Pediatric overuse injuries increase due to year round, one sport training
Specialization in youth sports has led to an increased number of overuse injuries in young athletes, often amounting to acute injuries or withdrawal from play, according to prominent sports medicine physicians who spoke with Orthopedics Today.
Parents may look toward athletes such as Tiger Woods, who began golfing as a toddler, and hold that immersing a child in a single sport at a young age will produce a professional-level athlete. However, in most cases, our sources noted that excessive practice most likely leads to injury rather than perfection.
“Parents think the more you pitch [for example], the better you are going to be in terms of playing further into college or into the professional level, but we believe, as physicians, the more you throw at that level, the less chance you have of a long career playing baseball or moving on to the next level because of the overuse injuries we see limiting these players long term,” Grant L. Jones, MD, an orthopedic surgeon and professor at Ohio State University, said.
Overuse injuries that go untreated, are not properly rested, rehabilitated or subsequently avoided through proper techniques, can progress to additional injuries and permanent limitations. “[Young athletes with overuse injuries] are more prone to injury at a younger age and more prone to injury at a higher level as they throw into their older years,” Jones said.
Typically, young athletes are advised to rest the injured joint about 3 months before they return to the particular sport. James R. Andrews, MD, of Andrews Institute for Orthopaedics & Sports Medicine, said, “Fatigue is the big factor in youth sports,” which he said has led to a 10-fold increase in overuse injuries since 2000. “For example, in youth baseball, our research at American Sports Medicine Institute, shows that if you pitch with fatigue, there is a 36-to-1 [increased likelihood that] you can injure your throwing shoulder or elbow,” he said.
The number of young athletes experiencing overuse injuries has increased, according to American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeon’s (AAOS) STOP Sports Injury program, which was launched after a decade-long study by Glenn S. Fleisig, MD, which linked injury to the number of innings pitched in youth baseball. According to data from AAOS and American College of Sports Medicine, more than 3.5 million athletes aged 14 years or younger incur sports medicine injuries, many of which are preventable.
‘Epidemic’ at hand
Physicians interviewed by Orthopedics Today echoed they had seen an increase in these type of injuries within their practice. “I would say that it is truly the epidemic at hand for the young athletes,” Eric W. Edmonds, MD, an orthopedic surgeon and co-director for 360 Sports Medicine at Rady Childrens Hospital in San Diego.
Mininder S. Kocher, MD, MPH, professor of orthopedic surgery at Harvard Medical School and associate director of the Division of Sports Medicine at Boston Children’s Hospital, noted the upward trend in overuse injuries during his 15 years of practice is due to the “professionalization” of youth sports as well as increased diagnostic ability and lack of free play. “Core strength and balance [are] things they would have gotten from free play like climbing and jumping, but free play is pretty much gone now,” Kocher said. Injury prevention clinics often create simulated tree-climbing exercises to mimic this activity, he said.
Pressure to compete at a higher level leads many young athletes to not only play more intensely but also more often, leading them to play a single sport year round. Omitting a rest period between seasons and not switching to a different sport with alternate motions and stress loads are major factors in the risk of overuse injury and burnout, according to physicians who spoke with Orthopedics Today. A common perception among parents, children and coaches is that athletes who are not playing for the entire year “are losing that advantage over somebody else who is also playing year round,” Edmonds said.
Kevin G. Shea, MD, of St. Luke’s Sports Medicine said, “It used to be that [young athletes] would play one sport in the fall, one in the winter, one in spring and one in summer. Now, they are playing soccer, baseball or softball indoors in the winter. [There is] an emphasis on year-round focus on one sport, [with] the same type of loads on that area.”
Climate also can be a factor in risk for overuse, according to Jones, who has undertaken a research effort on the influence of warm vs. cold weather on incidence of overuse injuries at Ohio State.
“We looked through the records of Major League Baseball and divided pitchers into those who had grown up in warm weather climates vs. cold weather climates,” he said. Data indicated decreased career wins, games started and career innings in those pitchers who grew up in warm weather climates vs. cold weather environments. He attributed the difference to pitching year round, and likely subsequent overuse injuries decreasing these baseball longevity metrics.
Physicians also pointed out that while there are upper limits set within baseball leagues for the number of pitches a player is allowed in a season, families and athletes seeking more playing time can often circumvent the rules. “People find ways to get around the rules and regulations set forth by Little League baseball,” Jones said. “They often put their kids in several different leagues during the summer, so there may be a pitch count in one league but they do not record that in another league [so] these kids are throwing a lot more than we know about.” Pitching showcases and other events outside the leagues also often do not count toward the pitch total of these athletes, he said.
