result of traumatic injury, rather than overuse. Common conditions include anterior cruciate ligament (ACL) tears, osteochondritis dissecans (OCD), and growth plate fractures.  Most sports medicine injuries are now treated minimally invasively with arthroscopy. Arthroscopy involves the use of a pencil-sized camera to see inside joints thru small incisions and lessens the amount of pain experienced after surgery.  During surgery, surgeons watch on a video screen while they perform surgery with their hands thru these small incisions. This is commonly compared to “video games” due to the required hand-eye coordination. Depending on the age and extent of surgery, surgery may be performed either in the outpatient (able to go home on day of surgery) or inpatient (spending one night in the hospital).  After surgery, I work closely with the athlete’s physical therapist and/or athletic training to improve the athlete’s recovery and return to sports.

As a pediatric sports medicine surgeon, I am also involved in the medical care of teams of young athletes. During my career, I’ve participated in the care of athletes at almost every level including elementary school, junior high, high school, college, professional, and Olympic athletes. Injuries become more common as the size and speed of athletes increase.  So physicians are most commonly involved in team coverage at the high school age and beyond, with football being the most commonly covered.  On the sidelines, the surgeon is involved in the acute assessment of injuries and decisions regarding the safety of athletes.

The final focus of my practice as a pediatric sports medicine surgeon is research. Pediatric sports medicine is a relatively new field and there is currently inadequate research to guide many of our decisions. Clinical research attempts to utilize information from the treatment of our patients to help identify the best form of treatment for future patients. For most young athletes, this means no difference in how they are treated but instead a few extra questionnaires to help us understand how they’re doing.  Research in the twentieth century now focuses on patient-reported results, rather than those measurable by the physician. I am currently involved in several national/international research groups that my patients participate in including:

-ROCK (Osteochondritis Dissecans/OCD)
-FACT (Clavicle Fractures)
-PLUTO (ACL tears)
-ANCHOR (Young Adult Hip conditions including femoral acetabular impingement/FAI and hip dysplasia).

As a pediatric sports medicine surgeon, I feel privileged to care for some the most dedicated and determined of the next generation.  Sports injuries in children and adolescents are major events in their life and helping to “heal” or “fix” them is a tremendously rewarding part of my job.

Wednesday, September 16, 2015

What is the Young Athlete Center?

Clinicians from Washington University and St. Louis Children’s Hospital have teamed up to form the all new Young Athlete Center, a program designed to provide comprehensive care for pediatric and adolescent athletes of all abilities with sports-related injuries. The Young Athlete Center has a multidisciplinary treatment approach, working in collaboration with physicians and clinicians from a variety of specialties, including orthopedics, sports medicine, physical therapy, adolescent medicine, pain management, sports psychology, rheumatology, cardiology, nutrition and more. Together this multidisciplinary team provides care for any health issues a young athlete may encounter.

The Young Athlete Center offers:
  • Same-day appointments
  • Comprehensive evaluations by Washington University orthopedic and sports medicine physicians
  • On-site radiology, imaging, casting and splinting services
  • Nonsurgical management of sports-related injuries
  • Minimally invasive, surgical treatment of sports-related injuries, with same-day discharge
  • Pediatric specialty care of fractures
  • Sports-related concussion assessments
  • Orthopedics, sports medicine, physical therapy, pain management, sports psychology, adolescent medicine, nutrition, rheumatology, cardiology, and others

The Young Athlete Center is directed by Jeffrey Nepple, MD, a pediatric orthopedic and sports medicine physician, and Mark Halstead, MD, a non-surgical sports medicine physician, both physicians at Washington University Orthopedics. The Young Athlete Center is located at the all new St. Louis Children’s Specialty Care Center in West County, with additional services at St. Louis Children’s Hospital in the Central West End.

Injury Prevention Education
The Young Athlete Center is also committed to improving injury prevention in youth sports. Nearly 3.5 million injuries occur in youth sports each year, with up to half of these being overuse injuries that could be prevented. The Young Athlete Center provides education on sports injuries and injury prevention through many methods, including social media, blog posts and public events. The Young Athlete Center hosted its first event, PlayFit, Stay Fit! on August 8, from 9am-noon at the new St. Louis Children’s Specialty Care Center. This  free, open house event included lectures from Washington University clinicians on injury prevention, sports concussions, sports anxiety and more. Participants had a chance to meet Orlando Pace, former offensive tackle for the St. Louis Rams, the official mascots of the St. Louis Rams and Blues, enjoyed wholesome snacks and refreshments, took home great giveaways, played fun games and activities, and took a tour of the new St. Louis Children’s Specialty Care Center. The Young Athlete Center also plans to host a lecture series for parents and coaches on common sports topics in the coming months; additional information on this lecture series will be announced soon.  

