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Kids and Sports: How Much Is too Much? |
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By Paul E. Hughes, M.D.
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Sports
participation in this country by both boys and girls has increased
progressively over time. As the popularity of sports has increased so has
the idea of year-round sports in which a child can participate in a single
sport of choice all year rather than seasonally. With increased
participation in one particular sport, there is less down time for
recovery from repetitive stresses such as throwing, jumping, twisting, or
running. Our children are putting themselves at risk for overuse injuries
as their bodies are placed under repetitive stresses at a time when their
musculoskeletal development is vulnerable. The open growth plates of
growing bones become more susceptible to stresses particularly during
growth spurts. With little or no time to heal or recover, inflammation,
pain, and deformity can occur about the joints of the knee, shoulder,
elbow, foot, ankle, and spine among other joints. Inflammation of the
growth plates or apophysitis is relatively common among children who are
active and suffer from conditions like Osgood-Slater’s (knee) or
Sever’s disease (calcaneus). Participation in sports
is healthy and should be encouraged. Sports promote a healthy and active
lifestyle at an early age, which we hope children will carry into
adulthood. Children who play sports can show improvement in social,
psychological, and physical skills. They do better academically on average
when compared with children who choose not to participate in sports.
Between the ages of 10 years and 18 years of age, adolescents build bone
mass that must last for a lifetime, and weight-bearing exercises, such as
running and jumping, help make the bones stronger. However, participation
in sports also means an increase risk of injury; 3.5 million children ages
14 and under get hurt annually playing sports or participating in
recreational activities. Each year there are more than 700,000 reported
emergency room visits for children ages 14 and under with sports-related
injuries.1 Endurance
Athletes. Both male and
female endurance athletes risk overuse. Stress fractures of the lower
extremities are relatively common and should be diagnosed and treated
early to prevent overt breaks and displacement. Treatment of stress
fractures may include rest, immobilization, and nutritional
considerations. Endurance athletes are known to have decreased levels of
sex hormones, which can lead to bone loss. Sports that emphasize low body
weight, such as distance running, gymnastics, skating, and cycling put
children at high risk. Females who stop menstruating for more than six
months or delay onset after the age of 16 years old can have absorption of
the calcium stores in their bones. Premature osteoporosis, or bone loss,
may be irreversible, and young athletes who become osteoporotic have
increased risk of stress fractures during their athletic training and
fractures later in life. Calcium intake for an adolescent athlete should
be increased to at least 1500 mg per day to protect male and females
against stress fractures. The calcium stores that build up are maximized
by around the age of 20 years of age.2 Gymnastics Gymnastics, a common
year-round sport, can cause too much strain on the growing bones of
children. Studies have shown that gymnasts are at increased risk for
spine, elbow, and wrist injuries. Spondylolysis, which is a stress
fracture of the pars interarticularis of the lumbar vertebral body, occurs
commonly in gymnasts but can occur in any sport that places the athlete in
hyperlordosis or back extension. This fracture can lead to displacement
and slipping of one vertebral body over the other leading to
spondylolesthesis. The symptoms of this disorder can range from nothing to
severe back or leg pain and hamstring tightness. The treatment includes
rest, cessation of sport, bracing, physical therapy, and even surgical
intervention if symptoms persist. The earlier spondylolysis is detected
the more likely it will heal with proper treatment. Injuries to the distal
radius growth plate are prevalent in gymnasts. One study showed there are
radiographic changes present in adolescent gymnasts at a rate of 50
percent regardless of evident wrist pain. This is more evidence that the
physiologic changes occurring during growth spurts place the athlete at
risk with repetitive stresses.3 Baseball/Softball The amount of throwing
and pitching involved in baseball and softball can place a child or
adolescent at risk. The traditional inning counts used in Little League
and other youth baseball leagues may not be an effective way to prevent
the overuse of a pitcher’s arm during the season. Overthrowing can place
an athlete at risk for stress to his or her growth plates, tendons,
muscles, or ligaments about the shoulder and elbow. Proximal humerus
apophysitis, or Little Leaguer’s Shoulder, occurs when the
stresses of throwing overwhelm the growth plate or physis causing
increased absorption of bone and pain. Pain is the most likely symptom and
radiographs of the shoulder may show widening of the physis in comparison
with the contralateral side. This is best treated by rest. Little
Leaguer’s Elbow is a wastebasket term for multiple disorders that
can occur in youth throwers. Apophysitis can occur at any of the
ossification centers of the elbow. Osteochondritis Dissecans and
Panner’s disease of the capitellum is characterized by underlying bone
absorption, or osteonecrosis, caused by the repetitive compression
stresses to the lateral aspect of the elbow. Tension injuries to the
medial aspect of the elbow can occur during throwing and include
tendonitis or ulnar collateral ligament (UCL) injury. If the continuity of
the UCL is disrupted, reconstruction or repair is likely needed if the
athlete wishes to continue to pitch or throw effectively. Not enough
research has been published concerning what the morbidity may be later in
life with these overuse stresses on the arm. It is likely that with
significant joint involvement, particularly in the elbow, contractures or
arthritis may result. To prevent these injuries some have proposed that a
pitch count be strictly enforced for each age level. Throwing in pain
should be discouraged because this is the first symptom of a problem.