Diagnosis and care
Once a child or adolescent seeks medical advice for pain or an inability to play, issues may arise in determining the course of treatment. Diagnosis can be more complex in overuse injuries since symptoms may wax and wane depending on activity, and pain is often slow to develop, Shea said.
“As far as diagnosis, something acute caused by a fall is immediately known to kids, while overuse can create aches and pains for weeks or months and does not have the same immediately obvious causality,” he said.
Overuse injuries can take many forms, including stress fractures in the hip, foot or tibia; osteochondritis of the knee, ankle or elbow; a torn ulnar collateral ligament; shoulder labral injury; spondylosis in swimmers, football players and gymnasts; rotator cuff tears; tendon and cartilage injuries; and youth leaguer’s shoulder and youth leaguer’s elbow.
“We see a lot of elbow and shoulder injuries predominantly in this population,” Jones said. “We see Little Leaguer’s elbow, which is an injury to the medial epicondyle or the growth plate in that area, and we see compression injuries on the lateral side of the elbow, such as osteochondritis dissecans lesions.”
Kocher also suggested that multiple concussions could arguably be considered an overuse injury as the likelihood for re-injury increases over time and multiple concussions have a cumulative effect, he said.
Nikhil N. Verma, MD, associate professor and orthopedic surgeon at Midwest Orthopaedics at RUSH, Rush University Medical Center, also pointed to ACL injury as a potential, secondary result of overuse. While it “may not be a true overuse injury, caused by repetitive movement or the same activity, there is a grey area,” he said, noting that fatigue associated with overuse can contribute to injury. In addition, as the volume or total hours of sports participation increases, so does exposure to injury, which results in increased risk of ACL injury.
Following diagnosis, athletes, parents and coaches fixated on competition or professional prospects may not receive the message of rest and alternating sports. The perception that “kids do not need to stretch, they are resilient and can recover quickly,” still exists, said Edmonds. “Whereas that may be true [to some degree], there is still the problem of overuse. Eventually, you wear down a machine. Whether it is a Porsche or a Kia, you can overdrive both of them,” he said.
Regimented rest and recovery
Rest from the sport in which the injury occurred is essential to heal pediatric overuse conditions. In general, the common recommendation is about 3 months of rest, however, physicians interviewed for this story noted timelines can vary — based on the exact injury, diagnostic and evaluation tools, and physician preference — and can be controversial. Edmonds recommended focusing on radiograph results to determine healing. Current variations in recovery timelines could lead an athlete to “doctor shop” in order to obtain a diagnosis with the least amount of rest, he warned.
“A lot of people will say you just have to rest until it does not hurt anymore. [The] problem is what 10 year old will say it hurts 6 weeks later?” said Edmonds. “They realize by saying something, they were not able to play baseball.” He suggested studies should be conducted to set and substantiate best practices on recovery times.
Kocher also suggested that pressure toward participation in sports before patients are fully healed may be rooted in sports culture. “Professional athletes are celebrated for getting back in the game,” he said, adding that athletes are not praised for taking the necessary time to heal. “But these are not little professional athletes,” he said. In fact, singular focus on getting back in the game may have long-term consequences if healing is compromised. For instance, if youth leaguer’s shoulder — distraction of the physis at the proximal humerus — is not properly rested, the involved growth plate will stop growing and the playing arm may be a few inches shorter in adulthood, according to Edmonds.
Physicians interviewed for this Cover Story also discussed how media coverage of surgical repair for injuries, like ACL tears, influences parents and athletes who may come to a facility with expectations to schedule surgery. “We do get a lot of pushback because parents often come in wanting a quick-fix for their young athletes,” Jones said. “They often come in wanting surgery right away and that is the absolute worst thing to do in this population because the return rate after surgery in particular shoulder surgery, in the overhead athlete is very poor at all levels including the major league level.”
According to a 2011 Sports Health article by Steven B. Cohen, MD, 23% of elite athletes were able to return to the same level of play following shoulder or elbow surgery. A study by Fedoriw and colleagues discovered 62% of pitchers in their cohort returned to pitching. However, 26% returned to pitching at pre-injury levels.
Rest and flexibility
Convincing parents and athletes that rest, flexibility, core strengthening, and possibly rehabilitation, are a needed part of a young athlete’s regimen can also be achieved by simple office exams that demonstrate inflexibility or lack of core strength.
“I think once you lay that out there and prove to them your point and that you are not just blowing smoke, then tell them this is something that is real,” Edmonds said. “You are setting it up for them that this is a serendipitous warning that your body is not doing exactly what it is supposed to be doing and you need to take advantage of that warning.”
