Riedel NYSAFP Winter Weekend 2009 A Culture of Extremes: Overuse to Underuse in Pediatric Sports...

Riedel

NYSAFP Winter Weekend 2009

A Culture of Extremes: Overuse to Underuse in Pediatric

Sports Medicine

Rodney Riedel, MD

Director of Sports Medicine

Mid Hudson Family Practice Residency

January 30, 2009NYSAFP Winter Weekend

Lake Placid, NY

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Special Thanks

• Mark Josefski– Mid Hudson Family Practice Residency

Director

• Mary Evans– Benedictine Hospital Librarian

Contact me at: [email protected]

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Goal

Increase Family Physician comfort with youth sports and how they affect our patients

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Objectives

• Contrast the history of youth sports with today’s culture

• Define the players involved with youth sports

• Identify Overuse and Underuse syndromes focusing on the root problem and etiology

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“ An ounce of PREVENTION is worth a pound of cure.”

- Benjamin Franklin (and others)

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Background

• 30 million kids and teenagers in sports

• Sports are leading cause of injury– CDC says ½ are preventable

• 1 in 3 will seek Tx for MSK injury/year

• Leading reason for 1o

care visit (Hambridge 2002)

• 16% of all ED visits– Greatest % in age 10-14

• What about those who drop out of sports?

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Two Problems

• Safe, injury free participation

• Staying in and committing to sports

Two Trends

• Obesity

• Overuse injuries

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History of Children in Sports

• Started by push of Teddy Roosevelt in Early 1900’s

• 1903 Luther Halsey Gulick– Was at YMCA– Helped start basketball with James Nasmith

and volleyball– First Director of Physical Training for NY

Schools– Started Public Schools Athletic League

(PSAL) in NY (still present)

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History

• Roosevelt, Gulick, and PSAL goals were:– Get kids in school– make kids soldier ready– teach kids to work together– Nation building by raising kids

with “brawn, spirit, self-confidence, and quickness of men essential for the existence of a strong nation” (Theodore Roosevelt)

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History

• By 1938 safety concerns for kids already started– Committee of the American Association for

Health, Physical Education, and Recreation:

“Inasmuch as pupils below tenth grade are in the midst of a period of rapid growth, with the consequent bodily weakness and maladjustments, partial ossification of bones, mental and emotional stresses, physiological adjustment, and the like, be it therefore resolved that the leaders in the field of physical and health education should do all in their power to discourage interscholastic competition at this age level because of its strenuous nature.”

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The Players

• Parent

• Coach

• Organizations

• Schools and Colleges

• Government• The Kid

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Parents

• Best intentions– Encourage child– Teach child

• May go astray– Relive or remake their youth– Choose sports for their child– Hold child back for physical advantage– Request hormones– Pay for college

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Coach

• Teacher– technique– protective equipment– character

developement

• Training– Community level– School req. variable

• Communicator• Motive

“Winning isn’t everything, it’s the only thing”- Vince Lombardi

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ABPD

• Achievement By Proxy Distortion (Tofler, et al. 1998)

– Inappropriate expectations of success by parents and coaches

– Differentiate the needs and goals of athletes from those of coach/parent

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Organizations/Gov’t

• USOC supposed to develop grassroots sports- Amateur Sports Act 1978

• 14% of schools have decreased PE due to No Child Left Behind

• Focus changed from raising strong kids for nation building to winning

• National Alliance for Youth Sports• Hoop Scoop

– ranks basketball as young as 4th grade

• AAU

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AAU

• Bobby Dodd, President of AAU since 1992– Under his tenure the number of

“National Championships” has gone from ~100 to >250

– Age of these has changed from most >12 to as low as 6 and most starting at 8

– “I don’t know how much all this really impacts an 8 year old..”

• commenting on AAP recommendation to focus sports through age 9 on enjoyment, not competition

2008 AAU 8 and Under National Champs

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Kids

• According to 1989 Michigan State Survey the #1 reason to participate is-

TO HAVE FUN!