More Information:

Friday, September 11, 2015

Lessons from The Sports Gene

I recently read the New York Times Bestseller, The Sports Gene, by David Epstein and wanted to share a few thoughts.

I thoroughly enjoyed the book and recommend it to anyone interested in high level sports performance.  The book is well written and filled with fascinating stories.  It delves into the medical side of genes (hence, the title) with a bit of science which may not be enjoyable for everyone.  Each of the 16 chapters addressed a different aspect of sports performance with a specific look to nature vs nurture.  From perceptual skills to visual acuity, to response to training, among many others.  But don't expect answers or recommendations as this field continues to evolve.

One theme throughout the book is assessing the science of the 10,000 hour rule as set for by Ericsson, et al.  While this is a huge topic, I took away a few thoughts.  No matter the genetic 'advantages' some may possess, practice and hard work are essential to athletic success.  An assessment of almost every high level athlete reveals an incredible commitment to their sport.  Chapter 2 is the story of an exception to this rule- Donald Thomas who became a world class high jumper with almost no practice.  His story is amazing but incredibly rare.  Most of the book reveals that athletic success at the highest level is only possible with an many, many hours of practice.  But genetic gifts such as body type, achilles tendon stiffness, vision, trainability among many others may allow those with a practice commitment even greater success.  And there clearly is no magic threshold for 10,000 hours of practice.  It was an average of many subjects in a study of musical success.  Practice in sports is key for success but there is no evidence to support the 10,000 hour 'rule' in sports.

Another take away point- especially pertinent to those of us caring for young athletes- is the concept of early sports specialization.  We, as physicians, have seen a trend of kids committing to one sport early and playing that sports year around.  We believe that such specialization has led to an increasing number of injuries as well as a different type of injuries (similar to those seen in older athletes).  Epstein makes several interesting points based around the following concept: near elite athletes invest more hours of practice compared to elite athletes until the mid- teen years.  At that point, the hours invested by the elite athlete increases.
1) Elite athletes may simply be gifted and not need that additional early practice
2) Future elite athletes may decrease their practice commitment in the midteen years in response to the realities of their sport or the affect of body changes (puberty).
3) Early specialization may actually be harmful to some athletes  (i.e., the near- elite) leading to a teenage decreased performance (the speed plateau in track athletes is one example)
4) Early specialization clearly decreases the opportunity to experiment with other sports that may actually offer a better chance of success.  Steven Nash, one example, played soccer primarily and only later switched to basketball.  

There are many, many other interesting stories and science facts throughout the book.  I recommend it highly.

Charles A. Goldfarb, MD
My Bio at Washington University

Monday, September 7, 2015

What is baseline testing for a concussion?

By: Mark Halstead, MD
Washington University Orthopedics

With so much attention these days to concussions in sports, I think it is helpful to explain what exactly baseline testing is all about as I find there is much confusion over what it actually does. The term baseline testing is also often not used correctly in the media so I hope to clarify some of that as well.

A baseline test can be one of several tests currently available to assess someone after they have had a concussion to either help determine if someone has had a concussion or to help determine if they have recovered from their injury to return to play. 

Several examples of sideline baseline tests include the SCAT3 (Sport Concussion Assessment Tool, 3rd edition), the King-Devick test, SAC (Standardized Assessment of Concussion), and BESS (Balance Error Scoring System) just to name a few of the more commonly utilized tests.

The SCAT3 actually incorporates the SAC and the BESS into its testing protocol. The goal is to test someone with one or more of these tests preseason and then to test them after a suspected concussion has occurred. If someone performs worse after a suspected concussion than they did on their baseline test, that increases the likelihood significantly that the person being tested did sustain a concussion.
Example of SCAT3 test which is freely downloadable to any individual free of charge
There are versions of the SCAT3 for athletes over the age of 12 and also a Child SCAT3 for those from 5-12 years of age. Unfortunately at this time, the Child SCAT3 has not had many of the components included validated for use in this age group and assumptions were made by the group who created these modified tests that these would be able to be applied to this age group. Research still needs the be conducted on the reliability of assessing for concussion with the use of these tests in athletes under the age of 12. For the SCAT3 that is used over the age of 12, the majority of the test components have been extensively researched although no published standard exists for determining, with absolute certainty, as to how poor one needs to perform to truly be diagnosed with a concussion.