At this point, physicians are able to suggest a recovery plan for the young athlete. “In the early stages [of an overuse injury], we certainly remove them from pitching or catching, let them hit or play first base or something where they do not throw as much,” Jones said, referring to pitchers. “We recommend a physical therapy program to work on stretching the posterior joint capsule, which often becomes tight in these young athletes, as well as a rotator cuff program to strengthen the muscles in the shoulder, particularly, the external rotator muscles,” he said.
Strengthening muscles both surrounding the injured area and throughout the body is important in maintaining joint health and warding off future injury. With pitchers, this includes “scapular stabilizing muscles within the back which help put the arm in the appropriate position to throw,” and “core strengthening exercises to work on the trunk, pelvis and hip muscles which are also important in the pitching motion,” said Jones.
Concentration on core strengthening and flexibility, in conjunction with physical therapy, if necessary, leads to a high rate (about 95%) of improvement within a 3-month rest period, Edmonds said. “Kids that come in usually have poor core strength and flexibility,” said Edmonds. “Once you can improve either one of those things or hopefully both, knee pain goes away, ankle pain goes away [and] it is amazing what it does.”
Growth spurts can also wreak havoc on young athletes as these can affect their flexibility and alter their core strength thereby making them prone to injury, according to Kocher.
Education — for parents, athletes and coaches — about the importance of building in breaks during intense training, incorporating cross training and strengthening the body as a whole with core exercises is essential for maintaining improvement in overuse injuries. Shea recommends young athletes keep a log of workouts with the number of hours spent per day, per week and per year and how they feel during those times.
Biomechanics and motion
Treatment for pediatric overuse injury may involve analysis of biomechanics and incorrect technique, which may have contributed to the initial injury or can lead to further complications. Jones said Ohio State University offers a physical therapy program for overhead throwers in which therapists analyze the throwing motion biomechanically. Commonly, staff find that children will compensate for pain by altering their technique.
“Often when these young kids get into problems throwing, they develop bad mechanics which place their elbow and shoulders in abnormal positions that predispose them to injury,” Jones said.
Verma co-authored a recent study that found a correlation between injury and pitching velocity, pitcher height and if a pitcher plays for more than one team. Traditionally, pitching injuries have been tied to breaking pitches or “fast balls,” but Verma said the cross-sectional study that looked at 420 pitchers found that speed, repetition and throwing motion predicted 77% of injuries.
“Throwing requires the shoulder and elbow to operate at a near failure level, so repetition of that will eventually cause issues,” Verma said. “It is simple physics — if you throw harder, faster and more often, [there is a greater risk for injury].”
He suggested that maximum velocity limits be set based on age, though he acknowledged such a move would be controversial and coaches will need to help create a balance between fostering potential and safety. Verma also suggested that programs that are beginning to look at risk factors could help identify overuse injuries in the making or mitigate them once symptoms have become an issue.
“We are finally beginning to identify some of the risk factors and that they are modifiable,” he said, adding that this often allows physicians to help athletes lower their risks for injury. Physicians, for example, can identify neuromuscular activation such as the flexion of the knee or hip flexor strength when jumping, Verma said. In the instance of an adolescent who jumps and lands straight-legged, this would provide an opportunity to reduce the child’s risk for knee injury through neuromuscular education by teaching proper landing methods, he said. Verma predicts that programs looking at neuromuscular activation and preventing ACL injury will increase in the next 5 years.
Education and further research may be the best tools to decrease the prevalence of overuse injuries among young athletes, physicians suggested.
“Overall, we probably as physicians need to do a better job of educating coaches, players and families about the importance of recommendations by Little League Baseball [for example] in terms of the number of pitches per game, number of pitches per year, number of months playing baseball per year,” Jones said.
Andrews suggested parents, coaches and athletes need to incorporate 3 months of rest, move away from year-round immersion in one sport and incorporate play or differentiation by entering multiple sports. – by Katie Pfaff
Fedoriw WW. Am J Sports Med. 2014; doi: 10.177/0363546514528096.
Fleisig GS. Am J Sports Med. 2011;doi:10.1177/0363546510384224.
For more information:
Eric W. Edmonds, MD, can be reached at Rady Childrens Hospital, San Diego, 3020 Children’s Way, San Diego, CA 92123; email: firstname.lastname@example.org.
Grant L. Jones, MD, can be reached at Orthopedic Sports Medicine, The Ohio State University, Suite 3100, 2050 Kenny Rd., Columbus, OH 43221; email: email@example.com.
Mininder S. Kocher, MD, MPH, can be reached at Harvard Medical School, Boston Children’s Hospital, Division of Sports Medicine, 319 Longwood Ave., Boston, Massachusetts 02115; email: firstname.lastname@example.org.
