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.

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

By: Jeffrey J. Nepple, MD

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.

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.