Kids, Sports, and Sports Injuries
Introduction:
Child athletes are unique in that they are growing and maturing, both physiologically and socially. Sports play a fun and exciting part of their growing up process, as they help children develop physical skills, learn about rules and teamwork, socialize with other children, and gain the important health benefits of exercise. However, an intrinsic part of sports is that injuries can occur – and sports injuries happen in children that are different from those seen in adults.
Musculoskeletal injuries are still the most common problems. Falls, collisions, and accidents are usually responsible for traumatic or “macro” injuries that require medical attention. Examples of these are fractures, ligament sprains, and lacerations (cuts).
“Overuse” injuries result from the repetitive stresses of sports on tendons, bones or muscle, which occur after repetitive practice of a specific maneuver like in gymnastics or the heavy conditioning that comes from routine training in team sports. Kneecap (patellofemoral) pain, stress fractures, and tendon problems are very common overuse injuries and are often disregarded until the child has been complaining for some time. One should be cautious to look out for early signs of overuse injuries during training of young athletes.
Finally, young athletes can suffer from medical concerns either from existing conditions or problems that worsen with exercise. Other examples of sports-related concerns include cardiovascular conditions, exercise-induced asthma, heat injuries, metabolic illnesses and concussions.
The best treatment for sports injuries is PREVENTION. Many of the risk factors that occur can be minimized or avoided, therefore it is crucial for everyone in youth sports to be aware of the common and the serious sports injuries that can occur so they can be identified early and prevented if possible. A thorough, yearly pre-participation exam is an opportunity to identify “intrinsic” risk factors including any medical and orthopaedic conditions that may affect sports participation and predispose an athlete to injury. This can be especially helpful for screening and counseling to try to prevent the concussions, head trauma, neck injuries, use of performance enhancing drugs, and causes of sudden cardiac death that are the most dramatic concerns in any sport.
This knol describes the prevalence of pediatric sports injuries, the reasons that they’re often different from adult sports injuries, five musculoskeletal problems that are specific to the young athlete along with their associated treatments, and a discussion on serious medical problems. A general treatment approach is also presented. This knol introduces the reader to common issues in pediatric sports medicine that individuals involved in youth sports should be aware of.
How often do sports injuries occur in young athletes?
Participation in organized sports is on the rise, though unfortunately, physical activity in young people in the general population is declining. In 1991 -1992, approximately 3.5 million boys and 2 million girls competed in high school athletics during 1991 and 1992 . In 2006-2007, the numbers rose to 4.3 million boys and 3.0 million girls . It’s been estimated that almost two-thirds of high school students reported participating on one or more school and/or nonschool sports team in the previous year . It seems that sports is popular in all cultures. One study found that 65.4% of whites, 55.2% blacks and 52.5% Hispanics reported sports participation. More males (69.9%) participate in sports than females (53.4%) [3].
Sports related injuries are the most common cause for injury in children. Bijur et al. found that 36% of injuries from all causes are due to sports , making it the number one associated reason for injury when all things were considered. In another study, 41% of injuries presenting to four pediatric emergency departments were sports-related . In elite competitive young athletes, fifty percent sustained one or more injuries per year. Thirty percent of the “overuse” injuries produced lay offs for around 20 days compared with only 13 days for athletes with an acute injury . Musculoskeletal injuries just like participation are typically more common in males than females.
Table 1. Classification of sports injuries
Non-catastrophic injuries (COMMON)
Acute injuries (usually caused by trauma or accidents)
Overuse injuries (usually caused by repetitive stress)
Medical problems
Catastrophic injuries (RARE but dangerous) – serious injuries that lead to death or permanent disability
Fatal
Direct – directly caused by sports activity (i.e. death from a fall in gymastics)
Indirect – indirectly caused by factors associated with the sports activity (i.e. sudden death from heat stroke during long distance running)
Nonfatal (with permanent disability)
Why do children get different injuries than adults?
Young athletes get different injuries than adults mainly due to the growing process. Growth refers to an increase in size, either of the body as a whole or of its parts . Growth and maturation make a young person’s anatomy and physiology different and are controlled by timed hormonal changes. Not only do size, strength and flexibility change over time, but an athlete’s metabolism and endurance also improve as internal organs mature. An interesting clinical observation put forward by Dr. Lyle Micheli at Children’s Hospital of Boston in the early 80’s was that during growth spurt, a relative increase in tightness of the muscle-tendon units occurs because bone growth exceeds that of the soft tissues (the same muscles and tendons). This leads to a decrease in flexibility of the joints which can lead to specific overuse injuries . With kids now starting some sports activities as young as three years old, parents and coaches should pay close attention to growth spurts, in order to modify training appropriately.