The King-Devick test is another test that may be used to assess for a concussion on the sidelines. It is a test that requires the athlete to read through three cards with numbers printed on them in a left to right fashion. The test is timed and is recommended to be conducted as a pre-season assessment and then potentially be used when assessing for a concussion. Originally developed as a screening test for reading difficulties in children, it was first shown to have some application for screening for concussions in boxers and MMA fighters in a study published in 2011 in the journal Neurology by Galetta, et al. Since then several other studies have been published evaluating its use. To date, limited studies have been published in the use of this test in athletes middle school age and below and for those that have been published, in this blog authors' opinion, have had some questionable methods and conclusions made regarding the use of this test. While this test may have some utility in the evaluation of concussions in athletes, more research needs to be conducted to ensure other factors do not effect performance on the test. This test is not available for free and the company does charge for the materials, whether they be in hand test booklets or handheld tablet version of the test.
Example of the King-Devick Test
Finally, the tests that probably are recognized most commonly by the public as a baseline test are the computerized neuropsychological tests such as ImPACT, Concussion Vital Signs, ANAM (primarily a military assessment), to name a few. These tests are conducted as a preseason assessment for an athlete and take about 20-25 minutes to complete. If an athlete sustains a concussion, these are tests that are primarily designed more to determine the recovery after an injury rather than being a tool to diagnose a concussion. Different providers, schools and clinics may have different protocols for the use of these tests following an injury. Dr. Halstead will use them once an athlete is very minimally symptomatic or symptom free to see if the athlete, on a post injury test, has returned to their baseline performance. Dr. Halstead does not typically use these types of tests in athletes who have not had a previous baseline assessment. 

Example of one test in the ImPACT test battery

Unfortunately, some consider these computerized tests as the 'gold standard' for concussion assessment. These tests are just one tool in the management of a concussion and concussions can be managed without their use. These tests also have an annual cost to the schools or organizations who are administering the tests. Test results are ideally interpreted by a physician or neuropsychologist who are trained in the interpretation of these results. They should not be interpreted by the coach or parent and these are not considered a 'red light/green light' type of test as far as returning an athlete to play following a concussion. 

Currently, the majority of these computerized tests are valid for use in athletes as young as 12. They must be repeated annually until the 10th grade due to increasing scores as a child gets older. Performance on these tests has been found to be affected by ADHD (Attention Deficit Disorder), depression, prior night's sleep, prior computer use, administration at home as opposed to controlled testing environment and race. You cannot "fail" a baseline test, but very poor test performance may be considered an invalid test and an athlete may be asked to repeat their baseline assessment. The test afterwards is not called a 'baseline' but actually a post injury test, which is often described incorrectly in the media. Again, an athlete cannot 'fail' a post-injury test but if they do not perform as well as they did on their baseline, and athlete is described as having 'not returned to their baseline.'

Dr. Halstead is the director of the Washington University Sports Concussion Clinic. He currently oversees the concussion programs for 8 local high schools, Washington University and the St Louis Rams. He also acts as the primary concussion consultant for the St Louis Blues. He is the lead author on two American Academy of Pediatrics statements about concussions entitled "Sport-Related Concussions in Children and Adolescents" and "Returning to Learning following Concussion."

If you would like your child evaluated following their sport-related concussion by the Washington University Concussion Clinic, please call 314-514-3500. Dr. Halstead also performs in office baseline assessments on individual athletes over the age of 12 who may be involved with teams that do not have a concussion program already in place. 

Wednesday, August 26, 2015

Anterior Cruciate Ligament Tears in Young Athletes

By: Matthew Matava, MD
Washington University Orthopedics

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. A ligament connects a bone to another bone. The ACL is instrumental in providing rotational stability to the knee during cutting, jumping, or pivoting activities. A young athlete who injures his or her ACL typically does so while cutting or pivoting without direct contact from another player. Girls are up to eight times more commonly injured than boys at all levels due, most likely, to differences in protective muscle firing patterns of the thigh muscles in response to a forceful stress on the knee.

