Staying Healthy Through Four Seasons of Sports

Uploaded by PackardChildrensHosp on 19.01.2012

Welcome to the first of our Your Child's Health University
presentations for this school year.
And I'm Nancy Sanchez, from community relations.
I'm very pleased to have you here with us this evening.
And to present this excellent presentation
our physician has brought.
It's my pleasure, in fact, to introduce, this evening, Dr.
Megan Imrie, who is Assistant Clinical
Professor of Pediatric Orthopedic Surgery, kind
of a mouthful, for the Stanford School of Medicine, Lucile
Packard Children's Hospital.
Dr. Imrie is a graduate
of Yale University.
And a UC San Diego School of Medicine grad.
She did her residency here at Stanford wherein she received
the resident research award.
Her many interests in research areas include scoliosis,
fractures, and other common pediatric orthopedic issues.
Tonight, Dr.
Imrie is going to address common sports related injuries
in children and ways to keep our children healthy through
all four seasons of sports.
Please note that this lecture is being videotaped, but the
question and answer period will not be videotaped.
And it will be posted on our Packard website as well
as Stanford ITunes for you to review later, or share with,
with others.
So it's my pleasure to introduce, tonight, Dr.
Imrie thanks so much for coming.
>> Thank you, thank you, Nancy.
And thank you for being here.
I know everybody has a busy schedule, especially this time
of year.
So, I appreciate you guys taking the time.
So, tonight, we're going to talk about trying to keep our
or yourself healthy, throughout the entire year of playing
And we'll talk first a little bit about how kids are
different than adults,
mainly in terms of their
skeleton and how that can affect injury patterns
and prevention.
And then we'll focus more specifically on injuries, starting
with non-musculoskeletal injuries. So that basically means
anything that's not your bones, muscles, tendons, ligaments,
that kind of thing.
And then look at acute injuries, or those injuries that
happen out of the blue, one time, sort of bad luck, and what
we can hopefully do to try to minimize those.
Although as I said here, it's sort of trying to prevent an
unpredictable event, which can be difficult.
And then we'll focus a little more on chronic or overuse
and trying to prevent these in growing athletes.
And then I'll just touch on a few sort of popular sports for
a few sport specific recommendations.
I just want to start by saying that my take home point is
that sports are great for kids.
And by no means should the prevention of sport's injuries be
not participating in sports because they definitely provide
physical fitness, coordination, discipline, teamwork,
really, time management, a number of skills and qualities
and experiences that are very valuable to kids and to
adults, and also to kind of keep in mind that life is a
risky event.
We can't prevent absolutely everything, so some things will
Bad luck exists.
We say in medicine, it's always better to be lucky than
And I think that's true as well just in life.
But I think there are some things that can be done to help
minimize risk and maximize enjoyment.
And then, how can we minimize this potential injury and
maximize the benefit of sports participation?
So some parents would think that this is how you would
stay healthy through all four seasons of sports.
Sort of, put your kid in a bubble, or protect them from
absolutely everything.
That's not quite feasible.
And we'll talk a little bit about what can be done.
So just sort of a little bit more of an introduction of
myself. As
mentioned, actually I grew up in this area, I don't know if
it that was mentioned, I grew up in Los Gatos, about thirty
minutes south
from here.
Went East for college, and then went down to UC San Diego
for med school, came back to Stanford for residency, went
down to San Diego again for my fellowship at Raby Children's
Hospital and then came on here at faculty about two years
And in addition I just wanted to mention that I speak to you
also as a former athlete.
So I was a competitive gymnast from the time I was six until
I was 21 and graduated from college here in the bay area.
And then also in college so I'm very familiar with doing a
lot of sports and what the good and bad of that can be.
So just kind of looking at the numbers about 30 million
children participating in organized sports at any one time.
Participation in high school athletics is increasing with
more than 7.3 million high school students participating
each year.
And high school athletics account for more than two million
injuries annually, including 500,00 doctors visits and 30,
There, if you look just beyond high school athletes to
include younger kids, there are 3.5 million sports-related
health care visits per year in all patients under fifteen
years of age.
And this has been estimated to cost society about 33 billion
And breaking it down by sport, basketball is sort of the
most frequent offender. And this is not looking at incidents
of injuries.
So it's not the basketball is a more risky sport than
else, it's just that more kids participate in
And so, even if you have a lower frequency of injury,
if you have more people participating
then your numbers will be higher.
So basketball, football, baseball are kinda the top.
And then some of your more risky things like gymnastics are
lower just cause there are fewer kids participating.
So there's some thought that immature bones, insufficient
rest after injury, and poor training and conditioning can
all contribute to overuse injuries, not necessarily to acute
injuries although fatigue, certainly, can play a role in
And that overuse injuries themselves account for half of all
sports injuries in middle school and high school kids. And
that'll sort of be the focus of the second half of
this talk because that's really where we can focus on trying
to prevent injury.
So, as part of the introduction, I wanted to talk about how
kids are different than adults.
That's obviously many different ways, but from an orthopedic
standpoint and from an injury, musculoskeletal injury
the biggest difference is that kids are still growing.
And so this is a picture here on the left of an X-ray of a
child's ankle, and on the right of an adult ankle.
And what that arrow's showing, in the child on the left a
growth plate, and on the right in the adult, you see that
the growth plate is not there anymore, or the growth plate
has fused.