Cessation of throwing is the first part of treatment for elbow and
shoulder injuries. Radiographs may be ordered initially or deferred as
clinical symptoms dissipate. MRI may be of use to evaluate the joint and
growth plates to stage disease or plan possible surgical intervention. If
an osteochondral defect is not detected early, it may be too late for
possible surgical fixation or other treatments that may help prevent
permanent morbidity.4 Knee Injuries.
Knee injuries are common among children who are physically active. Patello-femoral
pain syndrome is one of the most common injuries that a sports medicine
physician will see in his or her office. “Runners Knee,” as it is also
known, usually presents as anterior knee pain particularly with bent knee
activities. It affects more girls than boys and is usually caused by
overuse of the lower extremities. After adolescence female athletes have a
larger quadriceps angle than males, which results in a more lateral force
on the patella during quadriceps contraction. This can result in
subluxation or lateral tilting of the patella causing irritation of the
underlying cartilage. Treatment includes rest, stretching, and
strengthening of the quadriceps either done individually or under the
supervision of a physical therapist. If pain persists after such
treatment, surgical intervention can be considered.5,6 Many studies show that female
athletes are at a three to five times greater risk for an ACL tear than
their male counterparts. This is thought to be a multifactorial case for
this risk. Women are thought to have anatomic differences in pelvic
structure and lower extremity alignment (larger quadriceps angle), a
smaller femoral notch, and smaller ligament. Strength imbalances between
the quadriceps and hamstrings have been suggested with weaker hamstrings,
which can be used to protect the ACL during twists and landings. The ACL
in females appears to have more laxity than the ACL of males. Hormonal
differences between girls and boys may explain the increased risk in
females. Cutting, jumping, and twisting sports, such as soccer and
basketball, are notorious for ACL injuries in females. To help lower the
ACL injury risk, studies have shown that female athletes who have under
gone neurophysiologic training can reduce the risk of ACL injuries
compared with control groups. This involves stretching and strengthening
of the quadriceps as well as practicing landing mechanics.5,6 Sports Physical A pre-participation
physical exam, which is commonly required, gives the physician the
opportunity to review the child’s health and give advice on how to stay
safe and help prevent injuries. This exam helps identify athletes at risk
for injury and can provide athletes and their parents with valuable
information to help them exceed safely in their sport. This can be done by
advising in nutrition intake and avoiding potentially harmful supplements
or even steroid use, which is on the rise in high school athletes. The
pre-participation sports physical examination may be the only time many
teens see the doctor and thus may be one of the only chances for a child
to be advised about maintaining a healthy lifestyle. It is important to
remember that children are growing and any stresses that are too much or
too often can result in permanent changes to their musculoskeletal
development. Pain is the most common symptom and should never be ignored,
and no child should ever play in pain. Proper adult supervision is
important to protect our children from overuse injuries. For more information
about preventing sports injuries, go to the American Academy of
Orthopaedic Surgeons’ Web site at http://orthoinfo.aaos.org or
call 1-800-824-BONES. References: 1.
National SAFE KIDS Campaign (NSKC). Sports Injury Fact Sheet.
Washington (DC): NSKC, 2004. (www.safekids.org) 2.
Voss, LA, Fadale, PD, Hulstyn, MJ. Exercise-Induced Loss of Bone
Density in Athletes. Journal of the American Academy of Orthopaedic
Surgeons. 6:349-357, 1998. 3.
Teitz, CC, Hu, SS, Arendt, EA. The Female Athlete: Evaluation and
Treatment of Sports-Related Problems. Journal of the American Academy
of Orthopaedic Surgeons. 5:87-96, 1997. 4.
Hughes, PE, Paletta, Jr., GA. Little Leaguer’s Elbow, Medial
Epicondyle Injury and Osteochondritis Dissecans. Sports Medicine and
Arthroscopy Review. 11:30-39, 2003. 5.
Hewett, TE et al. The Effect of Neuromuscular Training on the Incidence of
Knee Injury in Female Athletes. The American Journal of Sports Medicine.
27:699-706, 1999. 6. Miller, MD et al. Review of Sports Medicine & Arthroscopy, 2nd edition. Saunders. 43-49, 60-65, 2002.
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