Figure 1. MRI of the knee showing a torn ACL
An ACL tear is usually associated with an audible ‘pop’, an inability to continue play, and knee swelling within 6 hours. Young athletes will injure other structures in the knee, such as the meniscus cartilage, approximately one-half of the time. The injury is accurately diagnosed by the characteristic injury history, a careful physical examination, and usually an MRI, which stands for magnetic resonance imaging. This highly accurate test is able to obtain internal images of the knee with a high degree of accuracy, without exposure to radiation (Figure 1).

Figure 2. Surgical view of a torn ACL being probed
Most young athletes with an ACL tear elect to have the torn ligament reconstructed in order to prevent recurrent knee instability. Surgery is usually delayed 3-4 weeks from the time of injury to allow any knee swelling to subside and to improve the knee’s range of motion. Surgery to reconstruct a torn ACL takes approximately one hour to complete and is usually done as an out-patient under a general anesthesia (Figure 2). Care is taken in growing children not to injure the growth plates around the knee during the surgical procedure. A graft taken from another tendon around the knee is used to replace the torn ACL without any significant consequences (Figure 3). Any other injuries that are present can also be addressed at the same time.

Figure 3. Surgical view of reconstructed ACL graft
Physical therapy is very important after surgery to allow full return to normal knee function. Children require crutches to walk for up to six weeks following surgery. Young athletes are progressed through a specified sequence of exercises to regain knee motion, strength, and the ability to run, jump, and cut. Most children are able to return to sports approximately six months following ACL surgery with success rates topping 90%.

What was once an injury that doomed an athlete to a premature discontinuation of sports, an ACL tear can now be effectively and safely treated with a high likelihood of success in returning to high-level sports and other activities.

Tuesday, August 18, 2015

Should my Child be Lifting Weights?

By: Terra Blatnik, MD
Washington University Orthopedics

In an era where CrossFit has become common place and the pressure continues to mount in youth sports, this is a question that most parents may have on their minds: “Should my child be lifting weights? Is it safe for my child to be lifting weights?”

Strength training is the term that we use in sports medicine for weight lifting and other similar activities. In adults, strength training has been found to have obvious benefits that include improvements in cholesterol and cardiovascular health. Kids may have similar benefits and it may also improve their bone health as well.  It can improve overall strength and appropriate training programs may lead to some benefit in acquiring sports skills.  

The biggest concern is safety in strength training. We don’t want our kids to get injured while participating in weight lifting or to affect their growth in a negative way. In both cases, if done in a supervised setting, these injuries and bone issues can be avoided. Most injuries with strength training occur at home in an unsupervised setting. These are typically muscle strains which could be avoided if done under appropriate supervision. 

Before beginning any type of exercise program, kids should be evaluated by a physician to make sure that it is safe. Once this has been completed, it is important for parents to find a well supervised program with adults that understand strength training in children. They should be well-versed in appropriate lifting techniques and know what limitations kids should have.  

The American Academy of Pediatrics recently made some recommendations regarding strength training in children that provide some good rules to follow. Kids should not begin any type of strength training until they are about 7-8 years old. At this age, they have enough control and balance to handle lifting weights. Programs should focus on light weight and high repetition lifting. Olympic lifting or maximum weight lifting should be avoided until kids are skeletally mature (at least 14-15 years in girls and 16-17 years in boys). Using one’s own body weight is another way that kids can participate in strength training and further minimize the risk of injury. These types of exercises include squats, lunges, burpees, push-ups, and pull-ups. Light weight resistance tubing can also be used in strength training with minimal risk. Every session should include a 10-15 minute warm up and cool down. Strength training should just be one part of an exercise routine for kids—they should also be active in cardiovascular exercise (running, swimming, jogging, etc) and sports specific training.      

Following these basic guidelines should allow safe strength training for kids and ease parental worries about injury.      

Thursday, August 6, 2015

Football and the Young Athlete

By: Matthew J. Matava, MD
Washington University Orthopedics

American tackle football has become one of the most popular sports in the United States replacing baseball in the minds of many Americans as the “national pastime”. Approximately, 2.8 million children age 6 to 14 play organized youth tackle football and another 1.3 million play at the high school level, making it among the most popular youth sports in the U.S.

