Children’s Sports Injuries — A Weighty Issue
By Jennifer Sisk, MA
Today’s Dietitian
Vol. 8 No. 3 P. 50

Developing bodies are prone to injuries sustained in sports and regular physical activity—and overweight and obesity can only complicate matters.

Involvement in children’s sports has skyrocketed over the past few years. In many sports, children and adolescents are being handled like miniature semi-professional athletes and trained accordingly. As the level of intensity and time devoted to training have increased, so have the number of injuries sustained each year by young athletes. While some of these injuries also occur in adults, others are unique because young bodies are still developing. The rising prevalence of overweight and obesity in children and adolescents further increases the risk of injury, not only during sports and exercise but also during routine daily physical activity. In fact, injuries that are usually triggered by middle-age weight gain in adults are now commonly seen in overweight children and adolescents.

Common Injuries in the Young Athlete
The growth spurt experienced in adolescence heightens the risk of injury in young athletes. Intense participation in sports during a growth phase can result in growth plate injuries. When a child is in a growth phase, structural changes and rapid growth rates make growth plate areas more susceptible to injury.

“The growth plate is like a cap on the end of a long bone. Eventually, it will cement as the skeleton matures, but in children it is the weakest part of the skeleton,” explains Diane King, MS, RD, ATC, CDE, a nutrition consultant, certified athletic trainer, and certified diabetes educator at Children’s Healthcare of Atlanta. Growth plate injuries are most common in boys aged 14 to 16 and girls aged 11 to 13 and are often associated with gymnastics, long-distance running, baseball/softball pitching, and contact sports, she says.

Particularly susceptible areas in young athletes are the knee and hip joints, lower spine, ankles, and feet, says Roger M. Lyon, MD, associate professor of orthopedic surgery at the Medical College of Wisconsin and pediatric orthopedic specialist at Children’s Hospital of Wisconsin in Milwaukee. In his orthopedic practice, Lyon sees sports injuries most frequently in children participating in soccer, football, wrestling, and gymnastics. Joint sprains, stress fractures, soft-tissue strains, contusions, and overuse injuries commonly occur and are often sport-specific. For example, soccer, basketball, and other sports that involve running and directional changes can cause ankle and knee injuries. Young gymnasts may injure their wrists, ankles, and knees. “Stress fractures, knee and hip injuries, and sport-specific sprains are common in athletic children,” Lyon notes.

Overuse injuries are associated with sports that involve highly repetitive movements, such as baseball pitching and swimming. “Young athletes are especially prone to overuse injuries because they may not have the strength or endurance to sustain long workouts,” King says. Muscle strength imbalances, poor flexibility, inadequate strength training, overtraining, and lack of appropriate rest/recovery can contribute to the risk of overuse injuries, she adds.

Injuries and Added Girth
While injuries in children of normal weight are generally associated with too much activity, injuries in children who are overweight and obese may result simply from carrying too much body weight. Statistics from the American Obesity Association (AOA) report that approximately 30% of children aged 6 to 11 and adolescents aged 12 to 19 are overweight and 15% are obese. In addition, the AOA reports that the prevalence of obesity among adolescents has more than doubled since 1971.

According to Lyon, children who are overweight and obese are at higher risk for growth abnormalities due to the increased stress of excess body weight. In his orthopedics practice, Lyon sees different injuries in children who are overweight and obese. In active children of normal weight, while growth area abnormalities do occur, they are more uniform, such as chronic stress fractures, Lyon explains. In children who are overweight and obese, however, there is a specific point of injury in the growth area, where the bone is overwhelmed by the forces caused by carrying excess weight, he says.

King adds, “Kids who are overweight or obese also have bone cartilage problems because the cushion can’t support the weight.”

“The body’s ability to cope with physical activity is overwhelmed by excess weight,” Lyon says. Although children and adolescents who are mildly overweight often participate in sports, those considered severely overweight or obese (50 to 100 pounds over ideal weight for age/height) generally choose not to participate in sports. With the exception of certain positions in football, says Lyon, excess body weight is a hindrance in organized sports. For many children who are overweight and obese, even routine physical activity—such as getting through their school day—may be burdensome, he emphasizes.

This lack of physical activity, coupled with excess body weight, amplifies the risk of injury. Scott Cole, wellness expert and creator of Get Fit America for Kids (see “Focus on Fitness” on page 82), says, “As kids get bigger, they tend to move less due to fear and discomfort and are more likely to become injured when they do decide to move or try to participate full-on in a sport or activity.”

While the cardiovascular and metabolic effects of pediatric obesity have been and continue to be vigorously researched, exercise-related injuries in children and adolescents who are obese and overweight have not been studied as much as sports-related injuries in young athletes. Very few research studies addressing injuries related to pediatric obesity and overweight have been published.

At the November 2005 North American Association for the Study of Obesity, researchers from the National Institutes of Health reported results of a study that compared orthopedic injuries in 227 children who are overweight and 128 normal-weight children. Approximately 13% of children who are overweight in the study had at least one fracture compared with less than 4% of children who are normal weight. In addition, the children who are overweight had more hip joint and bone abnormalities, knee pain, and movement limitations.1

King and Lyon do not need research data to know that certain injuries and conditions are definitely more prevalent in children with higher body weights—they see it in their clinical practices. “An overweight or obese child is more likely to develop hip dysplasia, shin splints, and other lower extremity joint problems,” says King. Other common injuries and conditions that develop in children and adolescents who are overweight and obese include the following:

• slipped capital femoral epiphysis—a dissociation of the upper part of the femur bone;

• Blount’s disease (tibia vara)—severe bowing of the legs, occurring in overweight toddlers (aged 2 to 3) and teens;

• painful flat feet—caused by attenuation and tearing of the tendons and ligaments in the foot;

• spondylolysis—fractured spinal vertebrae; and

• degenerative joint disease and osteoarthritis.

