Vanderbilt Sports Medicine Injury Prevention in Youth Sports: What Works, What Doesn’t and...

Vanderbilt Sports Medicine

Injury Prevention in Youth Sports: What Works, What Doesn’t and What’s Next

February 10, 2012

Alex B. Diamond, D.O., M.P.H.Assistant Professor of Orthopaedics and Rehabilitation

Assistant Professor of PediatricsVanderbilt University Medical Center

Co-Chair, Youth Sports Safety TaskforceTeam Physician

Vanderbilt & Belmont UniversitiesNashville Sounds & Nashville Predators

40th Annual MeetingSoutheast Chapter of the American College of Sports Medicine (SEACSM)


Disclosures• NO commercial relationships• Research & Educational funding

– NIH U54 Institutional Clinical & Translational Science Award


Objectives• Review basic principles of injury prevention• Introduce key youth sports safety topics• Discuss strategies to prevent injuries in young

athletes• Empower you to create a safer sporting

environment and culture for youth athletes


Injury Prevention is a Team Sport


Injury Prevention 101


Youth Sports: What We KnowThe Facts…• More than 38 million children and adolescents participate

in organized sports in the U.S. each year.– Another 10 million in some form of athletics

• Estimated 3.5 million children under age 14 receive medical treatment for a sports-related injury each year.– HS athletes account for additional 2 million injuries / 500,000

doctor visits / 30,000 hospitalization

Courtesy: Safe Kids USA & AOSSM


ER Data: Sports & Recreation• Leading cause of presentation for injury among adolescents

– Emery CA. Epi Ped Sport Injur, 2005.• CDC data (Gilchrist J et al. MMWR, 2007.)

– 2.4 million visits/yr (age 5-18)– 29% of all unintentional injury visits– 48% of injuries that require hospitalization or transfer involve

age 5-18• NSW population health survey showed only 8.9% of sports

injuries treated in hospital setting. – Mitchell R. J Sci Med Sport, 2010.


By the Numbers• Injury reported during sport among athletes age 5-14

– 28% of football players– 25% of baseball players– 22% of soccer players– 15% of basketball players– 12% of softball players

• Canadian study = more than 1 in 3 adolescents seek medical attention from a sport injury every year– Emery CA. CJSM, 2006.

AOSSM 2009 Annual Meeting Pre-Conference Program.


Public Health Relevance:Sports Matter for (and to) Kids

• Physical activity effects morbidity & mortality• Physical activity patterns track from childhood adolesc

adulthood• Injury is potential barrier to physical activity

– 8% of adolescents drop out of sporting activities/yr due to injury• Grimmer KA et al. J Adolesc Health, 2000.

– Leading risk for OA development• Injury Cost Model of the U.S. CPSC (2003)

– $588 million in direct expenses and $6.6 billion in indirect expenses from injuries in the top five female and male HS sports


Public Health Relevance:We Can Make a Difference

• Injury often predictable and preventable, not just “accidents”– As many as half the injuries sustained by youth

while playing sports are likely preventable


Emery CA et al. CJSM, 2006.

Safety cannot be delegated, it is a shared responsibility of…

• Parents• Coaches• Youth athletes• Safety advocates• Athletic trainers• Schools• Health professionals


Prevention Responsibility & Child Development

• Perceptual & cognitive status– Identify fewer hazards and do so more slowly

• Age ≤ 10 (pedestrian data)– Overestimate physical abilities– Lack of understanding for consequences– Sense of invulnerability

• Low level perceived risk + over-estimation ability = signif injury risk increase (age 11-14 OR 3.77-7.92) – Kontos AP. J Ped Psych, 2004.


Clinical Care Research

Approaches To Prevention


Sport Injury Prevention Literature Status

• ~ 12,000 published articles on sports injury prevention since 1938

– < 50% of the 12K were original research– Most were incidence & etiology studies– Only 492 actually evaluated efficacy or effectiveness

of interventions to prevent injury– Regulatory change rarely evaluated

Klugl M et al. CJSM, 2010.


Risk Factors for Sports Injury


Bahr R et al. BJSM, 2005.


Risk Factor Findings• Non-Modifiable

– Sex: Males (OR 1.16-2.4)• Exception: soccer, basketball

– Previous injury• Reinjury rates 13.1%-38%• Fball (reinjury vs 1st time injury: RR

1.4-1.7)– Sport Played

• Boys: hockey, football, basketball• Girls: gymnastics, basketball, soccer

– Age: Older– Level of play: Increasing

• Organized vs rec, game vs practice, playoff vs regular season

Emery CA. Risk Factors for Injury in Child and Adolescent Sport: A Systematic Review of the Literature. CJSM, 2003. (LOE 2-4)


Best Practice for Community and School Teams


CONCUSSIONKey Sports Safety Topics


Concussion Numbers• 1.6-3.8 million sports-related concussions/yr

– CDC MMWR, July 2007. • From 2001 to 2009, the number of sports and

recreation-related ED visits for TBI among persons aged ≤19 years increased 62% • CDC MMWR, October 2011.• TBI represents almost 9% of all injuries reported in HS

sports – National surveillance in 9 high school sports• Gessel LM et al. J Athl Train, 2007.