And so this is sort of the weak point of the pediatric
skeleton is the growth plate whereas an adult once that
fuses, the bone is actually pretty strong and your weak
becomes more ligaments, tendons, muscles. And that shift
doesn't happen one day.
The growth plate doesn't close just one day.
It's sort of a transition.
That adolescent time is a, a time of transition.
And then, all kids are not the same.
Kids mature at a different rate.
Especially when you get to that sort of pre-teen, teen
there's a marked variation in how mature kids are, how big
they are, what their coordination is, strength and stamina,
body fat versus muscle.
So you could have two 13-year-olds playing on a soccer
One is 6'2" and weighs 200 pounds and is all muscle, and the
other's voice hasn't changed and he looks like he's ten.
And that can lead to some issues on the field in terms of
So diving a little bit more into the growth plate A cuz I
think it's a very salient point and B because it's an
amazing structure, and one of the reasons I went into
pediatric orthopedics.
The official name for it is the physis and as I mentioned,
it's the weak point in the skeleton.
And the picture sort of to the top left.
See if my pointer works, yeah.
This is what it looks like, histologically.
And basically, what it is, is a bunch of cartilage cells at
the bottom of the growth plate, that divide and divide and
divide, and sort of form these columns of cartilage that
progress up towards turning into bone.
And it's almost like a taffy like consistence, consistency,
whereas bone is more like a hard candy.
So you have a differential in strength and material
properties between the growth plate and the bone.
And also, sort of your growth potential lies within those
specialized cartilage cells. So the growth plate is what I
consider the best and the worst part about the pediatric
skeleton, because when it goes well, it goes really well.
So this is an example of a six year old child, his, I say
about six week post-injury film, so six weeks after he fell
and broke his arm, those films are at the top and you can
see that the bone is healing in a pretty angulated way,
looking at it both in the AP plane, which is if you looked
at the hand from just straight on, and in the lateral plane,
if you look at it from the side.
And this child was actually referred to our practice for a
second opinion, because the adult orthopedist who saw them
had recommended surgery to fix this.
Because in an adult, if your wrist looked like that, you
would have significant dysfunction.
But the x-rays below are the same exact child eighteen
months later.
And you can see that, because of a functioning growth plate,
as the child's bone grows, it remodels over time.
It's so much smarter then we could ever be, figures it out
on its own and straightens out over time.
So this is what's the best thing about the pediatric
skeleton is the sort of potential and flexibility that the
growth plate provides.
However, it's also the worst thing about the skeleton cuz
when things go wrong they can go very wrong.
So this is a picture on the left, an injury film of a child
who had an ankle fracture.
So the break, let's see, where is my
Pointer? the break is right about here, so not nearly as
dramatic as the X-ray on the previous slide, but you can see
there was a little bit of injury.
And the X-ray on the right is that same child about four,
probably six to seven months later and you see a little bit
of irregularity of the growth plate.
And these are standing films, meaning the x-rays were taken
when the child was standing up, bearing weight.
And when you draw, the alignment.
You can see that, because the growth plate has closed on the
medial aspect, or the inside part of ankle, the bone is now
growing crooked.
So when the growth plate doesn't work, bones will grow
crooked, bones will stop growing, and bad things can happen.
And also, because of the properties of the, the growth
As I mentioned, it's a weak point in the skeleton, at risk
of injury, both acutely and in overuse conditions.
And we'll talk about that a little bit more.
And I also just wanna say that I have a tendency to talk
very fast, especially as I forget to talk slowly.
So if you miss anything, please don't hesitate to stop me.
Or if you have any questions as we go along.
If I use a word that you don't, aren't familiar with, please
don't hesitate to, to stop me.
Cuz, most likely, somebody else has the same question.
So, that's sort of the introduction.
The main difference between kids and adults is the growth
And is just also, differences in stamina, strength, balance.
And the fact that that's changing every day, because they're
growing, and changing every day.
So moving on to injuries and starting with non-
musculoskeletal injuries.
We'll talk first about sort of the serious stuff and that
is, there are sports related fatalities.
It's extremely rare but obviously very devastating.
So, these are kids who die because of a sports injury and
it's like I said, very infrequent but can be due to one of
three sort of categories and that's cardiac events, head
injuries and then heat stroke.
And heat stroke gets a lot of attention in the media and so
we'll talk a little bit about that.
So in terms of cardiac events or basically problems with
the heart.
The two main issues are what's called Commotio Cordis, which
basically means that very rarely if a ball or something hard
strikes a child or even an adults chest very hard it can
actually mechanically stop the heart.
And disrupt the electrical activity of the heart and
basically more or less cause the heart to stop, cause a
heart attack.
Very rare, that's why especially in hockey you want to wear
chest protection because if the hockey puck hits you at a
pretty high velocity, that could be a potential injury.
And the most important thing is rapid recognition and
immediate CPR on the field.
And so there shouldn't hopefully in schools and certainly at
competitions or meets, there should always be somebody
around who is CPR certified and
Could administer that if necessary, and this would not be
This would be somebody who gets hit, drops, doesn't move.
Isn't really breathing.
Doesn't, doesn't look good.
So it's, it's not subtle at all.
And very, very, very rare.
And then the other, cardiac event is hypertrophic
And this is, a condition of the heart where the heart muscle
is bigger than it should be.