• Only boys even rated winning and it was #8

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Pressure

• From Coaches or Parents (Stryer, et al. 1998)

– Dysthymia, Depression– Chronic Fatigue– Substance Abuse (Todd Marinovich)– Conversion and Eating Disorders– Overtraining/Burnout Syndrome

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Tiger Woods Phenomenon

AKA- What happened to Play Time?– since 1970 unstructured play decreased by 40% from

age 3 to 11• One of several factors contributing to Sport

Specialization– focusing on a single sport at earlier age– Coaches say you need it to succeed– Parents hope for scholarships– Year round teams:

• travel, all stars, school, recreational, church

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The Result?

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The Extremes

• Overuse– Stressors > healing– Training demands >

physiologic ability.

• Underuse– Kids quit

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“My elbow hurts”

• 12 year old pitcher• Plays on travel team and

all-stars• Plays year-round• No injury or swelling• Worse while throwing• >200 pitches/week• Better on his 1 day off

per week

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Physical

• TTP on the medial elbow at epicondyle

• FROM

• Pain with resisted wrist flexion

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Imaging

• Apophyseal widening • Normal

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Differential

• Medial epicondylar apophysitis• avulsion fractures • Ulnar collateral ligament sprain • Osteochondritis of the capitellum • Osteochondrosis of the radial head • Olecranon apophysitis • Ulnar neuritis• Cervical radiculopathy

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Apophysitis

• Apophysis: Bony prominence onto which tendons are attached. Secondary ossification center.

Apophysitis: Inflammation or avulsion Apophysitis: Inflammation or avulsion caused by repetitive microtrauma caused by repetitive microtrauma and and OVERUSE!OVERUSE!

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Pediatric Considerations

• Growth cartilage– epiphyseal plate– articular surface– apophysis

• Growth imbalance• Physiologic vs. chronologic age• Improper technique and training

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Overuse Injuries

• Little-league elbow• Little-league shoulder• Gymnast wrist• Osgood-Schlatter disease• Sever disease• Spondylolysis• Sindig-Larson-Johansson disease• Medial Tibial Stress Syndrome

(Cassas 2006)

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Apophysitis

• Osgood-Schlatter: tibial tuberosity

• Sindig-Larson-Johansson: Inferior patella

• Sever’s: Calcaneus

• Little League Elbow: Medial epicondyle

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Physis Injury

• Stress fracture or reaction

• Little League Shoulder: Proximal Humerus

• Gymnast Wrist: Distal Radius or Ulna

• Early diagnosis to prevent:– pain– physeal widening– Weakened bone strength– Growth abnormalities

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Characteristics

• “Little League” elbow– pain in 20-40% of 9-12 y.o.

• Osgood-Schlatter– 20% of ALL athletes

• Sever’s– Most common heel pain in children age 10-12

• Spondylolysis– 3-7% of population, higher in certain sports

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Diagnosis

• Presentation– No injury– “my ______________ hurts”– worse with activity, better with rest

• Physical– Point tenderness– Reproduce pain functionally

• Imaging– Suspicion for avulsion Fx– Spondylolysis

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Diagnosis: Sport Specifics

• Preseason conditioning

• Pitch Counts– # of games and #of teams

• Throwing mechanics– foot push off– core stability– trunk rotation

• 4 months OFF per year

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Treatment

• Rest

• Activity/Sport Modification– correct underlying problem

• PT

• Prevention!

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The “new” overuse injuries

• Ulnar Collateral Ligament of Elbow– Ongoing study by Dr. James Andrews at ASMI

showing drastic increase in # of UCL repairs by H.S. and younger children

– Due to too many pitches, too fast, inadequate rest– The evil radar gun

• Anterior Cruciate Ligament– Female athletic participation in H.S. increased 900%

from 1971 to present– 0.3-2.9 million– Increasing evidence showing relation to technique

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“New Overuse”

• Medical profession is keeping up– we are doing the

UCL and ACL reconstructions at a younger and younger age

– we should be doing all we can to prevent these

Physeal sparing technique

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Underuse

• Start organized sports earlier– AAP recommends no specialization until puberty

• There’s more kids– 9 million more kids age 5-19 from 1990 to 2006 but

team sports participation is down– when a kid gets cut he/she stops everything

• U.S. sports structure identifies and promotes stars

• # overweight kids tripled from 1980 (CDC=18% age 6-19)– continue that lifestyle to adulthood

