Prevention and Management of Pediatric Overuse Injuries

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Introduction and Overview

During the course of this webinar, we will discuss pediatric sports participation (specifically overuse injuries). We will review the role of sports medicine professionals in evaluating and managing these conditions, as well as the key role that they can have in prevention. I will address some of the position and consensus papers that have been developed specifically on the topics of overuse injuries and sports specialization. This is an area where we are starting to see not only consensus recommendations but also emerging evidence focusing on what sports specialization at a young age means to these individuals. I will highlight some of the key recommendations out of these various statements, and tie up with some conclusions and a presentation of a patient case that involves early sports specialization and injury.

Before I begin, I would like to acknowledge that a lot of what I will be presenting is from the 2011 National Athletic Trainers Association position statement on the prevention of pediatric overuse injuries and as such, the co-authors, the writing team, and the NATA pronouncement committee should be thanked for their efforts in putting that particular document together.

Sports Participation in the U.S.

In the United States, over 30 million children and adolescents are involved in sports. Data for the National Federation of State High School associations has demonstrated that over 7.8 million high school students participate in some type of inter-scholastic athletics, and over of half of all enrolled students in high school are competing in some type of high school activity.

There is significant evidence to demonstrate that participation in both physical activity and sports as a youth helps to develop physical and psychosocial components of health. There's evidence to suggest that participation in sports can: increase cardio-respiratory fitness; improve blood lipid profiles; improve selected psychological measures, including self-esteem; is beneficial for body composition; increase bone mineral density. Bone mineral density is one of the physiologic elements that decreases in the early 20s. The more that we can build up that through participation in sports and recreational activities in our younger children is beneficial.

When we're describing to children why they should be participating in sports, we talk about sportsmanship and being a good teammate and the physical benefits they'll get. Our main goal is to encourage the establishment of good health habits at an early age, so that they lead active lives, and avoid complications such as obesity, diabetes and other ailments that are the result of a sedentary lifestyle.

One of the common problems we tend to see is a push in youth sports. There are headlines from a variety of publications, highlighting the rising cost of youth sports. It's estimated that in some cases, per sport-playing child, families will spend thousands of dollars annually. If the child participates in hockey, parents can easily sink between $10,000 and $15,000 a year into their child's sports endeavors. One of the main parental motivations is to get their athlete to a level where they will earn a college scholarship.

Additionally, youth sports are a tourism draw in a lot of different areas. In some communities, they have built large parks with 10-15 soccer fields, in the hopes of booking large weekend tournaments that will bring in families, who in turn spend money in hotels and restaurants, thereby boosting the local economy.

Pyramid of Sports Medicine and Child Health

In the British Journal of Sports Medicine, an editorial was published in 2010 by Dr. Stovitz entitled “The Pyramid of Sports Medicine and Child Health.” As clinicians who are working in sports medicine to some degree, and working with children, it's an eye-opening way to look at what we do.

On the bottom of the pyramid is this firm foundation. It consists of physical activity promotion, energy balance, non-violence in sports, injury prevention, advocate and organize, a voice of reason and injury treatment.  The middle layer consists of emotional and physical well-being.  The top is child health.  I think in all of our roles as professionals (PTs, PTAs, athletic trainers and other clinicians), there are some things that we obviously focus on more so than others (e.g., injury treatment). But, clinicians participating in sports medicine can also do a lot of other things.

With regard to physical activity promotion, there are some studies that show that sports participation in youth is associated with higher overall levels of physical activity over time. If I segue into my other research area, which is the area of concussion, there are a lot of questions about whether or not children should be participating in certain sports because of the risk of injury. As providers in these areas, it is important that we talk about and promote physical activity and the role of sports if done safely, as a means to promote and keep children active. The benefits of participating do outweigh some of the risks, including some of the injuries that we'll discuss in a few minutes.

Injury prevention is a key area and one that we'll focus a lot on today. About 30 to 40% of adolescents seek medical attention annually for a sport related injury. It's important that we're collecting some of that data, sharing it, and looking at ways of tracking that data. Areas such as energy balance and the nutritional aspect, and promoting that as part of the healing and the recovery process is important. In addition, promoting nonviolence in sports through supporting rule changes, advocacy to parents and others is a key component of what we can do as well.

In addition to injury prevention, we are involved in injury treatment. As physical therapy professionals, we're beyond the point in a lot of areas where all we want to recommend is rest. We want to be a little bit more active and do some therapy and rehabilitation with these patients to ensure that we can return them to a level where they can participate again. In some cases, we also want to take on the role of being the voice of reason. This is where we'll get into more of the discussion with regard to early sampling versus sports specialization. There is a lot of pressure on some of these young children. It's important that we take an active role in advocating for the child, especially if they're a patient that we're seeing. We need to speak up and keep their best interests at heart. Finally, all of these foundational frames together lead to an overall improvement in a child’s health, through both their emotional well-being and physical well-being.

In our institution, one area that we have worked on with respect to sport-related injuries is assessing health-related quality of life, and quality of life in general. By using patient report outcome measures with these sports injuries, not only to try and better characterize them, but also to help better determine when these individuals are able to return fully to both school and sports. If we think about this framework, this prevention piece becomes extremely important, along with how we manage and treat the injured patients that we're seeing.

Long-Term Athletic Development

About one year ago, a position statement was published by the National Strength and Conditioning Association in the Journal of Strength and Conditioning. The purpose of this statement was to look at long-term athletic development, and as clinicians in sports medicine and strength and conditioning, how we go about identifying and developing pathways to encourage behavior that will hopefully keep these individuals active in the long term. The principles set forth in their position paper are as follows:

1. Long-term athletic development pathways should accommodate for the highly individualized and non-linear nature of the growth and development of youth.  
2. Youth of all ages, abilities and aspirations should engage in long-term athletic development programs that promote both physical fitness and psychosocial wellbeing.  
3. All youth should be encouraged to enhance physical fitness from early childhood, with a primary focus on motor skill and muscular strength development.  
4. Long-term athletic development pathways should encourage an early sampling approach for youth that promotes and enhances a broad range of motor skills
5. Health and wellbeing of the child should always be the central tenet of long-term athletic development programs.  
6. Youth should participate in physical conditioning that helps reduce the risk of injury to ensure their on-going participation in long-term athletic development programs.  
7. Long-term athletic development programs should provide all youth with a range of training modes to enhance both health and skill related components of fitness.  
8. Practitioners should use relevant monitoring and assessment tools as part of a long-term physical development strategy.
9. Practitioners working with youth should systematically progress and individualize training programs for successful long-term athletic development. 
10. Qualified professionals and sound pedagogical approaches are fundamental to the success of long-term athletic development programs. 

These programs need to be such that the rehabilitation side is working with strength and conditioning, if they're available at the high school level, or with some of our club and community sports to ensure a good transition between what we're doing post-injury, getting them back to their regular training, and then also from a preventive standpoint.