And if you've ever heard of, I think, in the past, there
were some basketball stars who were otherwise totally
healthy, and one day, just dropped dead on the court.
It's because of this, hypertrophic cardiomyopathy. And that'
s why we recommend a pre-participation physical for your
physician to evaluate your mainly family history.
Cuz this tends to be familial.
So, patients will have a parent or a grandparent who
died suddenly of a heart condition, usually in their 20's or
30's and it's tough to pick up on physical exam.
There are some things that can be detected, but this is one
of the reasons why the pre-participation patient physical
exam is required, especially in collegiate athletics,
because it tends to be a more mature kid that it would
Very rare but just to be complete I wanted to cover those.
In terms of head injuries, what we're talking about here is
a concussion and this is seen mostly in football, which is a
high impact, high intensity sport, but can be seen in other
sports, say in soccer too, players are trying to head the
same ball and they're heads collide or basically any time
the head strikes something hard.
And basically the brain has some movement in the head.
It's not perfectly fixed.
And so if you move really quickly the brain can move
forward, hit the front of your skull, and then move back and
the back of the skull and cause some bruising and bleeding
so to speak in the brain.
And why it's important.
Obviously, it's your brain, you only have one of them.
So you wanna make sure that you treat it well.
And then also, especially in younger patients, the second
impact syndrome, so the patients goes back to play
or the athlete goes back to play before they're fully
And they're unlucky enough to have a second event.
that second event is way worse than the first event. Because
they haven't recovered fully.
Because you can have a rapid onset of what's called cerebral
edema or brain swelling, that can lead to death within
So it's very important for patients.
Excuse me, for athletes to be fully recovered before they go
So if it's a first time concussion, the recommendations are
to take the player out for fifteen minutes See how they're
If they have no signs or symptoms of a concussion, which are
listed here on the right, And that includes headache,
dizziness, confusion, some unsteadiness, repetitive
questioning, disorientation.
Certainly, if they lose consciousness, that's a big red
If they can't remember exactly what happened.
Even things like irritability, nausea, vomiting, etcetera.
If they're totally fine after fifteen minutes, they observe,
excuse me, exhibited none of those symptoms, then you wanna
un-stress them a little bit.
Kinda get, blood flow to the brain, increased blood flow to
the brain, by doing either a sit-up or a pushup, or having
them bear down all those things.
Increase blood flow to the upper part of the body, into the
See how they do, and if they're okay.
Then, they can go back into competition.
I'd say the safest thing is just to leave them out for the
rest of the game especially if it's not the NFL and there's,
you know
not a ton riding on it,
It's probably better to say, hey listen, you hit your head,
why don't you sit out.
Just relax for the rest of the game.
But if they're okay they can go back.
However, they should not go back in the same game if they've
ever lost consciousness.
And certainly if they've lost consciousness as part of this
episode, if they've ever had a concussion in the past, or if
they have any signs or symptoms of a concussion they should
be kept out.
And then finally, heat stroke, children and adolescents are
especially prone to heat stroke for a couple of reasons.
For one, they can't really regulate their temperature as
well, and maybe that's why kids can swim in the freezing
cold ocean at Santa Cruz without even thinking about it, and
we can't.
Although I have a feeling it's just distraction.
But they have a harder time regulating their body
They don't sweat as much and they have a harder time
acclimatizing to the environment.
So it takes them longer to sort of adjust their body
temperature to the outside environment.
And so the guidelines are fairly common sense and that is,
to give time.
So you don't want to go from an air conditioned locker room
to a 110 degree field with no, you know start practice right
away with no sort of time to adjust.
You want to evaluate the weather conditions before hand, you
want to make sure it's not going to be a 115 degrees and 99
percent humidity.
Thankfully in California this is a little bit less of an
issue, but certainly we do have our share of hot days.
You want to make sure there is scheduled rest in the shade.
Look for participants who are at particular risk and I would
say that would be anybody who had an issue in the past or
just really isn't looking good.
Hydrate definitely before practice and during competition.
You don't want to wait until you're thirsty.
By the time you're thirsty that you're already dehydrated.
So you want to sort of stay on top of it and pre-hydrate, so
to speak.
Have chilled fluids readily available, enforce periodic
drinking, never, ever use water restriction as a form of
discipline and I've definitely had coaches who did things
like that.
And it's just not nice and not safe and then also discourage
deliberate dehydration for weight loss and that's I'd say
most common in wrestling for weight class as well as rowing
to basically stay under the weight for your particular class
in rowing.
And then make appropriate clothing adjustments.
And that's mainly in football.
To take the helmet off in between plays when you're not out
on the field.
So that most of our heat loss occurs through the head and if
you have your helmet on the body can't release that heat.
So you want to take your helmet off.
And then if you can, avoid scheduling events during noontime
when it's going to be hot and sunny.
Educate players and parents on what to look for which, again
thirst, dizziness, just not feeling well.
And then some people recommend daily weights and I think
this is more for Texas football
but recording daily weights to ensure that between practices
patients are adequately rehydrating because a lot of our
fluctuations in weight is water weight so to speak.
And then finally, just touching briefly on performing
enhancing substance use.
It's estimated that ten to 20% of adolescent athletes use
some kind of form of performing enhancing drugs, and the
most commonly known of his would be, steroids.
And there are significant side effects, some of which are
Which, for the adolescent brain, is sort of, the more
important part.
They don't
plan as well for the future.