Puberty is the period where the most growth and maturation occurs. Puberty typically starts by 13 years of age in girls and before 14 years of age in boys . Girls may grow as much as 8 cm per year, while boys may increase by around 12 cm . These values can be useful to help identify the peak growth spurt in children
Apophysitises
Some of the most common pediatric sports injuries are termed “apophysitises.” These are injuries to the growth plates, which are often the weakest link in the child’s musculoskeletal system. The apophyses are found at the ends of the bones where growth is occurring in children, specifically where tendons insert into bone near the growth plates. During exercise, these areas are subject to tension stresses that can cause injuries ranging from microfractures to the tearing away (avulsion) of a bony fragment. These injuries can present with localized pain and swelling. They are often worse with activities involving running and jumping and typically occur at the beginning of the pubertal growth spurt. The most common apophysitises occur in the front of the proximal tibia (Osgood Schlatter’s disease) (Figure 1). Other locations for apophyseal injuries include the posterior heel (Sever’s disease), the quadriceps tendon insertions into the front of the pelvis, the inferior pole of the kneecap, and the medial elbow (Little League elbow). A bony avulsion injury should be considered when pain is acute and severe, causing significant disability. Fortunately, these conditions are self-limited and resolve when the growth plate closes as puberty ends. Treatment in almost all cases is conservative, and most young athletes can continue their sports with only some modification or restriction of activities as necessary. Anti-inflammatories and ice often help with pain symptoms. The athlete and parents need to understand thef problem and its association with activity, in order to modify activity and monitor for signs of worsening, namely more pain, swelling, and dysfunction
Table 2. Common areas of Apophysitis Injuries
Osteochondritis dissecans
Another problem that is specific to growing children is termed “osteochondritis dissecans.” This is a problem where an area of bone underlying the cartilage surface covering the joint dies and, in some cases, dislodges creating a cavity on the surface of the joint. The suspected reason for the injury involves repetitive microtrauma, which may be more common in athletic children, resulting in changes to the blood supply to the affected area of bone. The most common area where this may occur is the knee (Figures 2 & 3), though these injuries also can occur in the elbow, the ankle, and the hip.
The diagnosis is often missed early on as these children usually present with a vague pain in the joint. The athlete may develop a slight limp early on. They may develop swelling and “catching” symptoms if the bone lesion starts to become unstable. The condition may develop in both sides in approximately 20-30% of cases
Fortunately, the natural history of these lesions is favorable if they are detected early on. Treatment is usually conservative especially when the athlete is younger. Activity modification to minimize impact to the affected area of the joint is recommended. Competitive sports should be avoided until the area is healed. Return to play in these athletes is always a difficult situation as young athletes and their parents usually do not like the idea of eliminating running and jumping type activities. Cycling and swimming are suggested conditioning as long as the patient remains asymptomatic, whereas running should be avoided if the area may be subject to impact loading
The lesions may take several months to recover and the physician may follow healing by X-ray or magnetic resonance imaging (MRI). Half of the lesions are estimated to heal within 10 to 18 months . Eighty-one percent of lesions healed in juveniles with conservative treatment .In a study of 31 cases of knee osteochondritis dissecans in 24 children (some occurred in both knees), no treatment was performed but individuals were advised to avoid sports activities until the pain disappeared. The pain resolved in an average of eight months without treatment; 24 of 31 lesions disappeared totally, four were absorbed into the bone with no pain, two developed some flattening of the joint with no arthritis, and one became a loose bone piece . In another series of 192 patients, 80% had symptoms for more than 15 months and 90% for more than 8 months . In the future, patients with a history of knee osteochondritisdissecans are at higher risk of developing osteoarthritis . If the fragment detaches (Grade 3 lesion) or becomes unstable (Grade 4 lesion), then an operation may be indicated. Symptomatic closed lesions can be treated by arthroscopic drilling to stimulate a healing response regardless of patient’s age . Other surgical procedures, such as fixation of the fragment or replacing the lost articular joint and bone surface with bone plugs or bone from a cadaver (allograft), can be considered
Growth plate fractures
The growth plates or “physes” can be found at the ends of the long bones and are sites of linear growth. However, they represent areas of weakness in the developing bone, especially during puberty when growth is occurring most rapidly. Fractures involving the growth plates can occur as a result of sports trauma. The upper extremities, particularly the wrist, are most commonly affected, often occurring after a fall on the outstretched hand. However, fractures in the lower extremities, such as the ankle, can occur in sports like soccer. Fortunately, they usually do not affect growth if they are treated properly. However, in some cases the growth plate becomes damaged, which can affect the overall growth that may occur in that area. Figure 4 outlines the types of growth plate fractures that can occur, with the higher types being more associated with growth arrest and abnormal alignment of the bone with development
Pediatric ACL tears
The anterior cruciate ligament lies in the center of the knee and limits forward movement of the lower leg relative to the thigh. This is typically injured when an athlete plants the foot and twists the knee, which occurs during cutting or landing during sports. The athlete often reports a pop in the knee with immediate swelling within minutes after the injury. It is estimated that almost 50% of children with this kind of story will have an ACL injury . ACL injuries occur more commonly in adolescents, but they can happen in younger children. In children, the tear can be partial or complete, involving the ligament only or involving a fracture of the distal ligament insertion (tibial eminence fracture).
