A Culture of Extremes: Overuse to Underuse in Pediatric Sports Medicine

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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, 2009
• NYSAFP 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 rodney.riedel_at_gmail.com
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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 todays
  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
  1900s
• 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
Winning isnt everything, its the only thing-
Vince Lombardi

• Teacher
• technique
• protective equipment
• character developement
• Training
• Community level
• School req. variable
• Communicator
• Motive

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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/Govt

• 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 gt250
• Age of these has changed from most gt12 to as low
  as 6 and most starting at 8
• I dont 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 gt healing
• Training demands gt 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
• gt200 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 caused by
  repetitive microtrauma and 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
• Severs 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
• Severs
• 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
• Theres 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 (CDC18 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
• lt4 of varsity h.s. FB play college
• lt1 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
• Dont 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 lt9
• 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 gt 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 rodney.riedel_at_gmail.com

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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 200524783-804.
• Stryer BK, et al. A Developmental Overview of
  Child and Youth Sports in Society. child Adolesc
  Psychiatr Clin N Am. 19987697-724.
• Brenner JS, et al. Overuse Injuries,
  Overtraining, and Burnout in Child and Adolescent
  Athletes. Pediatrics. 20071191242-1245.
• Metzl JD. Expectations of Pediatric Sport
  Participation Among Pediatricians, Patients, and
  Parents. Pediatr Clin N Am 200249497-504
• Klingele KE, et al. Little League Elbow Valgus
  Overload Injury in the Paediatric Athlete. Sports
  Med. 200232(15)1005-15.
• Hogan KA, et al. Overuse Injuries in Pediatric
  Athletes. Orthop Clin N Am. 200334405-15.
• Ommundsen Y, et al. Parental and Coach Support of
  Pressure on Psychosocial Outcomes of Pediatric
  Athletes in Soccer. Clin J Sport Med.
  200616(6)522-6.
• Cassas KJ, et al. Childhood and Adolescent
  Sports-Related Overuse Injuries. Am Fam
  Physician. 2006731014-22.

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Selected References

• Carr KE. Musculoskeletal Injuries in Young
  Athletes. Clin Fam Pract. 20035(2)385-415.
• Herman MJ, et. al. Spondylolysis and
  spondylolisthesis in the child and adolescent
  athlete. Ortho Clin N Amer. 200334(3)461-7.
• Wall EJ. Osgood-Schlatter Disease Practical
  Treatment for a Self-Limiting Condition. The
  Phys and Sportsmedicine. 199826(3).
• Anderson SJ. Lower Extremity Injuries in Youth
  Sports. Pediatr Clin N Am. 200249627-641
• Hogan KA and Gross RH. Overuse Injuries in
  Pediatric Athletes. Othrop Clin N Am.
  200334405-415.

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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/