It's harder for them to, anticipate something that they do
now, affecting them poorly in the future.
Research on smoking, has really shown that, that telling a
kid that their teeth are gonna
be brown and they are gonna have bad breadth now is much
more effective than telling them that they'll have cancer in
30 years.
And so the same sort of thing applies to steroids.
I think kids, adolescents would be more receptive to the
that if you take steroids you'll have pimples, you'll lose
your hair where you're supposed to have it and gain hair
where you're not supposed to have it.
Rather than them saying
things like, you'll have a high risk of stroke.
Or, your balls will shrink or you'll have irregular periods.
These things are a little bit less salient to them, but
certainly more important, so to speak.
And so I just recommend as parents, teachers, coaches, et
cetera that performance enhancing substances are included in
any drug or alcohol conversation.
That they can be as destructive and as bad for you, as other
substances and so just include them and have that discussion
Because there are a lot of kids who are using these without
us really knowing it.
Any questions so far?
So moving onto acute events, trying to prevent those
unpredictable events.
About 95% of these sports injuries that happen quickly are
minor, and usually from a minor trauma.
So rolling in a goal, tripping and falling on a wrist, that
sort of thing.
And it can range from sprains, which is a ligament issue, to
strains, which is a problem with a muscle or tendon.
Or contusions, which is a nice fancy word for bruise.
And you can bruise your muscle, and you can also bruise your
And the MRI here, basically shows what bone looks
like when it gets bruised and it basically has more
fluid than it should. And the general and prevention
recommendations are basically make sure that you have proper
and proper fitting equipment.
Excuse me.
And so this includes things like shin guards in soccer.
Make sure your shoes aren't too tight.
Make sure your shoes are tied.
I mean really kind of common sense sort of things that
because they're so common sense people often overlook them.
And then also following guidelines for team sports for
matching so trying to match kids not just by age but more by
weight and playing ability so that you don't have two
rushing towards each other, one of whom has two times the
body mass and two times the force than the other.
And the American Academy of Orthopedic Surgeons, The
Pediatric Orthopedic Society of North America, Canadian
Orthopedic Association, and The American Association of
Sports Medicine physicians have come up with this Play It
Where they focus and encourage kids to be in proper physical
condition to play a sport.
So recommending not using a sport to get into shape, but
actually trying to get into shape before you play your sport
minimize injury.
To know and abide by the rules of the sport.
The rules are usually there for a reason.
To wear appropriate gear, and to know how to use the
equipment, so make sure you know how to adjust ski bindings,
or how your shin guards should fit or how your mouthguard
should go.
And then always warm up before playing, and avoid playing
when tired or in pain because your reaction time, your
balance, your ability to self-correct will be compromised if
you're tired or in pain.
Even, and this isn't a conscious thing.
It's a subconscious sort of body reaction to fatigue and
So I wanted to focus on, kind of, two specific things, just
to make it a little bit less general, a little bit less
And so I'll start with trampoline and bouncy house injuries.
This isn't truly sports.
But if you ask any three or four year old, a bouncy house
is, should be an Olympic sport.
And there are about 110,000, trampoline or bouncy house
related injuries per year according to the U.S.
Consumer Product Safety Commission.
And that's much less than bike or many other types of
injuries, but still a significant number.
And injuries can range from very mild sprains to even
fractures requiring surgery, or cervical spine injuries or
more serious things.
And the main tips that we found, to minimize risk include
that, to be on a trampoline specifically, kids should be
older than six because if you're younger than that you don't
really have the balance.
On to the coordination to self-correct if you get a little
bit out of control.
To try to ensure that only one person on the trampoline is
on the trampoline at a time.
When we look at kids who visit the emergency department with
a trampoline injury, many times, I think about 50% of the
time, they were on the trampoline with somebody else.
And that other person's bouncing force threw them off cause
they weren't anticipating it.
If there's gonna be more than one child bouncing.
And I think that for a trampoline, that should be a pretty
consistent rule.
Only one person, but for a bouncy house, you know, the fun
of the bouncy house is being in with other kids.
So if you're gonna be in with other kids, everybody should
be about the same weight.
So that you don't have one much heavier, much larger child,
who when they bounce
will sort of toss the other kids around a bit more.
And that means for the trampoline, as a parent, to try to,
if you are going to be on the trampoline, don't really
bounce too much or if you can, if your child's old enough to
just watch from the sideline and take your turn.
They should be supervised at all times, no tricks unless
you're a gymnast or a diver and then follow all instructions
for the safety equipment, and that includes ideally for a
trampoline it would be in ground and then also for bouncy
houses insuring that they're secured very well to the
ground. About I think six or seven years ago we had a case
here where a bouncy house in I think, Los Altos Hills, was
not securely,
securely fastened.
It actually rolled down the hill with some kids in it and
there were a bunch of children who came in with injuries.
So you always wanna follow the safety guidelines.
So, that's sort of for younger kids.
Looking at one other specific injury that we can try to
prevent is ACL injuries.
The ACL is the anterior cruciate ligament.
It's here in yellow.
On the image on the right and basically it's one of the main
ligaments of the knee that helps prevent your shin bone from
moving too much in relationship to your thigh bone.
And you've probably heard a fair amount of this in the media
cuz there are a lot of athletes who have ACL injuries.
And the reason why it's an issue is because since the
ligament is inside the joint, it can't heal on its own.
