March, 2007
Taking Sports to Extremes
By Thomas G. Dolan
Today’s Dietitian
Vol. 9 No. 3 P. 52

Too much too soon can spell doom for aspiring athletes.

“Winning is everything” can be a losing philosophy, especially when it comes to children in sports. At least, that’s the considered opinion of the experts interviewed for this article, all of whom work with children who have suffered sports injuries. Although they don’t point to any statistics, these experts say that, on the basis of their day-to-day experiences as well as their contacts with colleagues in the field, the incidence of sports-related injuries in children is on the rise.

Kevin D. Plancher, MD, MS, FACS, FAAOS, associate clinical professor at Albert Einstein College of Medicine and director of Plancher Orthopaedics & Sports Medicine in New York and Connecticut, says, “More children are engaged in watching adults participate in sports and want to emulate them. Playing sports in itself can be a good thing, for it can help keep children healthy. But too often, they don’t go through the proper warm-ups adults do or participate in a way inappropriate for their age.”

“One key reason we see so many children in the emergency room is increased sports activity without supervision or proper equipment,” says Julia Retureta-Soler, MD, assistant medical director in the pediatric emergency department (ED) at Coral Springs (Fla.) Medical Center.

Yet, even children who participate in team sports with proper supervision and equipment are suffering more injuries, says Cynthia R. LaBella, MD, medical director of the Institute for Sports Medicine at Children’s Memorial Hospital in Chicago. “Previously, someone in junior or senior high school might have played sports three days a week in hour-long sessions. Now, they play five days a week in two-hour sessions,” she says. “Competition and pressure add to the number of hours. It’s too much too soon.”

“I think one of the big factors is that kids start specializing at a younger age and start playing the same sport all year ... on multiple teams,” says Keith May, PT, DPT, SCS, ATC, CSCS, a physical therapist and certified athletic trainer at Children’s Hospital of Atlanta. “A good example is baseball. They start in little league and then go on to play on multiple school and club teams, fall, spring, and summer ball. Kids are trying to look for that edge earlier on. Some of it can be related to parent and coach pressure—the desire to win at all costs.”

May says there continues to be the usual assortment of typical sports injuries: torn ligaments, sprained ankles, and dislocated shoulders. “But we’re seeing more and more overuse injuries, such as tendonitis, or growth plate injuries. We’re seeing the same elbow and shoulder stress injuries in baseball from kids using the same motions over and over.”

Plancher points out that most Major League hurlers adhere to pitch counts. “You see the coach take out a player in the fifth inning, and you wonder why because he’s been pitching so well,” he says. “But the fact is that he has only so many pitches he can throw without damaging his arm. Parents and coaches should recognize the number of pitch counts in their children and not let them be exceeded.”

Sports such as baseball, tennis, and volleyball that rely heavily on overhead motions carry the risk of repetitive motion injuries, says LaBella. She points out that parents often steer their children toward soccer rather than football to avoid injuries. However, although collision injuries can occur in younger children, most of these sort of injuries take place in high school where children have more strength, and collisions have greater impact. In younger children, soccer injuries number about the same as in football and are mostly due to sudden twists and turns.

“Yesterday, I had a teenage girl in for knee surgery,” says Retureta-Soler. “It used to be that we would only see adults with an overuse of knee joints. Soccer is a big sport for damaging knees.”

Other seemingly innocuous sports have also led more youngsters to the operating table. “Cheerleading is not what it used to be, all dancing and pom-poms,” Retureta-Soler says. “Now, there are very dangerous pyramid stunts in which a cheerleader will ‘fly’ from one person to the next. We’re seeing a lot of neck and head injuries.”

Away from the playing fields, aspiring dancers are also pulling up lame. “They are not supposed to start pointe shoes until they are 12. Now, they regularly get started at age 9, which can result in ankle problems,” Retureta-Soler says.

Basic exercises that are supposed to get you into shape and avoid injuries can pose their own dangers, says Plancher. For instance, he says weight training should not start until the child is at least age 9, and then only with supervision. Weights are built for 5’10” males, so many injuries happen when a younger child handles the barbell at the extremes. Multiple repetitions at a low rate are much better and much less dangerous than the impressive lift of a heavy weight. The standing military overhead press should never be done by a younger child; the incline press executed while laying on the bench is preferred.

Retureta-Soler, who sees fractures on a daily basis, explains that those injuries occur differently in children than they do in adults because of variables in bone density, porosity, and elasticity. A simple fracture may be put into a temporary splint with a follow-up with an orthopedic doctor. More serious fractures include a bowing fracture, which causes deformity by bending the plastic part of the bone; a buckle fracture in which the end of a bone is driven into another; and a greenstick, so called because of the elastic aspect of the young bone, which causes the bone to bend but not break completely.