Tibial eminence fractures are common under the age of 12, as the ligament is often stronger in younger children than the growing bone insertion. If a fracture is identified, this can be surgically fixed in many cases. For ligament tears (Figure 5), if the athlete is skeletally mature, most likely the individual will need a surgical reconstruction of the ACL, using his or her own tendon to replace the damaged ligament. Reconstructing the ACL usually allows the young athlete to return to sports more often, reduces the chance of developing a symptomatic cartilage tear, and results in less giving way symptoms . If the child is skeletally immature and their growth plates are still open, management can be controversial. The concern is the negative effects if the growth plate is damaged and affects future growth. Special surgical techniques for ACL reconstruction can be performed to spare the growth plate. The option to immediate surgery is to wait until the athlete matures skeletally to approximately within one year of growth closure, then perform the ACL reconstruction. Partial tears may be treated conservatively similar to other soft tissue injuries, though physical therapy should focus on restoring strength and proprioception (joint position sense) to the injured knee. In one study, thirty one percent of individuals with partial tears treated conservatively required subsequent ACL reconstruction, especially if the original tear is more than 50% of the ligament or if the athlete feels unstable . Consultation with an experienced surgeon is recommended in pediatric ACL cases
Discoid Lateral Meniscus
A discoid meniscus is a unique problem in the meniscal cartilage of the knee, which typically presents in children. The meniscus, which is a shock absorbing cartilage in the knee joint between the bones, typically has a “C” shaped appearance. In some individuals the meniscus is larger than usual, which can more easily lead to tear. This is more common in Asian populations, especially Japanese. The athlete with a tear may present with a clicking sensation in the outside part of the knee. This can become painful, cause swelling, and limit range of motion. The x-rays
may show a wider space in the knee with flattening of the bone (Figure 6). An MRI can easily identify the larger discoid meniscus. If a discoid meniscus is torn and painful, the treatment is to surgically repair the tear if possible and reshape the remaining meniscus arthroscopically, in a procedure termed “saucerization.” It is always the goal of the surgeon to preserve as much of the functional meniscal cartilage as possible in order to maximize its protective potential.
Medical problems can be serious
Musculoskeletal problems can be a big problem for the competitive young athlete, leading to missed practices and games. Medical conditions can similarly present problems and in some cases lead to serious problems, or in the rare and unfortunate situation death. The possible risk however should not deter athletes to train and compete, however, if the athlete experiences noticeable symptoms, he or she should seek medical attention for an appropriate evaluation. Cardiovascular conditions are most worrisome for causing a fatality. It’s been estimated that the risk of sudden death is 1 in 200,000 high school students and college athletes. Structural and electrical heart problems can lead to life threatening arrhythmias under the wrong combination of stresses. Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in the United States. There are other causes that physicians should be aware of. Commotio cordis has been a growing concern, where a fatal arrhythmia is caused by a blunt trauma to the chest, for example a baseball pitch to the chest or direct contact to the chest in soccer. Cardiac death has raised some controversy whether leagues should have an automated external diffibrillator on the sidelines.
Exertional hyperthermia (i.e. heat stroke) is the most common of noncardiovascular deaths . The physiology of young children puts them at risk during sports in hot weather. Immature children lack the glands and ability to sweat heavily to regulate one’s core temperature. Young athletes generate more heat for their body weight relative to adults, take longer to acclimatize to exercise in hot weather and often drink less fluids when thirsty. It is crucial to maintain hydration, to avoid exercise in a hot environment and to monitor for confusion, fatigue and other signs of heat injuires. Awareness and early recognition of heat injuries is the best way to get the athlete cooled down and prevent dangerous internal organ damage from overheating.
Existing medical problems such as asthma, rheumatoid arthritis, and hemophilia are conditions that if treated well can enable a young athlete to participate safely in sports. Consultation with an appropriate specialist for treatment and recommendations for sports participation is necessary.