There are other ligaments in the body that if you tear them,
will heal up on their own with rest and mobilization.
But the ACL, because it's exposed to the joint fluid can't
repair itself. So if it's torn, many times we have to
With surgery, in order for a patient to go back to playing
high level sports.
And obviously in kids who want to avoid surgery as much as
possible, and in, certainly in children who still have open
growth plates the surgery becomes more complicated because
we have to avoid the growth plate or cross the growth plate
with a repair.
And then we worry about disrupting the growth of the leg.
So we pay a lot of attention to ACL injuries for these
And our research has shown us that young women who are age
fifteen to 25 years old, are two and a half to nine and a
half times more likely to sustain a noncontact ACL injury
than males in the same age group.
So depending on what study you read, it ranges anywhere from
two and half to nine times.
And noncontact means that they tore their ACL, not because
they collided with another player, but doing something on
their own.
Either landing from a jump, pivoting, going for a ball, that
sort of thing.
And this is becoming an increasing problem because
thankfully girls are participating more and more in sports.
So for high school sports specifically, female participation
has increased by seven hundred percent over the last fifteen
years, so that's great, but if we can prevent ACL injuries
and if girls are more susceptible to them, then we should
look into what we can do.
And soccer and basketball are the sports are the most
frequent culprits although it certainly happens with
other types of activities.
And basically, through research they found that the
increased risk of girls versus boys is thought to be a
little bit related to girls' anatomies.
So, females usually have wider hips, especially adolescents.
You're starting to move into, sort of your womanly body, so
the hip is a little bit wider.
So girls may have a little bit increase values at their
meaning that they're a little bit more knock-kneed than
their boy
And they also then, partly related to their anatomy and
partly related I think, to
some gender differences that we still don't completely
they can land from a jump differently, so the girl landing
on the left
is, sort of, the more proper, or more ACL protective, or
more male-like to land which is knees spread out real wide,
nice deep squat, sort of absorbing the energy.
Whereas the girl on the right,
girls more frequently land from a jump in that way, where
the knees kind of buckle in.
Their landing is a bit more shallow.
And that puts a lot of torque on the ACL.
So, after researching the differences between landing in
girls versus boys, some researchers have come up with a
specific exercise program that focuses on the strength,
endurance and power of the protective muscles around the
Look at balance, look at coordination, really putting all of
these things together and trying to teach girls a new way to
land, especially in basketball.
And the figure down below shows some of those exercises that
they do.
And they've shown that pre-participation in a focused
plan metric, program like this, has reduced the incidence of
ACL tears in collegiate female athletic populations.
And so, using these exercises, incorporating them into
practice, into training, has shown, to decrease ACL tear
So that's great.
Any questions on acute injuries.
So looking at overuse injuries, the reason why we care is A.
) injuries are bad, pain is bad, but also injuries in
childhood can be a risk factor for future injuries of both
during an athlete's youth as well as into adulthood.
And sometimes this can be a contributor to long-term
degenerative diseases such as Osteoarthritis.
So the things that are happening now do have an impact in
the future.
And when we talk about overuse, what we mean is excessive
and repeated use that can result in injury to the bones,
muscles, or tendons involved in the action.
And this is, you know a big issue for many reasons and I
say that it's not uncommon for us to see patients in clinic
as well who are complaining of chronic pain and continuing
to do their sport.
And some of it may be pain but some of it may also be that
they don't want to do the sport anymore.
Either it's not fun anymore because it's painful or their
interests have changed but because of coach pressure, parent
pressure, even self-pressure they may be continuing to do
that activity.
So this cartoon is out of a, a great book called Staying Out
of Trouble in Pediatric Orthopedics and it heads the section
on injuries.
And basically, it's got the Doctor saying her chronic
shoulder pain persists despite therapy, all imagine tests
are negative.
Frankly, her shoulders may not be suited for year round
And the Mom is saying, you don't understand, swimming is her
The coach is saying you don't understand, she's an Olympic
And the kid's saying, you don't understand I just want time
with my friends.
And so, it's always important to keep it mind that an
overuse injury, or sort of a chronic pain or chronic injury
may be, either consciously, or, more often subconsciously, a
kid's way of trying to communicate that they
don't want to do the sport anymore potentially.
So it's important for us as physicians and for parents to
kind of keep that in mind.
Sometimes you can take it too far.
When I was doing gymnastics if I ever complained of pain the
first thing out of my mom's mouth was, you can quit if you
want to, do you want to?
Please quit, I'm tired of driving you 45 minutes back and
forth to practice, so do you want to quit?
And the answer was always no, but so you can take it a
little bit too far but it's important to kind of keep it in
excuse me.
The STOP campaign that Dr. Levine was mentioning came out of
the fact that, in sort of, the late'90s and early 2000s,
orthopedists were starting to see almost a meteoric rise in
these overuse injuries in pediatric athletes.
And this is really the brainchild of Dr. Jim Andrews, who's
a very, renowned sport orthopedist, who practices out of
And he was seeing a lot of overuse injuries, and a lot of,
sort of adult type injuries in younger and younger
And most specifically, injuries to the elbow ligament in
young baseball pitchers.
And Dr. Levine was talking a little bit about this
conception of surgery, and that's something that Dr. Andrews
noticed as well that the Tommy John surgery...