Despite the millions of children and adolescents who gain the physical, social and psychological rewards that youth football provides, many parents and other interested adults continue to ask, “Is youth football safe?” This seemingly simple question is one that does not have a simple answer. Parents and administrators are debating this openly – a testament to the major shift in public sentiment recognized over the past three years. While no sport is perfectly safe, the question is whether it can be made relatively safe and if the long-term consequences of any sport are worth the risk. It may surprise parents to know that at the youth level, organized football among 5 to 15 year-olds has 12% fewer injuries per player than organized soccer in the same age range, 50% fewer injuries than bicycle riding, and 74% fewer injuries than skateboarding. In general, football-related injuries tend to vary inversely with the players’ age (and associated size and force exerted through contact) in that youth players sustain less than one-third the injuries of high school football players, less than one-fifth the injuries of collegiate players, and less than one-ninth those seen in professional football players.

Despite the perception that that the majority of football participants will eventually sustain an injury, a recent study by USA Football which included more than 60,000 individual athletic exposures (participation in a practice or game) for nearly 2,000 youth football players, found that more than 90 percent of the youth players did not suffer an injury that restricted participation; fewer than 10 percent of players incurred an injury, and of those injuries, two-thirds were minor allowing athletes to return to play on the same day.

The majority of football-related injuries occur to the musculoskeletal system, most notably the lower leg, ankle, and foot. The most common injuries among high school football players are ligament sprains. Fortunately, most of these are relatively minor and are effectively treated by nonoperative means of rest, ice, compression, and elevation of the injured area. Some ligament injuries may be season ending for a number of youth football players.

Non-orthopedic conditions are also seen in football. With summer training camps comes an increased awareness and vigilance for exertional heal illness. Young athletes account for approximately half of all heat-related injuries. High school athletes, especially males, are at the highest risk for requiring emergency treatment for this avoidable condition. Unfortunately, approximately two-thirds of football players sustaining heat illness are either overweight or obese. Other risk factors for heat illness include: practicing in the mid-day heat, wearing dark-colored uniforms, donning full pads and helmet at all times, limiting water breaks, diabetes, and sickle cell trait in African Americans. Frequent water breaks to replenish lost fluid are imperative to prevent heat-related illness. Athletes should be weighed before and after activity to replace fluid losses. An athlete should not be allowed to return to play if he has lost over 3% of his body weight following activity until those fluid losses replaced. In conclusion, football, under its current rules, will never be entirely safe and free of the risk for injuries. Therefore, it is important that there is always the proper available care to treat mild injuries with continued surveillance for more significant injuries. Instruction in proper tackling and blocking techniques, use of well-fitted equipment, and adherence to the rules of the game, are necessary means to reduce the risk for serious injury to youth players. At a minimum, first-aid training should be considered for at least one coach or league official present at all youth football practices and competitions. Given the limited resources of many youth leagues, it is imperative for those health care professionals with an interest and expertise in sports medicine to do what they can at the local level to help maintain the safety of the game so that today’s youth players can continue to enjoy all of the positive benefits of American football.

Tuesday, August 4, 2015

Youth Sports Specialization: 10,000 Hour Pathway to What?

Washington University Orthopedics

We will live in the age of an epidemic of youth sports injuries. More than 3.5 million youth sports injuries occur every year in athletes 14 years of age or younger. Over half of these injuries appear to be related to overuse and could be prevented. As medical providers, we see more and more pediatric and adolescent athletes with adult-type injuries to bones, joints, and ligaments. The obvious question becomes – Why? Youth sports have changed dramatically in the last few decades and barely resemble the sports many of us as parents played growing up.

Sports specialization is among one of these major changes. Youth school-based sports, have become overshadowed by the growing industry of club sports and travel teams. Youth athletes now have opportunities to play a single sport year round, even participating on multiple teams at the same time. Young athletes (and parents) are now subjected to growing pressure to specialize in a single sport or risk jeopardizing their chance of playing high school or college sports. Unfortunately, many parents believe this myth. Sports specialization (defined as focus on a single sport year round) has long been common in the high school athlete, but is now increasing in the junior high and middle school athlete. Sports specialization in youth sports often occurs as an effort for the child and parents to maximize our child’s “potential”. All parents want to see their children succeed, and many wouldn’t mind to raise the next professional or Olympic athlete or have their child earn a college scholarship. Malcolm Gladwell in his book Outliers recently popularized the 10,000-hour rule in developing a skill. Simply put, Gladwell noted that 10,000 hours of quality practice are needed to reach the highest level of skill for a given activity. That’s a lot of hours – especially for a child … 40 hours a week for nearly 5 years…. 20 hours a week for nearly 10 years. While many elite level athletes indeed reach this, studies have shown many reach the highest level prior to 10,000 hours. The path to 10,000 hours for the youth athlete is no guarantee as well, with many athletes sidelined by injury or burnout. Unfortunately, the 10,000-hour rule is the mindset many parents have adopted and supports single sport specialization.