Whenever possible, Retureta-Soler says, the child is taken to the ED where he or she can be treated more comfortably and efficiently. Retureta-Soler also says orthopedic doctors can generally handle most of these cases, although in some instances, a specialized pediatric orthopedic physician may be required.

Plancher says many doctors who claim to be able to practice sports medicine may have limitations. “Sports medicine has become a kind of catch-all phrase, and not every doctor has the background to be able to practice it effectively,” he says. “A nonsurgeon is not in the position to recommend surgery, and a surgeon may recommend it when it is not necessary. A qualified orthopedic physician will be more likely to find the middle ground.” Plancher also advises that an MRI scan be administered to provide objective evidence of the nature of the injury, with the treatment plan based on those results.

Trouble Ahead
The doctors agree that the key warning sign to potentially serious injury is pain, whether it be sharp and immediate or low-intensity and chronic. “Pain is a great warning sign,” May says. “A lot of coaches expect kids to ignore it. But pain is your body’s way of telling you something is wrong. Any time there is swelling or soreness, that’s a sign. There may also be a decrease in performance. For instance, a baseball pitcher may not be able to throw as hard as he could before.”

Lower-grade chronic pain is more likely to be a symptom of repetitive motion damage, says Retureta-Soler, who adds, “You shouldn’t really feel numbness, either.”

“Any time you have difficulty moving any part of your body, such as your elbow not straightening out, is also a warning sign,” adds Plancher.

The child losing interest in a sport could also be a signal of a physical ailment, says LaBella. “This happens when he [or she] is just going from practice to game to practice with less and less enthusiasm,” she says. “This indicates that he [or she] has not enough time for his [or her] homework, hanging out with friends, or other things that kids do. This can show that he [or she] is literally not feeling good because of the sport and is also more vulnerable to other injuries.”

The experts say that outside an obvious injury, the best and most effective remedy is rest. Plancher recommends RICE (rest, ice, compression, and elevation) for 48 hours. If the pain doesn’t subside, then take your child to a sports medicine or orthopedic doctor.

Generally, the experts say, younger children with less developed bodies are more at risk than older children, who have grown stronger—especially if they have had training and conditioning along the way. The danger to older children results from increased competition and more pressure from peers, parents, and coaches. Society accords a great respect to athletes, especially in terms of financial awards. Excellent high school athletes often feel pressure to maintain their performance levels to give them a shot at earning a college scholarship.

Whereas there is always the danger that an athlete can overdo it by going from one sport to another, the bigger danger, says LaBella, is specializing in one sport. “I’m a big fan of playing more than one sport and being exposed to a variety of different activities,” she says. “It balances out the neuromuscular framework, both physically and psychologically. Year-round sport is a risk. This is especially true of sports like gymnastics and skating, which can be taught ... year-round both outdoors and indoors. Performing seasons are very intense. At the minimum, every sport should have at least one day off a week and one month off a year—contact sports especially. Professional football players understand this. They understand that rest and recovery is a part of training.”

Proper equipment is also important. “One of the big advantages of organized sports is that kids benefit from adult supervision and required equipment,” LaBella says. “Rough contact sports like football, hockey, and lacrosse have requirements that manufacturers must meet. The equipment must be scientifically tested. So it’s important that kids be fitted with the most advanced and improved equipment.”

LaBella adds that parents may provide the right equipment but not take into consideration how fast their children are growing. A football helmet that fits one year may be too small the next—the same with shoes. On the other hand, she says, sometimes parents try to compensate for rapid growth by buying a shoe one half size too big, which poses its own dangers.

Also, as May points out, “equipment may protect from more acute, dramatic injuries, such as a football helmet preventing head injuries. But equipment won’t prevent the injuries resulting from overuse.”

Retureta-Soler mentions that many sports, especially the most popular ones, have committee recommendations for safe amateur play, and parents should seek them out and follow them.

“Parents often trust the coach and think he [or she] has the child’s best interests in mind,” Retureta-Soler says. “But they have to use their own good judgment. If the sport does not look safe, then it probably is not. At the end, it’s the parents who end up paying the orthopedic bills.”

One serious injury can wreck a fledging career, but constant pounding can be just as devastating, according to May, who says overused and stressed muscles should not be ignored. “Students often don’t realize their potential in high school and have their future in college sports ended as well,” May says. “Typically, if you catch a condition in time, and you follow the prescription of rest or rehabilitation, you can recover. But if the wear and tear goes too far, it cascades into other things, and the once star athlete will never be the same.”

“What should never be forgotten,” says Plancher, “is that sports, especially at a young age, should be fun. If the fun is taken out of it, then something is wrong. Having fun doesn’t mean the child shouldn’t have instruction and practice. But the sport should contribute to the child’s health, not his [or her] detriment.”

— Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.