Tommy John was a, a famous pitcher who had a ligament
And so, and I think the data shows that he actually was a
better pitcher after the surgery.
And so there was sort of this misconception perpetuated in
some circles that the surgery would make you better, make
you stronger.
And so, seeing these injuries, and seeing almost a cavalier
attitude of some parents towards their kid's injuries.
really got Dr. Andrews and a lot of us,
you know, paying attention and concerned.
So STOP stands for Sports Trauma Overuse Prevention
developed by Dr. Andrews in Alabama, and it's been endorsed
by many professional organizations as well as athletes.
Sort of the three main people are Dr. Andrews, Sam Bradford,
Is that his name?
Rams quarterback who was an Oklahoma Sooner?
I think that's his name.
And then John Smoltz who is a baseball pitcher.
And they've done a lot of community service.
I'll give you the website at the end.
It's got a lot of great information, and they've really been
sort of champing this around the country.
And their mission is to keep kids in the game for life.
So, they don't want kids to stop, stop playing sports.
They want sports to remain enjoyable, kids to remain injury
so that they can continue to participate as long as they
And the proposed reasons for the increase in injuries, were
their immature bones, insufficient rest after an injury,
poor training or conditioning.
And really, the specialization in just one
sport, with year round participation.
So in the'90s, 2000s, when they were seeing this rise in
injuries, it also somewhat correlated with a shift in, or
an increase in travel teams, you know camps and really the
ability to do one sport year-round where say in the 60's
you couldn't really play basketball competitively all year
if you
wanted to, you couldn't really play baseball all year
if you wanted to. You had to kind of specialize if you
to play a sport throughout the year, you had to do different
And so there's some thought that that correlated.
So, some of the recommendations is again common sense stuff.
Holding ongoing discussions about the importance of rest.
Kids think that they're invincible.
Sometimes we think that they're invincible and don't need as
much rest cause they seem to be doing fine.
But their bodies do need rest, they do need to
The mandating of preseason physicals.
Looking not only for some of those serious things that I was
talking about, like a cardiac history, but also looking to
see if they have any subtle injuries, that maybe they don't
really think about or don't notice, or don't want to mention
because they don't want to not make the team, they don't
want to not be able to participate in tryouts.
But really picking that up and holding them back if they
aren't a hundred percent.
Enforcing warm up and cool down routines, encouraging proper
strength training.
Again, preparing kids' bodies appropriately, before they go
out into competition.
And then really trying to encourage participation for fun.
Limit emphasis on winning, so the kids may feel more
comfortable saying that something hurts.
That they want to, that they feel that they need to stop.
As mentioned, discourage earlier specialization,
treat things early, and then, for the heat stroke, make sure
you drink enough water, educate athletes on proper nutrition
performance and make sure that they're eating well, and
drinking enough, et cetera.
Make sure that the equipment is maintained well, and then,
encourage kids again, to speak up, if they have any issues,
not feel that that's, that they're gonna be punished for
So, again Kind of, we're going to sort of beat a dead horse
here, so let me know if I'm becoming too repetitive.
But it's important to play multiple sports especially when
you're younger.
So, studies have shown that 70 percent of kids who are
younger than thirteen years of old, years of age that only
specialize in one sport up to that point, will drop out of
organized sports.
And they say that it's due to burnout.
So if you want your kids to participate in sports for life,
you might want to encourage that they try different things.
Again, listen to your child and listen to your child's body
for me one of the most important things is if your kid is
limping, that's an outright physical sign that they are
doing too much, that they need to back off, that they have
some injury that needs recovery.
And then have your child be prepared, both physically, make
sure that they're strong, that their endurance is good, that
they're stretching, and then also that they're prepared
mentally for what their sport may entail as best you can.
So, just a quick point on stretching.
Cause I do think that this is very important.
And I do see a lot of kids in my clinic who have injuries, I
think related to tight muscles and a lack of stretching.
And basically stretching is especially important during
rapid phases of growth.
And so that would be again sort of preteen, years
twelve, thirteen, fourteen, when you're growing at your
And the way I think of it is that the bones are growing
faster than the muscles can keep up, so kids will get a
little bit tighter, if not, you know measurably so, at least
functionally so.
And places where big muscles insert next to growth plates
will be, again a weak point of the skeleton, coming back to
the growth plate as a weak point Skeleton.
So looking at this picture here, this is an x-ray of a knee,
looking at the knee from the side.
And this sort of shaded box, what it's showing is the growth
plate at the knee.
The anterior growth plate.
So if you've ever heard of Osgood-Schlatter, it's a pretty
common knee condition.
And basically it results from a big, strong, tight quad
tendon that inserts through the patella,
that becomes the patellar tendon and then inserts right on
the front part of your shin bone,
right in the anterior tibia, and it's right next to that
growth plate.
So that muscle, every time you're running, kicking,
is pulling on that bone and that taffy-like growth plate is
stretching, is getting stressed, is getting inflamed.
And so that's what Osgood-Schlatters is.
And if you stretch properly, keep that muscle loose there
won't be quite so much of a pull on that growth plate and
the pain either won't happen or will subside fairly quickly.
And this is sort of the equivalent of patellar tendonitis in
an adult.
So once that growth plate fuses, it's a solid bone.
That's no longer the weak point.
The weak point is now where the tendon attaches to the bone
or within the tendon itself.