King says 30% to 50% of cases of slipped capital femoral epiphysis occur in children who are overweight and obese. Many weight-related injuries and conditions, such as painful flat feet and osteoarthritis, commonly occur in adulthood as people age and gain weight over time. “These should not be occurring in children,” says Lyon.

Injury Prevention and the Role of Exercise
King emphasizes that sports injuries—whether in children who are normal weight or overweight—are prevented by consistent flexibility programs, appropriate resistance and strengthening programs, and appropriate rest between exercise sessions.

However, recovery from injury is more difficult for children who are overweight and obese. A recently published study found that children who are overweight are more likely to have lingering symptoms of pain, weakness, or recurrent injury after an acute ankle sprain than children who are normal weight with the same injury.2 With the right treatment, an active, injured child of normal weight “gets back into the game quickly,” says Lyon. For children who are overweight and obese, because body weight is a major contributing factor to injury, weight reduction must be part of the treatment. “Once problems develop, recovery for these kids is hard. Resolving the weight issue and trying to get overweight kids to exercise regularly is most difficult,” he says.

What types of exercise can help children who are overweight and obese lose weight and prevent injuries? Cole recommends walking at a moderate pace to start, and as fitness level increases, faster intervals can be added to the walking session. “Overweight and obese kids need a tailored exercise program,” says Lyon, “one that includes nonimpact exercise like swimming and stationary cycling.” King agrees that walking, biking, and swimming—activities that are less weight-bearing—are more tolerable for children who are obese who are beginning to exercise for the first time. These non– and low–weight-bearing exercises, along with resistance exercises with tubing or bands and stretching, can help tone muscles, increase endurance, and improve balance and coordination, which may in turn help prevent exercise-related injuries, says King.

In organized group activities, children and adolescents who are overweight and obese may be discouraged from exercising because they fear potential reactions—and embarrassment and humiliation—from their peers. Getting children and adolescents who are overweight and obese to start exercising and stay motivated to maintain a regular program is difficult. First, physiological and psychological barriers to exercise must be overcome. A June 2005 study documented that adolescents who are overweight have a limited tolerance for exercise caused by excess body mass, which requires greater cardiorespiratory effort to move.3 Besides the extra body weight, children and adolescents who are overweight and obese may have poor muscle strength, impaired balance and coordination, and movement limitations. Poor self-esteem, negative body image, and fear of embarrassment add to the barriers to exercise.

“In addition to having a weak upper body and some movement limitations, overweight kids usually lack self-confidence,” says Cole. “The best type of exercise is the one the child has fun doing. Family involvement is important,” King notes. Recreational activities such as skating, golf, dancing, free play, and family fitness should be encouraged, says King. Cole, who conducts school assemblies on fitness nationwide, says his Get Fit America program for kids combines yoga and tai chi for gentle exercise and is appropriate for children of all ages and body weights. “Overweight children can be surprisingly flexible and they enjoy the yoga poses and slow martial arts movements,” says Cole.

Is Society to Blame?
Prevention of activity-related injuries—especially in children who are overweight and obese—hinges on appropriate and regular exercise. However, very few opportunities for encouraging exercise in children who are overweight and obese exist in today’s society. Many schools have eliminated physical education classes in favor of academics and participation in team sports has become too competitive for many children and adolescents—no matter what their body weight.

Compliance with an exercise program, even one prescribed by a physician, is difficult, according to Lyon. The same factors that contributed to their weight problem—societal barriers to regular exercise and easy access to fattening foods—also contribute to noncompliance with an exercise program. “It’s a sad statement about society,” Lyon says. A weight-related injury adds to the likelihood that a child who is overweight or obese will not comply with prescribed exercise.

By removing physical education from schools, adults are sending the message that moving the body is not important, Cole believes. “The greatest injury for children today is the lifelong one being inflicted upon them by a society that doesn’t consider physical fitness, creativity, imagination, and real food as standard fuel for a healthy life,” he says. “The ultimate injury is taking physical fitness away from kids.”

— Jennifer Sisk, MA, is a certified wellness educator with the American College of Wellness, a certified fitness instructor with the Aerobics and Fitness Association of America, and an editorial advisor for Today’s Diet & Nutrition magazine.

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Resources
• American Academy of Orthopedic Surgeons. Exercises for Young Athletes. Available at: http://orthoinfo.aaos.org/fact/printer_page.cfm?topcategory=Children&Thread_ID=2

• American Obesity Association. AOA Fact Sheets. Obesity in Youth. Available at: www.obesity.org/subs/fastfacts/obesity_youth.shtml

• Get Fit America for Kids Web site: www.getfitamerica.us

References
1. Associated Press. Overweight children are more at risk for broken bones and joint problems. U.S. News & World Report. November 22, 2005.

2. Timm NL, Grupp-Phelan J, Ho ML. Chronic ankle morbidity in obese children following an acute ankle injury. Arch Pediatr Adolesc Med. 2005;159(1):33-36.

3. Norman AC, Drinkard B, McDuffie JR, et al. Influence of excess adiposity on exercise fitness and performance in overweight children and adolescents. Pediatrics. 2005;115(6):e690-e696.