Current Trends in Youth Sports Injuries Jeff G. Konin, PhD, ATC, PT Associate Professor & Vice Chair.

Current Trends in Youth Sports Injuries

Jeff G. Konin, PhD, ATC, PT

Associate Professor & Vice Chair

Konin Copyright 2009

Objectives of This Course

1. Identify the epidemiology of injuries sustained by children playing sports

2. Discuss practical injury prevention programs for simple implementation

3. Identify trends in the use of protective youth sports equipment

4. Discuss the impact emergency planning has on reducing catastrophic youth sports injuries


National Center for Sports Safety

& Safe Kids USA

• Approximately 20 percent of children and adolescents participating in sports activities are injured each year, and one in four injuries is considered serious.

• Children and adolescents who are just beginning a sport or activity are at greater risk for injury.

Epidemiology of Youth Sports Injuries:

Startling Statistics!


National surveillance for sports injuries among US high school student-athletes, 2003 youth risk behavior survey

Hootman, JAT 2006*

• N = 15,214, in 2003 (athletes = 53.7%)

• High risk dieting behaviors were associated with greater injury rates – fasting, dieting, vomiting

• Also tobacco, alcohol, psychological distress


Slowly Creeping Up…………..

• 1.5 million injuries a year with BMX bikes

• 2.6 million injuries a year skateboarding

• Over 3 million injuries per year in-line skating

• 65 thousand injuries per year horseback riding

• Nearly 68 thousand kids were treated last year for trampoline injuries


Who Manages Youth Injuries?

• Parents• Coaches• Friends

• Physicians• Physical Therapists• Athletic Trainers• Physical Educators• Others


What role does obesity play in today’s youth sport’s injuries?


Here are some celebrities and athletes that the

government has deemed "overweight": Michael Jordan: 6'6": 216 lbs: 25Bobby Labonte: 5'9": 170 lbs: 25

Karl Malone: 6'9": 259 lbs: 28Yao Ming: 7'6": 310 lbs: 27Brad Pitt: 6'0": 203 lbs: 28

Keanu Reeves: 6'1": 223 lbs: 29Cal Ripken: 6'4": 210 lbs: 27

Nykesha Sales: 6'0": 184 lbs: 25Will Smith: 6'2": 210 lbs: 27

Bruce Willis: 6'0": 200 lbs: 29

Be careful with BMI – people can over or under react!


Sports Psychology in Children’s Sports

The mind of a child is

highly influenced

by the parent and

coach!


Abrams, Center for Sports Parenting 2005

“70 percent of kids drop out of sports by age 13, and the main reason is pressure from parents and coaches.”

Bob Bigelow, one of the authors of ``Just Let the Kids Play,'' believes the odds of winning a scholarship are even more remote than many other experts say, estimating that just 1 in 300 high school senior athletes will get a fabled “full ride.''


Unrealistic expectations of parents

In Northern California today:

> There are about 2,000 club soccer teams> There is a decline in the number of multi-sport athletes as kids specialize in one sport to maximize their scholarship chances.


• The Northeastern University Center for the Study of Sport in Society found that, of black teens, 66 percent believe they will ultimately play pro ball.


Behavioral Response Of InjuryThe Injury Itself

• The stressor, loss of self-control


Behavioral Response to InjuryEmotional Responses

Denial

Anger

Frustration

Bargaining

Depression

Acceptance


Educate The Athlete…and the parent!

• First – assess parental knowledge in general and current disposition

• Explain facts about the injury• Realistic expectations of recovery• Importance of psychological skills as a

part of the rehabilitation process• Allow athlete to educate you


Case Study

• How would you counsel a 12 year old child and parents referred to you with OSD and wanting to return to playing basketball?

• Topics might include: learning what the MD told them, their goals, their realisms, their timeline, what they googled, child’s interests, compliance, motivation, past experiences

Protective Equipment:

Rules, benefits, considerations & knowledge


Purposes of Protective Equipment

1. Dispose & absorb forces2. Limit anatomical movement3. Support joint structures4. Support musculotendinous

structures5. Enhance proprioceptive

feedback6. Secure protective pads

Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009


Protective Equipment Guide• Does the equipment protect the

area of concern appropriately?• Can the athlete perform the

skills required for his/her sport and position while wearing the device?

• Will the device maintain proper anatomical alignment?