So what it can be a tendonitis in an adult is often, what we
a physitis or an inflammation of the growth plate in a kid,
just because of the differences in their skeleton. And the
same condition can happen in the heel and it's called Severs
Apophysitis. And again basically it's the big Achilles
muscle, coming down and inserting near a growth plate on
the heel. And again if you're not stretching enough, if your
calves are tight, that big muscle is going to be pulling,
the growth plate and causing pain and inflammation at the
growth plate.
So I find stretching probably one of the best things you can
do to prevent these sort of irritating knee and heel pain
that many, many kids have.
All right.
So, now I'm gonna talk a little bit about some sports
specific recommendations.
So I focused on, sort of the three, top sports in the
And what I would say we see the most often in our clinic
here at Packard.
So starting with basketball, it's the most popular sport in
high school, and the leading cause of sports related
injuries in the US,
over a million and a half per year.
Most common injuries are relatively minor, like ankle
sprains, and jammed fingers.
But it can also include fractured fingers, knees injuries,
the MCL, and then the dreaded ACL,
bruising, facial cuts, foot fractures, including stress
And the recommendations are, basically again, maintain
proper fitness, get ready for your season.
There are higher injury rates if you're not in shape.
Don't go at zero to 100% immediately, so don't not play at
all and then play an entire game, without any building up in
the meantime.
And that includes aerobic conditioning as well as strength
and agility.
And then, again, consider an ACL Prevention Program,
especially in your high school or collegiate athletes, and
especially for girls' programs and try to incorporate it
into the team's warm-up, and then stay hydrated and avoid
burn out.
Baseball is probably the most studied in our field probably
because the injuries, I'd say, have the most lasting
And we have very good data on how overuse and specialization
in baseball can lead to injuries, and we're talking mainly
about shoulder and elbow injuries, some of which are serious
enough to ultimately require surgery, so we really pay a lot
of attention to this.
And so we're basically talking about what you may hear of as
Little Leaguer's elbow and Little Leaguer's shoulder.
And Little Leaguer's elbow is kind of a general term that
means usually pain on the inside part of the elbow or the
medial part of the elbow, although it can refer to basically
any pain about the elbow.
The most common cause is what's called medial epicondylitis,
and that's in that top drawing there.
The left-hand side is the abnormal elbow and the left-hand
side is the normal elbow.
And basically, hopefully it's big enough.
that you can see a little bit of widened space between this
fleck of bone here and then the main part of the elbow, or
humerus, versus this side it's much closer.
And again, this is a growth plate problem.
So there's a growth plate in between the medial epicondyle
which is the bony part on your own elbow that you feel if
you hit,
if you hit right behind it, that's your funny bone. In a
kid, that's usually separated from the humerus so that's
always separated from the humerus by a growth plate until it
fuses in adolescence.
So it's a weak point in the skeleton, especially with
throwing, especially with pitching.
You have a lot of force across the elbow and it can separate
through the physis.
It can also refer to something called osteochondritis
dissecans, which is part of the cartilage can break off from
the elbow, especially in gymnasts and baseball players.
Or the
Ulna collateral ligament tear, which is this Tommy
John injury, that Tommy John surgery, which is seen in
It used to be seen only in adults, but now has been seen in
kids because they're throwing too hard, too much, too early.
And then little leaguers shoulder we're usually talking
about proximal physil inflammation or separation. So each
has two growth plates one at the top and one at the bottom.
And so, that can be a weak point in the skeleton at each
And so, in the shoulder, the proximal humeral
physis is right about here.
And so, with a lot of pitching, or with a lot of swimming,
again, you can start to get some stress, even some
separation of that growth plate,
Indicating overuse, too much of the same motion, too much of
the same activity.
So, again, Dr. Andrew's group recently published a study.
This was in the Journal of American Sports Medicine, just
this winter.
Looking at a ten year prospective study of young baseball
And he looked at 481 youth pitchers between nine and
fourteen years of age, and followed them for ten
years, and looked at the incidence of injury.
And they define injury, not just as a little tweak or
sprain, but as one of three things:
Elbow surgery, shoulder surgery, or retirement from the
sport, because of a throwing injury.
And of this find there were many findings.
To me the most striking finding is of the 481 pitchers, only
2.2% were still pitching at the end of the study.
So 98% had stopped pitching over the course of the ten
5% had serious injuries.
So 5% of the 481 had a serious injury.
But that means that basically the remaining 93% that stopped
did so for other reasons and it's not clear if it was loss
of interest or if they were better at other positions or
if there's some other reason.
But I thought that, that was pretty, pretty impressive.
He found that if a pitcher pitched more than 100 innings per
year, they were three and one-half times more likely to
sustain an injury requiring surgery of either their elbow,
shoulder or, a career-ending injury, basically.
And there was a trend to increased risk of injury if a
participant also played catcher during the same season.
So catcher's a lot of stress on the body as well, and so
those two may have somewhat of a cumulative effect, although
the numbers in the study weren't big enough to be able to
statistically say that that was a finding.
So, the recommendations for injury prevention and some of
these are repetitive,
Again, warm up properly, stretch, run, easy throwing,
rotate playing other positions besides pitcher.
Concentrate on age-appropriate pitching and we'll go over
this in the next slide, sort of the Little League's
recommendations as to when to throw what pitches, how many
pitches to throw per game and how many days of rest between
pitching days that athletes should take.
If there's pain pitchers should stop.
