Prevention and misconception are chief concerns in battling youth sports injuries

Although rising rates of participation in youth sports is a positive trend, the increase in youth sports injuries has been far from proportional. Physicians report seeing more injured young athletes and, more alarmingly, they are seeing a substantial increase in young athletes with injuries previously considered to be exclusive to collegiate and professional athletes.

“It has become epidemic,” said Champ L. Baker Jr., MD, FACS, of the Hughston Clinic in Columbus, Georgia.

According to Safe Kids USA, 3.5 million children aged 14 years and younger receive medical treatment for sports injuries each year; 30% of parents reported that their child had been injured in team sports, and 50% said the child had been injured more than once.

Young athletes are particularly at risk for injury due to improper techniques, ill-fitting equipment, errors in training, pressure from coaches or parents, failure of early injury recognition, the shift to single-sport “specialization,” and inherent muscle imbalances, according to James R. Andrews, MD, president of the American Orthopaedic Society for Sports Medicine (AOSSM).

“Parents markedly underestimate the risk factors associated with a specific sport their kids participate in,” Andrews told Orthopedics Today. “They mean well, but they do not understand the risk factors.”

James R. Andrews, MD, is co-chair of the Sports Trauma and Overuse Prevention (STOP) program to educate players, parents, coaches and health care practitioners about the increased injury rate seen in young athletes. Image: American Sports Medicine Institute

Orthopedic surgeons are seeing younger athletes at increasingly earlier stages of development with overuse injuries — a disturbing trend, as more than half of these injuries are preventable.

Parents who may be eager to get their children on the fast track to performing at a high level in one particular sport may be doing more harm than good, as overuse can keep a child out of the game far earlier than they may leave otherwise.

“If they are overworked or suffering from overuse and injury when they are younger, they usually do not make it to the upper levels,” Andrews said.

According to Andrews, young pitchers who throw more than 80 pitches a game increase their risk of injury by 360%. Those who pitch for more than 8 months in a year increase their risk of injury by 500%. Those who pitch despite fatigue increase their risk of injury by 3,600%.

Four Ps

As a physician, dealing with young patients and their parents for a problem such as overuse can be daunting, as many want to get back on the field sooner than could be considered healthy. Baker, a former AOSSM president, stressed what he referred to as the “four Ps”: the physician, the patient, the parent, and pain. All four have to be given proper attention, but he noted that pain and the physician are likely to know best.

“You have to tell these patients, the reason you hurt is essentially so you do not do it anymore,” he said. “You put your hand in a fire, it hurts, and you take it out. That is a protective mechanism. Pain is your friend. It is telling you to be aware of what you are doing. Listen to your body.”

Concessions must be made for patients with overuse injuries, but physicians should be quick to note that such injuries do not mean the cessation of activity.

“You need to find a way for that athlete to have some relative rest,” Bradley J. Nelson, MD, said. “If they are a year-round soccer player, maybe get them to take a break and do something like swimming.

Andrews added, “In other words, these young athletes should cross train.”

STOP Sports Injuries

Andrews noted the importance of educating players, parents, health care providers and coaches on injury prevention.

“You could cut the amount of overuse injuries in youth sports by 60% with just common sense and getting down to the grassroots level with an educational process,” he said.

Andrews is co-campaign chair of Sports Trauma and Overuse Prevention (STOP) Sports Injuries, an initiative designed to raise attention to the rapid increase in youth sports injuries and offers steps to help reverse the trend.

Organized and presented by the AOSSM, the program teaches proper prevention techniques, discusses the need for open communication among those involved in the lives of youth athletes, and encourages participants to take “The Pledge” — a promise to become advocates for sports safety and take preventative measures to ensure the safety of young athletes.

Ensuring athlete safety, Andrews stressed, does not mean reducing overall participation so much as safely approaching the matter.

“We would much rather have kids playing sports and being involved in sports in a healthy fashion,” he told Orthopedics Today. “We are not against that at all. But we cannot have them getting injured and operated on all the time … let [your child] cross train, let him or her play more than one sport.”

