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)

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 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:

• Schedule an appointment with the Young Athlete Center: 314-514-3500 or request an appointment online
• Learn more about common conditions treated by the Young Athlete Center
• Register for the Play Fit, Stay Fit! event online or call 314.454.KIDS (5437)
• Follow the Young Athlete Center on Twitter (@stlyac)      

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

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. 

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.

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.