Proper Planning Keeps Kids in Game

Your kids love to go non-stop, but you might not realize it could be hurting them.

More than three-and-a-half million children under the age of 14 suffer sports and recreation injuries each year. As many as half of those aren't the broken bones you might think. Certified athletic trainer Michael Ramirez of Stormont-Vail HealthCare says new data shows 30- to 50-percent of all pediatric sports injuries are from overuse.

Ramirez says year-round youth athletics has brought a lot more younger patients his way. He says a lot has to do with hamstring and quad flexibility. He sees shin splints from running on hard surfaces over time. He also sees a lot of shoulder injuries with baseball, softball and volleyball.

Ramirez says preventing overuse injuries begins before games and practices with proper stretching and warmup. It also means kids knowing their limits, and since kids don't want to sit, parents and coaches need to take the lead, whether it's taking breaks or counting ptiches.

Ramirez likens the body tissue to a paperclip. If you keep bending it and bending it, he says, it's going to break.

Ideally, Ramirez says, you want kids to vary activities, rather than do the same sport year-round. If they do specialize, give them a break - a couple weeks off between seasons.

Ramirez also says pay attention to your child's aches and pains. While adults can brush it off, in kids, the body's usually trying to tell you something's going on.

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Helpful websites:
National Athletic Trainers' Association
Physician and Sportsmedicine

The following is part of an article from "The Physician and Sportsmedicine":
Overuse Injuries in Children and Adolescents
John P. DiFiori, MD


In Brief: With the growth of youth sports programs, overuse injuries in young people have become common. Making the diagnosis can be challenging, but often the real hurdles are in identifying the causes of injury. Growth-related factors require special considerations in injury management. A directed history assessing these and other causative factors and a systematic exam help formulate a comprehensive rehabilitation program. Recommendations for a successful return to activity and prevention of reinjury include avoiding heavy training loads and early sport-specific training, taking adequate rest periods, and ensuring proper supervision.

The benefits of regular exercise are not limited to adults. Youth athletic programs provide opportunities to improve self-esteem, acquire leadership skills and self-discipline, and develop general fitness and motor skills. Peer socialization is another important, though sometimes overlooked, benefit. Participation, however, is not without injury risk. While acute trauma and rare catastrophic injuries draw much attention, overuse injuries are increasingly common.

Diagnostic and treatment efforts should focus on how the injury developed and consider issues that are unique to growing athletes. An understanding of these concepts provides the basis for making specific injury-prevention recommendations.

Kids' Activities Intensify
The true magnitude of youth sport participation in the United States is difficult to measure. Approximately 35 million children and young adults between ages 6 and 21 participate in sports, including 6 to 8 million in school programs (1,2). Over the last three decades participation among young women has increased dramatically (2). Involvement in nonscholastic clubs, in sports such as volleyball, basketball, softball, and gymnastics, also appears to be increasing. Furthermore, parents are hiring "personal" coaches and trainers to furnish specialized training beyond that provided by schools or clubs (3). Between school and club programs, private instruction, and popular summer sports camps, many youngsters are training and competing year-round. Though it is uncertain if more children and young adults are involved in sports, it seems clear that those who participate are doing so in a more extensive way.

Because training has become more sport-specific and nearly continuous, overuse injuries are now common among young athletes (table 1: not shown). Recent data indicate that 30% to 50% of all pediatric sports injuries are due to overuse (4-6). In a study (4) of children (aged 5 to 17) who presented to a sports injury clinic, 49.5% of 394 sports injuries were classified as overuse, with boys and girls displaying a similar frequency. The relative percentage of overuse injuries varies by sport, however. In a 2-year study (5) of 453 young elite athletes, 60% of swimmers' injuries were due to overuse, compared to 15% of soccer players' injuries. Athletes who had overuse injuries lost 54% more time from training and competition than those who had acute injuries.

How Overuse Occurs
Overuse injuries occur when a tissue is injured due to repetitive submaximal loading. The process starts when repetitive activity fatigues a specific structure such as tendon or bone. With sufficient recovery, the tissue adapts to the demand and is able to undergo further loading without injury. Without adequate recovery, microtrauma develops and stimulates the body's inflammatory response, causing the release of vasoactive substances, inflammatory cells, and enzymes that damage local tissue (7). Cumulative microtrauma from further repetitive activity ultimately causes clinical injury. In chronic or recurrent cases, continued loading produces degenerative changes leading to weakness, loss of flexibility, and chronic pain (8). Thus, in overuse injuries the problem is often not acute tissue inflammation, but chronic degeneration (ie, tendinosis instead of tendinitis).

Contributing Factors
An understanding of the risk factors contributing to overuse injuries is the cornerstone of prevention. These risk factors have typically been classified as intrinsic or extrinsic. In children, issues specific to the immature musculoskeletal system deserve special consideration (table 2). (See "Case Report: Knee Pain in a New Runner," below.)


Table 2. Factors Contributing to Overuse Injury


Intrinsic Factors
Growth (susceptibility of growth cartilage to repetitive stress, inflexibility, muscle imbalance)
Prior injury
Inadequate conditioning
Anatomic malalignment
Menstrual dysfunction
Psychological factors (maturity level, self-esteem)

Extrinsic Factors
Too-rapid training progression and/or inadequate rest
Inappropriate equipment/footwear
Incorrect sport technique
Uneven or hard surfaces
Adult or peer pressure


Growth-related factors. Two factors related to growth are particularly important. First is the susceptibility of growth cartilage to repetitive stress. In children, growth cartilage is present at the articular surface, physes, and apophyses (9).

