By Jennie McKee
A roundtable discussion on how high-intensity sports are affecting children
Anyone who thinks overuse injuries aren’t a big problem for today’s young athletes should think again. Children who play sports such as football, basketball, and soccer have a growing risk of incurring stress fractures, tendinitis, and a host of other overuse injuries.
What’s behind this trend—and what can orthopaedic surgeons and other physicians do about it? Three experts from the Division of Sports Medicine at Children’s Hospital Boston—Lyle J. Micheli, MD, director; Mininder S. Kocher, MD, MPH, associate director; and Cynthia Stein, MD, primary care sports medicine practitioner—shared their insights at a symposium at the annual meeting of the American Orthopaedic Society for Sports Medicine and with AAOS Now.
AAOS Now: How have youth sports changed in the last few decades?
Dr. Kocher: Children are playing at higher intensities and at younger ages. Grade schoolers may be playing in multiple leagues. By high school, many adolescent athletes concentrate on one sport and play all four seasons, which means they don’t cross-train or change loading environments.
Youth sports have also become big business. In sports such as basketball, many athletes go directly from high school to the professional leagues. Scouts attend youth sporting events, even in the middle school age group.
Dr. Micheli: I agree—youth sports have become much more serious. It used to be that only children who participated in individual sports such as gymnastics and figure skating would train 15 or 20 hours per week, but now we’re also seeing an increased intensity in team sports. It’s a new phenomenon.
Dr. Kocher: It used to be easier to take young athletes out of sports to let injuries heal. Now, they are facing the same kind of pressure to perform as professional athletes. Almost every family tells me that their child is an “elite” athlete who will get a college scholarship and then go professional, even though this is statistically unrealistic.
AAOS Now: How do those changes relate to young athletes’ injuries?
Dr. Micheli: We still see acute traumatic injuries, but we’re also seeing a dramatic increase in overuse injuries in children, as well as training-related injuries—primarily related to the volume of training—that we didn’t see in the past.
Dr. Kocher: We rarely used to see anterior cruciate ligament (ACL) injuries in skeletally immature athletes. Now, ACL injuries are commonplace. Of the approximately 150 ACL reconstructions I perform every year, two thirds are on skeletally immature patients.
We are also seeing injuries such as meniscal tears and cartilage injuries, osteochondritis dissecans of the knee, Little League elbow and Little League shoulder, stress fractures, patellofemoral pain, Osgood-Schlatter disease, and Sever’s disease.
Mininder S. Kocher,
AAOS Now: Do you think most orthopaedists are aware of the changing injury pattern for young athletes?
Dr. Micheli: Most aren’t in a position to see the big picture; unless they’re actively involved in the youth sports leagues, they’re not seeing the change in training patterns.
Dr. Kocher: The old pediatric orthopaedic paradigm was that children did not get these injuries. We must recognize that the injury patterns have changed. For example, traditional wisdom was that teens rarely required shoulder or elbow surgery. Now, many pitchers coming out of high school and joining the major leagues have undergone a surgical procedure on the shoulder or elbow.
AAOS Now: What questions should orthopaedists ask young athletes?
Dr. Stein: I ask questions such as, “Do you have pain or discomfort?” and “How long have you had these symptoms?” Many times young athletes will have pain for months or even years and assume it’s either “growing pains” or just part of participating in a sport. It’s important for athletes, parents, and coaches to understand what overuse injuries are and how they can be treated—or, better yet—prevented.
Dr. Micheli: It’s essential to get some sense of the volume of training the child has been undertaking. Ask them questions such as, “How many hours per week do you swim or do gymnastics?” and “What level gymnast are you?”
We often see overuse injuries in young athletes who have gone from a low level of physical activity during the summer to training intensively over a relatively short period of time for a fall sport. In these situations, the physician should inquire about how the level of training changed at the time the patient started experiencing pain.
AAOS Now: Which sports have the highest injury rates? What are some of the most common overuse injuries?
Dr. Kocher: Injury patterns tend to be specific to the sport, the age of the athlete, and the intrinsic risk factors of the athlete. Acute injuries, such as ACL tears, occur in football, soccer, basketball, and skiing. Overuse injuries such as stress fractures occur more frequently in runners, dancers, and gymnasts. Throwers have unique overuse injuries in their shoulders and elbows, such as osteochondritis dissecans of the elbow, medial epicondyle apophysitis, proximal humerus physeal stress fractures, and internal impingement of the shoulder. Gymnasts can sustain distal radial physeal stress injuries with potential growth disturbance.
Dr. Stein: Spondylolysis frequently develops in dancers and gymnasts, and the number of concussions is increasing. ACL injuries, especially in female athletes, are also on the rise.
AAOS Now: What about the role of ongoing growth and development? What are other risk factors?
Dr. Kocher: Many overuse injuries occur during periods of rapid growth and relative tightness.
Other risk factors intrinsic to the athlete include alignment, laxity, strength, and body habitus. Extrinsic risk factors may include intensity and frequency of play, playing surfaces, protective equipment, and coaching.
AAOS Now: What are some of the most important principles regarding successful treatment of these injuries?