Evidence for single sport specialization improving sports performance is very limited. Only in gymnastics and ice skating does this appear to be true, where intensive specialization at a young age may be the only route to ever reach an elite level. However, it’s not a coincidence that that overuse injuries are extremely common in these sports as well. Sports specialization at an early age in other sports like football, basketball, baseball/softball, and soccer doesn’t appear to have clear long-term benefit. The improvement in “skill development” that comes with youth sports specialization, must be weighed against the detrimental effects on “athletic development”. The short-term improvements in performance come with a risk of overuse injury, alterations in skeletal development, and burnout. Playing multiple sports in the growing child exposes their bone, growth plates, joints, muscles, and ligaments to varying forces that encourage healthy development. Exposures to multiple sports also leads to development of varying physical and cognitive skills that often transfer to their primary sport and make them a better athlete. Most college coaches admit to preferring to recruit multi-sport high school athletes for these very reasons. The World Cup Champion United States Women’s Soccer Team is a perfect example. Martin Rogers recently reported on the value of non-soccer sporting activities in these elite athletes in USA Today: http://usat.ly/1LZAwJs

"Having that variety is an awesome thing and I would encourage any young athlete or parent not to restrict themselves. Doing different things develops different parts of your body. It can help prevent injuries and definitely help prevent burnout." -Lauren Holiday, U.S. Olympic soccer player 

"It is really unfortunate seeing how things are going with some kids these days. It is easy to fixate on those 10,000 hours but sport is such a subtle thing. You might not realize that what you're doing in volleyball is improving your spatial awareness and communication, but in reality maybe it is." -Whitney Engen, U.S. Olympic soccer player 

If our goal is to develop healthy, balanced athletes with the best chance to succeed in sports in high school and beyond, youth sports specialization should be avoided and delayed until high school. Young athletes are unlikely to set such limits, so parents need to. Athletes should have at least a season (3 month period) of rest from any given sport, as well as having at least a day of rest from sports per week throughout the year. Stopping the epidemic of youth sports injuries begins protecting one athlete at a time.

Sunday, August 2, 2015

Sports Participation for the Pediatric Thrower

By: David Piskulic, DPT, SCS, ATC/L
St. Louis Children’s Hospital Physical Therapy

It’s summer time! And that means several things…no school, sunshine, and lots of America’s favorite pastime: baseball. Participation in youth baseball leagues and youth sports in general has increased significantly in recent years. Unfortunately, there has also been an increase in sports related injuries. In fact, 3.5 million children under the age of 14 are seen annually for sports related injuries. 

Youth throwing injuries have been a particular area of increased concern. Injuries that were normally seen in professional athletes are being seen in our young athletes. The link to the article below discusses the current environment of youth participation in baseball and its implications towards injury. There is also a free handout with pitch type, pitch count, and rest recommendations for youth baseball players to help prevent some of these injuries.

Click here to continue: http://www.medbridgeeducation.com/blog/2015/12/sports-participation-for-the-pediatric-thrower-how-much-is-too-much/

Wednesday, July 29, 2015

Sports Injuries of the Upper Extremity in the Young Athlete

By: Charles A. Goldfarb, MD
Washington University Orthopedics

Sports injuries to the hand and upper extremity are common in all ages. These can be bruises, sprains, injuries of ligaments, tendons, and cartilage, and fractures. These can be acute (meaning happened just now) or chronic (older than 6 weeks). Most often, it is a hand surgeon who cares for injuries to the hand and wrist but sometimes another doctor or surgeon with particular expertise in this area may be the caregiver. Sports injuries to the young athlete (for the purposes of this discussion, less than 18 years of age) are a bit more complicated than injuries to the adult as 1) the injury patterns are different compared to the adult and 2) the growth plate must be considered.

The injury patterns may be different in the young athlete. Often, in kids, the bone (and maybe the growth plate) are weaker than ligaments (definition- a ligament connects two bones together and provides stability). Therefore, instead of ligament tears, the bone may break instead. While this sounds worse, most of us believe that this is a better injury because bones heal better and more predictably than ligaments. The classic example of this injury is to the thumb- the skier thumb or gamekeeper thumb. In adults, it is always a ligament that tears but in kids, the bone breaks.

