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:

"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.

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