Concussion Prevention: Equipment

• Football Helmets• Mouth Guards• Head Gear


Football Helmet Ratings: STAR Evaluation System

• 5 Stars– Riddell Revolution Speed

• 4 Stars– Schutt ION 4D– Schutt DNA Pro +– Xenith X1– Ridell Revolution– Riddell Revolution IQ

• 3 Stars– Schutt Air XP

• 2 Stars– Schutt Air Advantage

• 1 Star– Riddell VSR4

• 0 Stars– Adams A2000 Pro Elite

Virginia Tech National Impact Database. May 2011.

Reduction in concussion risk


Mouth Guards• Effects of mouth guards on dental

injuries and concussion in college basketball. – Labella et al. MSSE, 2002. (LOE 2)

• Findings:– No difference in concussion rate – Significantly lower rate of dental

trauma


Head Gear in Soccer• Withnall et al. BJSM, 2005.

– Three equipment types tested– No attenuation of mechanical

forces due to heading ball– 33% reduction in acceleration

forces from direct head-to-head contact

– Further evidence needed for effect on injury or concussion prevention


Navarro RR. Curr Sports Med Reports, 2011.


Summary of Helmet Benefits in SportsMcIntosh AS et al. BJSM, 2011.


Heading in Soccer• Straume-Naesheime et al. Br J Sports Med,

2005. (LOE 3) – Norwegian elite footballers– Computerized neuropsychological testing– Conclusion:

• No evidence of impairment due to heading exposure or previous concussions


CDC’s “Heads Up” Initiative• Goal: Improve prevention, recognition, and

response to concussion among young athletes

Courtesy: Julie Gilchrist, MD, FAAPCDR, US Public Health ServiceDivision of Unintentional Injury Prevention


“Heads Up: Concussion in Youth Sports”• 2007• 26 member partnership• Target = volunteers, parents• Content:

• Audience ready & appropriate• Fact sheets for coaches, parents,

and athletes• Clipboard • Magnet• Poster• Concussion quiz

Targeting Youth Sports


Evaluation: Youth Sports Toolkit• Changed knowledge, attitudes, behavior

– 63% viewed concussion more seriously– 77% reported more skill in indentifying potential

concussions– 72% educated others: athletes, parents, other

coaches

CDC Unpublished Data


YOUTH SPORTS LEGISLATION: CONCUSSION


Youth Sports Safety Legislation:National Level

• Children’s Sports Athletic Equipment Safety Act (HR 1127)– Latest Major Action: 3/28/11 – Encourage and ensure use of safe football helmets.

• Protecting Student Athletes From Concussions Act of 2011 (HR 469)– Latest Major Action: 2/25/2011 – Regulations establishing minimum requirements for

prevention and treatment of concussions.


Youth Sports Safety Legislation: State-Level

• As of October 2011, 31 states (plus D.C. & the city of Chicago) have enacted youth concussion laws

http://nflhealthandsafety.com/


OVERUSE INJURIESKey Sports Safety Topics


Overuse Injuries• Why is it happening more often?

– Sports specialization at younger ages

– Intense year round competition and practice

– Growing bodies more susceptible to injury

– Parental and coaching pressure and unrealistic expectations

– Super competitive youth sports culture


Overuse: Prevention Strategies• Activity modification

– Avoid playing for multiple teams at same time– 1-2 days/wk off from competitive sport or training– 2-3 months/yr away from same sport– Incorporate cross training– 10% Rule: Maximum 10% increase in training

program variables/week


• 70% of kids participating in sports drop out by age 13- Lose benefits that sports provide

• Overtraining syndrome- Series of psychological, physiologic, and hormonal changes

that result in decreased sports performance

Parents and Coaches Beware!

“BURNOUT”


Estimated Probability of Competing in AthleticsBeyond High School

NCAA Research. Updated September 27, 2011.


Organized Sports Participation FactorsEncourage & Maintain• Fun• Success• Variety• Freedom• Family participation• Peer support• Enthusiastic leadership

Discourage• Failure• Embarrassment• Competition• Boredom• Regimentation• Injuries

AAP COSMF & COSH. Pediatrics, 2001.