Another reason that kids’ injuries are different is related to their developing bones and joints. This includes their growth plates (definition: the part of the bone responsible for its growth, seen as a line on x-ray). With overuse (such as too much pitching or too much gymnastics), the bone, the joint, the growth plates, and the ligaments may all be affected. The classic example is the gymnast wrist (to be discussed in more detail in a later post). But briefly, this is an overuse injury of the wrist with a stoppage of growth of the radius.

Yet another reason that kids are different than adults is that when a bone breaks (or fractures)- and we all know this happens in sports- the injury often affects the growth plate. We believe this type of injury is especially common as the growth plate start to close at ages 10-15, depending on the particular area. The growth plate that is nearly finished growing becomes an area of weakness until it completely closes and, therefore, can be the site of a fracture. A growth plate fracture can be stressful for everyone, but in most cases these injuries do quite well. It is important, however, to see a doctor who treats kids regularly to increase the chance of a great result.

A few examples of the most common upper extremity sports injuries in young athletes include:

1) Elbow
    a. Ligament injury (most common, MCL)
    b. OCD (osteochondritis dissecans of the capitellum)
    c. Dislocation
    d. Fracture of humerus including condyles, olecranon, radius
    e. Ulnar nerve injury or instability

2) Wrist
    a. ligament injury (most common, scapholunate ligament tear)
    b. gymnast wrist (injury to radius growth plate)
    c. TFCC tear (cartilage of wrist)
    d. Wrist instability
    e. Tendonitis
    f. Fractures of the forearm and wrist (most common, scaphoid fracture)

3) Hand
    a. Fracture of any bone
    b. Ligament injury (skier thumb)
    c. Joint dislocation (most common, PIP joint)
    d. Tendon injury (most common, mallet finger or FDP avulsion)

Thankfully, most injuries to the young athlete heal well and we can return the athlete to sports soon after healing. But, some injuries require specialized care including prompt diagnosis with consideration of age, the effect of growth, and the particular sport to allow ideal treatment. This is true for all injuries including those of the upper extremity, hand and wrist.

Monday, July 27, 2015

What is Sports Medicine?

By: Mark E. Halstead, MD
Washington University Orthopedics

Often times I am asked what exactly a sports medicine provider does. Generally it is assumed that I do surgery and that I just watch a bunch of sports events and help provide care for those athletes. Some of that may be true but it is far from what sports medicine really is about. Someone can be involved with sports medicine as a doctor, athletic trainer, physical therapist, nutritionist, psychologist, and chiropractor, just to name a few specialties. I chose to be a sports medicine doctor who does not do surgery. Typically that is referred to as a primary care sports medicine doctor. Primary care sports medicine doctors go to college, then medical school and then do a residency in family medicine, emergency medicine, internal medicine, physical medicine and rehabilitation, or my choice, pediatrics. A sports medicine doctor can also be a surgeon, typically an orthopedic surgeon who deals with bone, joint, ligament and muscle injuries. Some general surgeons can be sports medicine doctors as well. There are also sports medicine doctors who specialize in problems athletes can have with their heart (cardiologist), lungs (pulmonologist), nerves/brain (neurologist), or eyes (ophthalmologist).

As a primary care sports medicine doctor, I can find out what problem an athlete may have with their bones, joints, muscles or ligaments like a surgeon does, but if they need surgery I send them to someone who does surgery. But I have the added benefit of having special training in sports problems that aren’t related to just the bones and joints. One of the things that I deal with a lot is a sports concussion. We will be sure to cover that topic a lot in future blog posts.

Over the years, I’ve had the ability to provide medical care to a lot of different types of athletes including athletes on the St. Louis Rams, St. Louis Blues, St. Louis Cardinals, US Women’s Figure Skating Team, and many college athletes including those from Washington University, Vanderbilt University, University of Wisconsin, University of Missouri, St Louis University and many others. I’ve been to a ton of high school football games and other sporting events and am proud to say I’ve been the team physician for Lafayette High School since 2007.

At the Young Athlete Center, we have a lot of specialists in sports medicine who are available to make sure we provide the best care to keep all the athletes we see healthy and get them back their sport as soon and safely as possible.