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.

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. 

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.

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.

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.