SPECIFIC PREVENTION STRATEGIES


Educational Programs & Rule Changes• Adherence to rules & limit illegal play

– 6.4% of overall injuries in 9 HS sports were related to rules transgressions (98,066 injuries/yr)

• Collins CL et al. Inj Prev, 2008. (RIO)• Teaching proper fundamentals & technique

– Tackle with head up (↓head/neck trauma)• Educational & Awareness campaigns

– Improved knowledge & attitudes, outcome data sparse on injury reduction


Protective Equipment• Eye goggles (lacrosse) – ↓incidence of head &

face injury (RR 0.52)– Webster et al. MSSE, 1999.

• Knee pads – ↓ incidence of knee injuries (RR 0.44)– Yang et al. Am J Epi, 2005.

• Knee braces – no protective effect (RR 2.24)– Grace et al. JBJS (Am), 1988.– Contradictory evidence (MCL, ACL, ↑LE injury)


Lace-Up Ankle Braces• McGuine TA et al. AJSM, 2011 (LOE 1)

– HS Football & Basketball (M & W)– Lower incidence of acute ankle injuries

• Degree of severity unchanged– No effect on other LE injuries– Benefit for both 1st time & prior sprain– Findings independent of shoe type, taping, field

surface


Proprioception & Ankle Sprains• McGuine T et al. AJSM, 2006.

– Injury rate• 6.1% balance training program vs 9.9% control

– 50% risk reduction if prior sprain & perform intervention


Neuromuscular Prevention Strategies• Systematic review (12 studies; RCT/controlled intervention studies)• Effective in reducing knee & ankle injuries

– Preseason conditioning• Functional & sport-specific training• Proprioceptive balance training

– Structured warm-up (strengthening, stretching, plyometrics, sport-specific agility, +/- education)

• Optimized when sustained during sporting season (RR 0.2-0.73)• NNT: 4-10 for minor/moderate injuries; -66 for serious injury (ACL)

• Not Effective– Stretching alone; stretching + warm-up & cool-down

• No difference in timing of program (pregame, halftime, etc)

Abernethy L et al. BJSM, 2007.


Neuromuscular Interventions• Hewett TE et al. AJSM, 2006.

– Meta-analysis 6 studies– Neuromuscular training programs may reduce risk

of ACL injury in female athletes– Encourage use of training programs that also

emphasize performance enhancement as means to motivate compliance

• Increased program effectiveness in athletes


Neuromuscular Training Programs• Contradictory findings regarding

improvements on performance– Lindblom et al. Knee Surg Sports Trauma Arthrosc,

2011.


SPORT SPECIFIC STRATEGIES


Baseball• Safety balls

– Reduced risk of ball-related head & body injury by 23%

• Marshall SW et al. JAMA, 2003.

– Mixed findings Re: commotio cordis

• Chest protectors– No risk reduction of

commotio cordis evident• Viano DC et al. J Trauma, 2000.

• Sliding– Proper technique & timing– Break-away bases

• Hosey RG et al. AJSM, 2000.

• Faceguards– Risk reduction of

oculofacial injury by 35%• Danis RP et al. Inj Prev,

2000.


Overuse Injury: Baseball• Pitchers with history of significant shoulder or

elbow injury were more likely than uninjured counterparts to have…– Pitched more months per year, more innings per

year, more pitches per game and more pitches per year.

– Participated in showcases and pitched through arm pain or fatigue.

Olsen SJ et al. AJSM, 2006. (LOE 3)


Ray TR. CSMR, 2010.

Youth Baseball Overuse Injuries

• Proper throwing biomechanics

• Arm fatigue– Age-specific pitch count

& rest guidelines– Refrain from participating

in…• Multiple leagues• Year-round baseball• Scouting showcases

• Pitch type ?


Competitive Cheerleading• Coaching education & training

– Lower injury risk if…• Coached by individuals with a college degree and more

years of coaching experience vs those only with HS diploma and fewer years experience

Shulz MR et al. AJSM, 2004. (LOE 2)


FUTURE EFFORTS IN YOUTH SPORTS INJURY PREVENTION


Outline for Success• Development and Delivery of Effective Programs

to Reduce Burden of Sport Injury– Scientific approach– Create awareness– Build partnerships– RE-AIM

• True Change– Establish position on public health (& sports league)

agenda


Youth Sports• Three “big picture” concepts

– Safe participation• Children & adolescents at increased injury risk

– High levels of exposure at a time of major physiological change

– Socialization for lifelong pleasure in the sport– Setting for health promotion delivery

• Adoption of active lifestyles as adults • Requires attitude adoption

– Community: Resist shift from child-oriented goals to adult-oriented goals

– Sports Health Professionals: Prevention-centered thinking


The World We Live InMatheson GO et al. CJSM, 2010.


www.vanderbiltsportsmedicine.com

Please Visit


Thank You

• Alex Diamond, D.O., M.P.H.– [email protected]– 615.936.2455

http://www.childrenshospital.vanderbilt.org/sportssafety

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