Many medical illnesses can worsen during exercise and early sports participation before recovery can lead to dangerous progression of the condition. Examples of acquired problems include concussions, where another hit to the head before the first has recovered can sometimes lead to brain damage and sometimes life-threatening swelling. In rare but serious cases, the simple viral cold can result in dangerous heart enlargement with exercise. A ruptured spleen can occur with trauma in a patient with infectious mononucleosis even 3 or 4 weeks after the flu symptoms have resolved. It’s necessary for the parents and their athlete with a medical illness to see their primary care physician or local sports physician to see when it is safe to return to training and then competition. It’s always better to be safe than sorry.
Treatment of Sports Injuries in Children
Rehabilitation can help return an athlete to sports quicker in most cases. An accurate evaluation and good patient and parent education improve the compliance. Younger children aged five and six typically do better with individual attention and a very creative exercise program, while older children can participate more in a structured therapy program . Modification of activities, ice, compression, and elevation (MICE) is initially the standard plan of care, but the specific recommendations vary from case to case and, in most cases, should be discussed with a healthcare professional.
1. Modified activities. A period of rest with no sports activities for 24 to 72 hours after a serious injury is appropriate, especially if the child needs to be evaluated by a health professional. Modified activities, including therapy exercise, can then be considered.
2. Ice. Ice is useful for up to 15 minutes over an area of pain and swelling. Direct contact of ice with the skin should be avoided if possible. A wet towel under the ice can prevent unnecessary frostbite. Neither ice nor heat used after 72 hours have been demonstrated to have long term effects though they can have symptomatic relief when applied .
3. Compression. An elastic bandage can be used to apply gentle pressure to the affected joint or injured area. The bandage should be applied snuggly but not too tightly, in case further swelling occurs and circulation becomes impaired.
4. Elevation. Raising an injured extremity above the level of the heart, which is easier in the lying down position, can help reduce swelling from an acute injury.
Pain medications such as over the counter anti-inflammatories are typically safe for short-term use in young athletes who have no medical contraindications. Stronger medications for an injury need to be prescribed by a health care professional before use in children.
Immediately following an injury, if necessary, an injured limb can be supported using a rigid splint. Moldable splints are available which are not expensive and can be very useful at the field side, before transporting an injured athlete to see a doctor. After seeking medical care for an injured extremity, a splint, cast, walking boot and/or crutches may be recommended to help all of the injured structures heal.
The road to recovery follows a typical course: 1) control pain, 2) improve range of motion, 3) recover strength and flexibility, and 4) restore function. Within that general framework, there are many different therapies and strategies to recover from various injuries. Specific stretching and strengthening exercises can be designed in a rehabilitation program. Sports specific exercises can be introduced as the athlete improves. Working with a qualified health professional with knowledge of treating sports injuries is beneficial. With significant musculoskeletal injuries that cause disability and swelling, supervised exercises can be useful. Discuss with your doctor whether the injury warrants follow-up rehabilitation to promote healing.
Checklist to return to sports
1) The athlete should be SAFE to return with little risk for re-injury. This includes allowing adequate time for the injured tissues to heal properly, and not just being pain-free which may be achieved early on in the healing process.
2) The athlete should be EFFECTIVE with performing their sport-specific tasks. If the athlete can’t do their sport, it’s usually better to modify their activities until they can do things properly.
3) The athlete should be relatively PAIN-FREE. Pain is a warning that an injury is not yet healed.
Prevention is the best medicine
Many sports injuries are preventable. Proper training is one of the most important keys to preventing injury in young athletes. Adequate adult supervision along with properly educated coaches and referees can help ensure children learn the proper techniques and rules for optimal play and safety. More specifically, setting appropriate limits for the amount of training is necessary to prevent burnout and overuse injuries –and to allow enough time for recovery of nutrition, fluids and energy. The playing environment should be safe with good playing surfaces and well designed and properly maintained equipment (e.g., breakaway base pads in baseball). Protective equipment that has passed respected safety standards, such as those promulgated by the American National Standards Institute (ANSI), should be checked for the right fit, be changed regularly as recommended by the manufacturers, and be worn appropriately during play. When a helmet is too old, is not properly sized, or is worn without the straps applied properly, it is not going to protect as promised.
Look and Listen
Parents and coaches should be especially careful when managing sports injuries in young athletes. If the child complains of pain, swelling, or disability with no injury – or constitutional symptoms, such as pain at night, fever or weight loss – these should be considered warning signs to promptly seek medical attention. Early medical care can often help avoid complications from an injury that can hinder a child’s ability to have fun and enjoy sports
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