And if the pain persists even after they stop, they
should see a doctor.
No consecutive days.
Don't play year round.
Don't use a radar gun, so that kids are only focusing on
throwing as absolutely hard as they can.
Encourage communication about how the arm is feeling.
Again, emphasize control,
accuracy and good mechanics, rather than just, the
outcome, the speed, the
location, that kind of thing.
Master the fastball first, and then get to more
complicated pitches.
And then speak with a sports medicine professional or
trainer, if there are any concerns.
So, communication.
Listening to your body.
So these are from the Little League guidelines looking at
maximum pitch count per game and basically it goes up from
50 to 105 as kids get older and this is really sorta
reflecting the strength of their skeleton as the growth
plates are closing as their skeleton is getting stronger and
more adult like they can pitch more and more, excuse me.
This is required rest periods, and I would say, talking to
patients in my clinic, these aren't necessarily followed,
not routinely followed.
Younger patients, less than sixteen, have much stricter
So more than 61 pitches in a day, not just in a game, but in
a day, they should be taking off three days from pitching.
And if you're pitching less than twenty, 25, then that's not
too many per day, so you can keep going.
And then age recommendations for various pitches.
And really the focus is on the curve ball, waiting for the
skeleton to get a bit more mature before applying the stress
across the elbow that the curve ball requires.
And as a non-ball sport athlete, I don't completely
understand some of these other ones.
I've never heard of a fork ball or a screw ball.
I don't watch a lot of Giant's baseball so I'm not really
sure what those pitches are.
And if any of you know I'd love to see them.
And these are online by the way, the Little League
So just a few more words on baseball. I would say that your
child and you are your child's best advocate. So if your kid
is playing on multiple teams those coaches aren't going to
be keeping track of what they're doing with their travel
team or what they're doing with their school team and so,
it's up to you or you know, especially as an adolescent it's
time for them to start taking responsibility for their body
and for their health and so they should be paying attention
to this because nobody else is really going to be looking
out for them necessarily.
So I would say even though these are the recommendations
in talking to patients, they're routinely not
followed or kids just don't add it all up in their head.
They don't realize that you know, if they're pitching after
You know, kind of playing catch but getting more and more
force then that counts.
That adds up.
And I'll see patients and I'll say well did you rest.
And they say oh yeah, I definitely rested.
And I say did you stop you're travel team.
Well no there was a tournament and they really needed me to
play so I just played for those four days.
And I say well.
Did you stop playing at home?
Well no, you know, and if I wanna keep going Hey, I don't
want to lose my skills or I don't want to fall behind.
And you know, I understand those pressures, but the body's
not gonna heal if it's not truly rested.
So just add it all up in your head.
Just like calories, it catches up a lot faster than you
think it will.For those of you who are calorie counters. I'm
not admitting to being one.
So, finally, finishing up with soccer, we see a lot of
soccer out here. When I drive around on the weekend,
I think that there's not a patch of grass anywhere in the
greater Bay Area that's not covered with soccer players.
Which is great, because it's a great sport.
It's extremely popular.
Injuries are usually to the legs, both acute and overuse.
Again, sprains, strains and ACLs.
And then there's Patellar tendinitis,
I see this all the time in soccer players, because they're
really using their quads.
If you see a soccer player's
quad, it's like Adonis, Herculean size.
And that's in a growing scale it's in a lot of stress on the
growth plate.
And Achilles tendonitis and Sever's apophysitis.
There can be upper extremity injuries usually resulting from
Can be just sprains, but also I'll see wrist fractures and
that kind of thing.
And then very rarely concussions, face injuries, neck
injuries in really aggressive games.
So prevention.
Broken record, pretty much similar things, pre-season
physical, make sure the equipment is good.
So, some evidence that
molded cleats are better than the screw ins.
Poor field conditions that can increase injury rates.
So, if it's been raining, and you have a really slippery
field, you're gonna have more falls, potentially more
And then, using properly sized synthetic balls. Leather
balls can become waterlogged, and be more heavy, and
therefore dangerous.
Especially when trying to head the ball.
And then, there actually have been injuries from mobile
goals that fall on players.
So if you can get a fixed goal, that'd be great.
And try not have little brothers or sisters climbing
On those aforementioned goals. And then again hydrate
adequately, and pay attention to environment.
So again, trying to prevent heatstroke.
And again as with all sports avoid burnout.
Listen to the body, train for the sport, and then if you
take some time off, if you have to take some time off, ease
back in with appropriate graduated training.
So these are some of the websites.
The POSNA website on the top is the Pediatric Orthopedic
Society of North America.
They have great information for parents.
Not just on sports injuries, but on general pediatric
orthopedic conditions.
I'd say that they were especially strong in throwing
injuries for baseball.
And then the female athlete triad which is abnormal menses,
osteopenia, and stress fractures.
So we'll see that in cross-country runners, usually in
Gymnasts as well.
That sort of thing.
And then the ortho info at is the American Academy
of Orthopedic Surgeons website.
They have some good, I'd say more general, information, but
still some good handouts for parents and not just for
pediatric orthopedic injuries but also if you're an athlete
yourself and have some aches and pains
there are things for adults as well, on that website. And
then the is the Jim Andrews STOP
program website that really has
just an abundance of information,
handouts that can be printed for coaches or for other
parents, and I think a lot of good resources.
So with that, thank you for your attention.