The campaign — which has received “a tremendous response” from AOSSM’s collaborative partners, including the American Academy of Orthopaedic Surgeons (AAOS), the American Academy of Pediatrics, the American Medical Society for Sports Medicine, the National Athletic Trainers’ Association and the National Strength and Conditioning Association –will air public service announcements and has an informational Web site — stopsportsinjuries.org.

Other injury trends

Andrews said there are approximately 3 million more high school athletes today than there were 10 years ago. This is a good thing, but he is alarmed by another trend: a 500% to 700% increase in injuries, including those not usually seen in children.

“Injuries we used to never see until the athletes were in the college or professional ranks … we are now seeing in kids 14, 15, and 16 years of age,” Andrews said. “That has gotten our attention.”

A trend that physicians say is leading to the increase in overuse injuries is that of specialization: the notion that an athlete must focus on one sport to develop their skills as fully as possible.

The dangers of specialization are more than physical: A young athlete forced into one sport for the entirety of his or her development is at high risk for burnout. Andrews said that 70% of kids 13 years of age and younger are dropping out of competitive sports because they are burnt out.

“As kids, athletes need to experience every sport they can,” said Orthopedics Today Sports Medicine Section Editor John A. Bergfeld, MD. “They may be good pitchers, but they might like playing golf or running cross country or playing touch football. It is too early to specialize.”

Specialization usually also means high-level, repetitive, year-round training, which contributes to fatigue and potential overuse injuries.

Bergfeld told Orthopedics Today that while higher levels of specialization lead to short-term improvements, the long-term gains plateau quickly.

The desire to become a high-level athlete within one particular sport can be especially tough to combat in patients — and parents of patients — who think that an injury may be standing between them and getting back on the road to stardom.

“The reality is, if you are a 16-year-old kid and you have had your elbow operated on, you are not going to the major leagues,” Baker said. “You have already been pre-selected by injury.”

“The reality is, if you are a 16-year-old kid and you have had your elbow operated on, you are not going to the major leagues.” — Champ L. Baker Jr., MD, FACS Image: The Hughston Clinic

Communication

Not diminishing athletic aspirations is a critical part of the effort, and Nelson said it could be the difference between cooperation and disagreement.

“The worst thing you can do is tell a parent to tell a child they just need to stop pitching or playing so much soccer,” Nelson said. “I do not think that is helpful. You need to get the parents and the kids to understand these injuries are going to affect their ability to participate in sports potentially throughout their life.”

The legacy of Tommy John

Ulnar collateral ligament reconstruction (UCLR) — known otherwise as Tommy John surgery — has also gained attention due to its success in numerous high-profile professional athletes. As children suffer from overuse injuries earlier and earlier, the rate at which they qualify for the surgery has also increased.

Andrews said he has seen a “five- to sevenfold increase” in Tommy John injuries to high school children and younger since 2000.

“I used to see just a handful of those kids each year,” he said. “Now I am seeing 50, 60, 70 a year. I will bet this year I will see 100 of them.”

“It is alarming,” Andrews added. “It is a pitiful situation. It should not happen.”

A number of factors contribute to younger athletes eventually needing UCLR, including overuse, poor mechanics, and pitching against radar guns.

“These young kids are all worried about throwing 85 to 90 miles-per-hour, and their ligaments aren’t built for that type of speed at such a young age,” Andrews said.

The notion that surgery can somehow fully repair every child’s arm and allow them all to return to full play is dangerous at best, Baker said, and comes from the procedure’s high-profile success.

“Mr. John did us a disservice by being such a good ballplayer, winning more games after his injury,” Baker joked.

Is the problem systemic?

“None of this will ever change until the system recognizes that it is wrong and changes,” Andrews said.

Parents will often tell physicians that their child cannot stop playing because they will lose their spot on a team or fall behind in team activities. Coaches and leagues may not alter activities due to trying to increase league revenues.

“The tail is wagging the dog,” Andrews said.