The articular cartilage appears most vulnerable to injury at the ankle, knee, and elbow. The development of osteochondritis dissecans at these sites is poorly understood and is possibly related to repetitive microtrauma (10).

Apophyseal injuries, including tibial tubercle apophysitis (Osgood-Schlatter disease) and calcaneal apophysitis (Sever's disease), are commonly attributed to overuse (11). They result from traction-induced microtrauma at the tendon-bone attachment. Contributing factors include the weakness of the growth cartilage relative to the tendon, and poor flexibility and increased traction during the adolescent growth spurt.

Physeal injuries may also be caused by repetitive loading. Growth plate injuries have been reported in the proximal humerus in throwers (12) and a badminton player (13) and in the proximal tibia of a runner (14). In gymnastics, repetitive loading of the wrists can injure the distal radial growth plate (15). It appears that metaphyseal ischemia inhibits mineralization within the zone of provisional calcification, prolonging chondrocyte life. This, together with continued division of chondrocytes in the proliferative zone, results in widening of the growth plate (16). Physeal injuries may produce partial or complete growth arrest (17).

The second growth-related factor that contributes to injuries is the rapid change in the relative lengths of the long bones and their adjacent muscle-tendon attachments. Joint tightness can develop when bones lengthen faster than muscle-tendon units, producing inflexibility and dynamic muscle imbalances. The discrepancy may also increase traction on the apophyses and stress at the joint surface (eg, patellofemoral joint).

Other intrinsic risk factors. Patients who have overuse injuries often have a history of previous injury, which may signal repeated errors in training or technique, an inadequately rehabilitated injury, or an unaddressed cause of the original injury. Menstrual dysfunction, often associated with a decrease in bone mineral density, appears to increase the risk of stress fractures in some athletes (18,19).

Alignment abnormalities have been associated with overuse injuries; these include pes planus, pes cavus, hyperpronation, tibial torsion, patellofemoral malalignment, femoral anteversion, and leg-length discrepancy. Although difficult to quantify, excessive ligamentous laxity also may predispose patients to overuse injury. Examples include anterior knee pain in a runner with a hypermobile patella or shoulder pain in a swimmer with glenohumeral instability. Laxity measurements are relatively static and may not accurately represent the dynamic situation (eg, velocity of pronation in a runner). The contributions of alignment problems and joint laxity to overuse injuries remain unclear because prospective studies are few (20). These limitations should be kept in mind when addressing anatomic alignment and joint laxity in individual rehabilitation programs.

The child's level of conditioning is another important consideration. Youngsters will likely benefit from developing general strength and endurance before participating in a training program. Unfit children may lack the proprioceptive skills, and weak and/or inflexible musculoskeletal structures may be unable to withstand the forces of training. Proper preparation and age-appropriate activities may help reduce injury.

Psychological factors should also be considered. Pressures from peers and adults often play a role (see below), but it is important to recognize that the child's level of maturity and self-esteem will influence motivation and the ability to focus on conditioning and safety.

Extrinsic risk factors. Changes in the components of the training program are frequently associated with overuse injury. Though variations in the frequency, intensity, and duration of training are necessary to improve performance, another important training element is often overlooked: rest. Gradual training progression accompanied by scheduled recovery periods is often well tolerated by young athletes. Abrupt increases in any facet of training and/or inadequate rest intervals often lead to overuse injury. An example is a young tennis player who enters a summer camp to work on his serve. Accustomed to practicing two hours per day, five days per week with the high school team, the athlete now spends four to six hours each day emphasizing the serve and quickly develops a rotator cuff tendinopathy. Parents and coaches should be aware that training programs designed for adults are not appropriate for young athletes. In fact, because of the great variation in physical and emotional maturity among children and adolescents, individualization of training schedules is encouraged.

Faulty equipment is another risk factor. Footwear should be well-fitted and suited to the demands of the activity. Running shoes should be replaced at regular intervals because they can lose more than 40 percent of their shock-absorbing capacity after 250 to 500 miles (21). Other examples include the grip size and string tension of a tennis racquet and the fit of a bicycle. Equipment changes may also result in injury. A well-conditioned track athlete who switches from training flats to spikes for interval workouts may develop lower-extremity problems from changes in running mechanics.

Poor technique can also produce injury. In tennis, for example, flexing the wrist at ball impact during the backhand stroke commonly causes lateral epicondylitis. Instruction in proper technique helps treat and prevent overuse injury. Finally, changes in training surfaces may lead to injury. Rapidly introducing hill running, running on a beach or other tilted surface, and running on uneven or hard surfaces can trigger injury.

Pressure from others, especially adults, may play a role in the development of overuse injury. Parents and coaches who promote excessive intensity or who encourage a "no pain, no gain" or win-at-all-costs attitude may well contribute to injury. Assessing a child's motivation can be helpful: Is he or she genuinely interested in playing, or doing so only because of others' expectations? Children who have uncharacteristic symptoms or fail to progress as expected with treatment may be expressing their lack of interest in the sport.

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