Kevin G. Shea, MD, can be reached at St. Luke’s Sports Medicine, 600 Robbins Rd., #401 Boise, ID 83702; email: email@example.com.
Nikhil N. Verma, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison St., Chicago 60612; email: firstname.lastname@example.org.
Disclosures: Edmonds serves on AAOS and AOSSM committees, POSNA board and has a financial relationship with Arthrex and Orthopediatrics; Kocher serves on AOSSM committees, is on the board of directors for POSNA and AAOS and is a consultant for Smith & Nephew, OrthoPediatrics and Biomet; Andrews, Jones, Shea and Verma have no financial disclosures.
How can physicians adequately address varied rest and recovery timelines for young athletes with overuse injuries, which can create opportunities for parents and coaches to “doctor shop” for faster return to play?
Rest to avoid recurrence
I tell patients that the time to recovery depends on multiple factors such as: the anatomic location, sport, the age of the patient and the severity of the injury. I also think it is important they take an active role in their recovery. For example, in throwing athletes with medial epicondyle apophysitis or proximal humeral physiolysis, I rest them from throwing completely for 6 weeks. During that time, the patients attend physical therapy working on rotator cuff, periscapular and core strengthening. At 6 weeks, if pain free, they advance to a gradual throwing program. They are allowed to return to play when they complete the throwing program without pain over a 4-week to 6-week period.
Many patients and parents are initially unhappy with this approach. However, I explain to them that these injuries can take a significant amount of time to heal and that treating them aggressively with rest should decrease the likelihood of recurrence. Furthermore, most of the exercises they perform while “resting” may improve the athlete’s performance once he or she returns. When patients have a recurrence of the overuse injury, the clock starts over, which can increase the total time out of sports dramatically.
Educating patients and families on the injury and laying out a detailed, goal-based plan of treatment can minimize “doctor shopping.” Having a knowledgeable and engaged physical therapist can be invaluable in keeping patients and families on the treatment plan. We have also developed patient handouts containing information about many of the common overuse injuries we see.
John D. Polousky, MD, is surgical director of sports medicine at The Rocky Mountain Youth Sports Medicine Institute, Rocky Mountain Hospital for Children in Denver.
Disclosures: Polousky has no relevant financial disclosures.
Nuanced approach necessary
I feel there are a variety of important principles to embrace when considering variability in physicians’ management recommendations for pediatric overuse injuries and the phenomenon of patients questioning or treatments that may limit their children’s athletic activity or slow their return to competition:
The first is that we clearly need to work together as clinicians and clinical investigators to improve the available evidence through research. We should be striving for a deeper understanding of the varying effects of rest and rehabilitation on young athletes of different ages and comparing protocols in studies. Since interest in youth sports and the resulting epidemiological phenomenon of youth sports injuries seems to be growing, we need to similarly grow our attention towards collaborative efforts in the establishment of clinical guidelines for our treatments, which most commonly includes basic rest and physical therapy exercises.
For example, at many of our professional conferences, the emphasis in scientific presentations and symposia is on comparing different surgical treatments for when these injuries are at their worst. However, if we can shift our focus toward proving the effectiveness of specific measures to prevent or treat overuse conditions in their earlier forms — which we see two to five times more commonly in our offices than the severe form — then we may decrease the need for such surgeries.
Despite the lack of well-established guidelines for treatment, each clinician should use his or her existing knowledge, diagnostic skills and clinical intuition to create recommendations for care. In some scenarios, it can be important to maintain one’s position and not make compromises or engage in negotiations with parents, some of whom can be strong willed, when it comes to their kids’ sports “careers.” While specific protocols for rest and/or rehab are not as well-established or systematic as dosing of common medicines, for example, it is critical to impart one’s clinical opinion on what regimen will best serve the patient and not waver in that opinion.
When parents resist treatments that limit their child’s activity, they are often trying to be the best advocate for their children, in trying to allow them to continue “what they love doing.” In these scenarios, one can explain the overuse injury as a difficult challenge that will have to be overcome with a team approach that includes the patient, parent and physician.
If parents understand that the greatest risk of going back to sports too early is a recurrence or persistence of the overuse injury — which could result in double or triple the time missed from sports — they may accept a specific regimen more readily.
Benton E. Heyworth, MD, is clinical instructor, Harvard Medical School, and attending orthopedic surgeon, in the Division of Sports Medicine, Department of Orthopaedic Surgery, at Boston Children’s Hospital.
Disclosures: Heyworth has no financial disclosures, and serves as committee member for AOSSM and POSNA.