According to Bergfeld, the most prevalent societal issue within youth sports — and one that contributes to overtraining and eventual overuse or injury — is that of too much organization.

“There is no free play,” he said. “The children are not learning skills of life. They all have coaches, they have uniforms, schedules — all the way from little kids right up through when they get into high school.”

“It is hard to convince people to play sports for fun,” Nelson said. “The kids feel that if they are not on the top traveling team, then it is not worth playing.”

Society has more at stake than league money and injured youth: According to Andrews, the approximate combined annual health care costs for the treatment of youth sports injuries is $2.5 billion. Late sequelae can account for an additional $3 billion. The extreme costs, he said, make youth sport injuries a health reform issue.

“When these kids are hurt at such a young age, that compounds the health issues throughout their entire lives,” he said.

The most important messages

Ultimately, for physicians the changes that need to be made go beyond the way young patients are treated – and until those changes are made, the youth sports injury trend will not go away.

“At a younger level, the goal is to keep the kids in the game and participating,” Nelson said. “This whole idea you have to win at the young age level and create these extremely competitive travel teams hurts kids in both ways. It hurts some of the kids because they are overdoing it, and it hurts some of the other kids because they are not participating.”

Bergfeld stressed the importance of remembering that the games are, at the base level, for the children — not the parents.

“The game has been taken away from the kids,” he said. “There is too much organization, and the kids are losing a lot of the values they learned through playing sandlot sports. I think that part this societal problem is harder to solve.”

Though patients typically do not come in until they have been injured, Andrews insisted it is up to the orthopedic community to focus on prevention.

“It is our obligation as physicians — particularly sports medicine physicians — to get involved in prevention so that these kids can grow up to be productive citizens, enjoy a healthy lifestyle and perhaps go to college and play sports,” he said.

For injured children — through overuse or otherwise — Baker pointed out that misconceptions can be dangerous.

“The perception is it is not a big deal,” he said. “Get hurt, get fixed, come back next year like so-and-so did. In actuality … it may not be you. There are problems associated with any operation. We are very good at what we do, but you would hate to think a preventable injury based on overuse has resulted in a surgical procedure.”

“There are so many things you cannot prevent,” Baker added. “If we could slow down the progression of preventable injuries to youngsters, I think we would all be much better off.” – by Robert Press

• James R. Andrews, MD, can be reached at the Andrews Sports Medicine and Orthopedic Center at St. Vincent’s in Birmingham, AL. 805 St. Vincent’s Drive, Suite 100, Birmingham, AL 35205; 205-939-3699; e-mail: Contact Mike Oliver at MikeO@asmi.org.
• Champ L. Baker, Jr., MD, FACS, can be reached at the Hughston Clinic in Columbus, GA. 6262 Veterans Pkwy, Columbus, GA 31908-9517; 706-324-6661; e-mail: cbaker@hughston.com.
• John A. Bergfeld, MD, can be reached at the Cleveland Clinic Sports Health Center, 5555 Transportation Blvd., Garfield Heights, OH 44125; 216- 445-4836; e-mail: bergfej@ccf.org.
• Bradley J. Nelson, MD, can be reached at 2512 South 7th St., Suite R200, Minneapolis, MN 55454; 612-273-8000; e-mail: nels5101@umn.edu.

References:

• Current comment from the American College of Sports Medicine. August 1993--"The prevention of sport injuries of children and adolescents. Med Sci Sports Exerc. 1993;(8 Suppl):1-7
• Flesig GS, Weber A, HAssell N, Andrews JR. Prevention of elbow injuriesn in youth baseball pitchers. Curr Sports Med Rep. 2009;8(5):250-254.
• Matsuura T, Kashiwaguchi S, Iwase T, et al. One-year prospective study on elbow overuse injuries in child and adolescent baseball players. Paper #44. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 6-9, 2010. New Orleans.
• Olsen SJ, Fleisig GS, Dun S, et al. Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers. Am J Sports Med. 2006; 34(6): 905-912.
• Powell JS, Barber Foss KD. Injury patterns in selected high school sports: a review of the 1995-1997 seasons. J Athl Train. 1999;34: 277-84.