Dr. Kocher: Pediatricians emphasize that, “A child is not a little adult.” In pediatric sports medicine, we must remember that, “A child athlete is not a little adult athlete.” If caught early, many injuries will heal with nonsurgical treatment. Children are moving targets in terms of their growth and development, meaning that their size, muscle development, muscle laxity, sexual development, and psychology are constantly changing. Our treatments need to take this into account.
Also, we shouldn’t give a young player an injection just to get him or her back on the field. We should stop the child’s participation in sports, if necessary, to allow for healing.
Dr. Stein: I agree. For most injuries, the body heals well if given the opportunity. Time out of sports or at least modified activity is often needed. Physical therapy is also very important to help the body heal and reduce the risk of future injury.
AAOS Now: What can be done to prevent these injuries?
Dr. Kocher: Orthopaedists and other physicians should address intrinsic and extrinsic risk factors that may predispose patients to injury, including tightness and weakness, overactivity, psychological issues, low bone density, alignment issues, and eating disorders. For example, when treating a young pitcher with medial epicondyle apophysitis, the orthopaedist can look for imbalances such as a tight shoulder posterior capsule and an elbow flexion contracture. The patient can undergo physical therapy and can work with a pitching coach to address technique issues, such as lack of trunk rotation or dropping the arm when throwing. In addition, the family can be counseled about appropriate pitch counts and avoiding overuse.
Dr. Micheli: Overuse injuries almost always involve training errors. It’s important to increase the volume of training in a slow, progressive fashion. At our clinic we advocate the “10 percent rule,” which states that a child should not increase his or her volume of training by more than 10 percent a week. That means if the child runs 20 minutes three times a week, he or she can probably safely run 22 minutes three times a week the next week.
Well-designed and properly fitted equipment is also important. For example, running shoes should provide good support and shouldn’t be worn for too long.
Because coaches aren’t required to be credentialed, parents should be aware that the coach may not know much about how injuries occur and how they can be prevented.
Resources such as the pitch count guidelines issued by the USA Baseball Medical and Safety Advisory Committee and the International Olympic Committee (IOC) consensus statement on training of the elite child athlete are helpful.
Lyle J. Micheli,
Dr. Kocher: Strength and conditioning training can help prevent injuries and improve performance. Strength-training programs for older children and adolescents have different goals from adult programs because children are not typically able to increase muscle bulk but can increase muscle efficiency and strength. Strength-training programs that use low weights and high numbers of repetitions have been shown to have low injury rates in children.
Early detection is the key. If we can catch these injuries in the early stages, we can modify the patient’s activity to allow him or her to heal and regain normal anatomy and function. If injuries such as loose bodies in the elbow from osteochondritis dissecans or unstable osteochondritis dissecans lesions of the knee aren’t treated early, surgery may be required. We can usually get those patients back to sports, but we worry about their long-term outcomes.
AAOS Now: What research is being done or needs to be done on overuse injuries in young athletes?
Dr. Stein: Ongoing studies are showing that fatigue and overuse greatly increase the risk of injury.
A study published in 2006 compared 14- to 20-year-old baseball pitchers who had either shoulder or elbow surgery with age-matched controls. Those who pitched 8 or more months per year were five times more likely to have had surgery than those who pitched less than 8 months per year. Those who regularly pitched while fatigued were 36 times more likely to have had surgery compared to those who never pitched while fatigued.
Cynthia Stein, MD
Dr. Kocher: More research needs to be performed on preventing injuries and on understanding the risk factors. We need large prospective field epidemiologic studies to look at how much activity is too much and what the injury risk factors are.
AAOS Now: What else is important for reducing overuse injuries in young athletes?
Dr. Stein: Even though we have studies that link year-round sports to overuse injuries, it can still be difficult for athletes to limit activity. We need regulations to protect young athletes.
Dr. Micheli: I couldn’t agree more. I really think this country should develop a credentialing or certification program for youth sport coaches.
Dr. Kocher: I also would like to emphasize that despite the negative aspects, youth sports has tremendous benefits. Exercise decreases children’s risk of obesity and diabetes and leads to better cardiovascular and bone health. It also can have many psycho-social benefits, including improved self-esteem, lower rates of teen pregnancy and recreational drug use, and higher career success later in life.
I think the goal for young athletes is to realize the benefits of sports participation while avoiding injuries.
References and links to additional resources can be found in the online version of this article, available at www.aaosnow.org
Jennie McKee is a staff writer for AAOS Now. She can be reached at firstname.lastname@example.org
Statistics on youth sports injuries
Safe Kids USA, a member of a global network of organizations whose mission is to prevent accidental childhood injury, offers the following statistics on youth sports injuries:
- Every year, more than 3.5 million children aged 14 years and younger are treated for sports injuries.
- Nearly half of all injuries sustained by middle school and high school students during sports are overuse injuries.
- Almost 40 percent of patients who are treated for sports-related injuries in hospital emergency departments are children aged 5 to 14 years.
Olsen SJ 2nd, Fleisig GS, Dun S, Loftice J, Andrews JR: Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. J Am Sports Med 2006;34:905-912.
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