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Exercise

• Is Medicine– Decrease risk of: DM, HTN, CAD, Colon CA,

Depresion– Control weight– Build bones– Boost immunity– Meet friends, build memories, teach life skills

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New York Times 11/30/08by Juliet Macur

• “Born to Run? Little Ones Get Test for Sports Gene”– Marketed to children age 1 and up– looks at single gene (ACTN3) and its two

variants (R and X) which correlate with fast-twitch muscle

– Supposed to define your future propensity for power/sprint sports vs. endurance

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Reality

• Median pay for all 17000 pro athletes in 2004 = $48,310

• 7 or 8 gymnasts every 4 years go to Olympics– out of 2 million

• <4% of varsity h.s. FB play college– <1% of those play pro– average NFL tenure is 3.2 years

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What can we do?

• Identify when sports become unhealthy• Identify over competitive families• Understand the importance of sports to your

patient– RTP quickly and safely

• Don’t focus on winning– elite soccer school in france has NO games– Brazil has no organized soccer until 8 or 9

• Take advantage of the PPE• Communicate with coaches/ATC• Appropriate referrals- Know your PT

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What can we do?

• Research into reality– Competition may be harmful at <9– Mature movement developed 6 or older– More pitches = more injury

• Encourage well rounded development with sport variety and not early specialization

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Conclusion

• Youth sports have been around for > 100 years– lost their focus

• Parents, Coaches, Organizations, etc.– Have own agenda, Kid gets lost

• Overuse- year round, early specialization

• Underuse- burn out and quit, lose all benefits of exercise

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“Alumnus Football”

For when the One Great Scorer comes

To write against your name,

He marks- not that you won or lost-

But how you played the Game.

- Grantland Rice 1930

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Thank you/Questions?

Contact me at: [email protected]

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Selected References• Tofler IR, et al. Developmental Overview of Child and Youth Sports for the

Twenty-first Century. Clinics in Sports Medicine 2005;24:783-804.• Stryer BK, et al. A Developmental Overview of Child and Youth Sports in

Society. child Adolesc Psychiatr Clin N Am. 1998;7:697-724.• Brenner JS, et al. Overuse Injuries, Overtraining, and Burnout in Child and

Adolescent Athletes. Pediatrics. 2007;119:1242-1245.• Metzl JD. Expectations of Pediatric Sport Participation Among Pediatricians,

Patients, and Parents. Pediatr Clin N Am 2002;49:497-504• Klingele KE, et al. Little League Elbow: Valgus Overload Injury in the

Paediatric Athlete. Sports Med. 2002;32(15):1005-15.• Hogan KA, et al. Overuse Injuries in Pediatric Athletes. Orthop Clin N Am.

2003;34:405-15.• Ommundsen Y, et al. Parental and Coach Support of Pressure on

Psychosocial Outcomes of Pediatric Athletes in Soccer. Clin J Sport Med. 2006;16(6):522-6.

• Cassas KJ, et al. Childhood and Adolescent Sports-Related Overuse Injuries. Am Fam Physician. 2006;73:1014-22.

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Selected References• Carr KE. Musculoskeletal Injuries in Young Athletes. Clin Fam Pract.

2003;5(2):385-415.

• Herman MJ, et. al. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Ortho Clin N Amer. 2003;34(3):461-7.

• Wall EJ. Osgood-Schlatter Disease: Practical Treatment for a Self-Limiting Condition. The Phys and Sportsmedicine. 1998;26(3).

• Anderson SJ. Lower Extremity Injuries in Youth Sports. Pediatr Clin N Am. 2002;49:627-641

• Hogan KA and Gross RH. Overuse Injuries in Pediatric Athletes. Othrop Clin N Am. 2003;34:405-415.

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Interesting Books

• “Game On: The All-American Race To Make Champions of our Children.” by Tom Farrey. New York: ESPN; 2008.

• “Training a Tiger”• “Driven”

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Websites

• www.exerciseismedicine.org/– ACSM push for physician involvement in

fitness of patients

• www.fitness.gov/– Presidents Council on Physical Fitness and

Sports

• www.amssm.org• www.acsm.org• aausports.org/• www.usoc.org/

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