Have widely publicized surgical-treatment successes in the professional athlete community been a help or hindrance to youth athletics?

Freddie H. Fu

Expectations too high

Young patients’ parents frequently think their child is like an NFL player or a professional athlete – they are not. They a regular kids. They need to have some fun, learn to be team players, all of those things are more important than just being very good. Prevention and stopping the injury are more important.

[Tommy John surgery] is overdone. Many of them do not succeed. You do not see the ones that do not come back. They see some player use [platelet-rich plasma treatments (PRP)] and go back to playing in a few weeks, and they think everybody else is the same way. A good example is a torn ACL — a professional player comes back and plays; now all the kids want to come back in 6 months, which is impossible.

Professional athletes have much more support, and they are probably in much better shape … they have trainers they work with every day, they work out every day. High school and college athletes do not have time to do that. So, all of these operations — PRP and such — all of the young athletes want to use it. Their expectations are too high.

Professional athletes’ injuries and recoveries have little to do with the injuries that we see every day. Professional athletes who “make it” do not have many injuries in high school. If they had injuries, they would not be there. And when a professional gets hurt, they have much more help. We mentioned Tommy John — it is just like that. “I want to be Tommy John.” What about the players who did not come back?

It is dangerous in the sense that the expectations are too high and there is too much disappointment. I always tell the athletes they have many things to do in life other than athletics. You can have some fun. And when they hurt themselves more than once, I tell them maybe it is time to think of something else to do. The point is, you have a lot of life to go. Injuries can give you a perspective on life and show you that you have more important things to do in the long run.

Many injuries occur because of poor technique, overuse, poor coaching or conditioning … some of those can be prevented. Hopefully, if we do more work for prevention, we do not need to come to treatment. Treatment is improving and we are learning how to do it better, but there is no surgery or treatment that can be guaranteed to be 100% successful. Treatment is good, but we need to do more in terms of prevention.

Freddie H. Fu, MD, DSc (Hon), DPs (Hon), is the David Silver Professor and Chairman at the University of Pittsburgh Division of Sports Medicine.

Bernard R. Bach Jr.

Certain surgeries overdone

There is clearly a perception by parents and coaches that if [Tommy John surgery] is performed, the athlete will return to – and possibly exceed – their pre-injury status. Overall there are probably too many of these procedures being performed.

In my mind, the clear-cut indication is the player who has a single, specific, macrotraumatic event. Many athletes will have a “toggle” on valgus laxity evaluation, possible abnormalities on MRI and/or stress radiographs, but in my opinion these are not absolute indications for reconstruction. We have noted in the White Sox organization that many athletes who have recovered from Tommy John surgery will, within 2 years of UCL reconstruction, require shoulder surgery. This is suggestive that abnormal mechanics play an important role in both elbow and shoulder conditions in the overhead throwing athlete.

It is surprising how often we detect abnormalities — tight hamstrings, core weakness, scapular dyskinesia, posterior shoulder tightness — in addition to observed throwing mechanics that may place the elbow at risk. Our goal with the STOP campaign is to “keep athletes out of the OR and on the playing field.” The emphasis on pitch counts, avoiding year-round play, avoiding overlap between house, travel leagues and showcase tournaments, cross training and proper mechanics are all efforts to reduce these significant injuries that are being seen in epidemic proportions.

If a high school athlete requires UCL reconstruction the statistical likelihood of advancing to an elite level such as professional baseball is exceedingly low. All of us in sports medicine who care for adolescent athletes have seen the “stud” 13- or 14-year-old pitcher that injures the elbow throwing too often, too many pitches, throwing curves too prematurely ... there is a relative graveyard of injured elbows out there.

We need to continue to educate coaches and parents about overuse injuries. I think it is important to educate these adults that once the elbow is seriously injured — no matter how good our reconstructions may be — the elbow will not be normal.

Bernard R. Bach Jr., MD, is the Director of Sports Medicine of Midwest Orthopaedics at Rush.