• Is the device potentially hazardous or injurious to other participants?

• Is the device legal by the rules and regulations of the sport?

Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009


Commotio Cordis: Incidence by Sport

52%

12%

12%

10%

7%4% 2%1%

BaseballSoftballIce HockeyFootballSoccerLacrosseKarateRugby

Blunt trauma during 20mSec window, VFib15% survive commotio cordis events


Commotio CordisOptimal Management

• Chest protectors, softer balls, etc have all been proposed

• Consensus is be prepared with an AED!


Mouth Guards• Stock, mouth formed,

and custom-fitted• Required for lacrosse,

ice hockey, football, field hockey

• Recommended for basketball & soccer


Concussions in Children


Mechanisms of Injury

• Concussion– Acceleration-deceleration forces result in

shearing forces which distort the vascular and neutral elements of the brain – chemical cascade

• Cumulative effect!!!!!!!!!!!!!


S & S of Concussion

Physical Symptoms

Headache

Vision difficulty

Nausea

Dizziness

Balance Difficulties

Light sensitivity

Fatigue

Emotionality Symptoms

Irritability

Sadness

Nervousness

Sleep disturbances

Cognitive

Memory loss

Attention disorder

Reasoning difficulty


Post-concussion Syndrome(PCS)

• Vary in symptoms & length of presence

• Always have medical professional assess and determine safety for clearance

• Do not go by athlete comments alone

• Beware of physician shopping

Various Scales Used to Grade Concussions

Grade 1 (mild) Transient symptoms; no LOC; symptoms and mental status abnormalities resolve within minutes

Grade 2 (moderate)

Transient symptoms; no LOC; symptoms and mental status abnormalities last longer than minutes

Grade 3 (severe) Any LOC


Source: JAT 2004 Position Statement

People working with younger (pediatric) athletes should be aware that recovery may take longer than in older athletes. Additionally, these younger athletes are maturing at a relatively fast rate and will likely require more frequent updates of baseline measures compared with older athletes.


Because damage to the maturing brain of a young athlete can be catastrophic (ie, almost all reported cases of second-impact syndrome are in young athletes), athletes under age 18 years should be managed more conservatively, using stricter RTP guidelines than those used to manage concussion in the more mature athlete.



F/U Guidelines• Avoid meds – only acetaminophen from MD • Avoid ingesting alcohol, illicit drugs, or other substances• Instructed to rest, but complete bed rest is not

recommended• Eat a well-balanced diet that is nutritious in both quality

and quantity• An athlete should be awakened during the night to check

on deteriorating signs and symptoms only if he or she experienced LOC, had prolonged periods of amnesia, or was still experiencing significant symptoms at bedtime



Recovery patterns of athletes reporting posttraumatic headache following sports-related concussion

Register et al, JAT 2006*

• Prospective randomized experimental study• 375 concussed high school and collegiate athletes average

age 16.65 +/- 1.87• Self-reported graded symptom checklist (GSC)• Days 1,3, & 7 post injury data collection• Conclusion: young athletes reporting PTH following a

concussion endorse a higher number of symptoms and demonstrate decreases in neurocognitive performance when compared to those not reporting PTH

• Thus, headache is a sign of incomplete recovery


Concussion Gender Differences in YouthDivine et al 2007 MSSE*

• Female athletes have higher severity o symptoms and longer recovery rates

• This was only seen when comparing non-helmeted athletes

• Unsure of reasons why


Concussion Management

What would you say is the most practical and affordable method of decision-making following a concussion for those settings without large budgets and personnel resources?


Younger Athletes Slower to Recover from Concussions, Studies Showposted 02/02/09 5:45 pm ROCKVILLE, Md. - Every year more than 300,000 people report getting concussions from sports. But experts say millions more likely go undiagnosed. And while we see professional athletes like Super Bowl quarterback Ben Roethlisberger bounce back, for kids and teenagers it can be a long road to recovery.


Rotator Cuff and Periscapular Muscle Strength in Adolescent Male Baseball Players

Kelp-Lenane et al. JOSPT 2008*

• Assessed strength relationship for 55 11-15 y/o male baseball pitchers – Tanner 2 or 3, pitching for 2 years, no pain

• PS muscles were significantly weaker than RC muscles in dominant and non-dominant of all subjects

• Strength differences do not appear to be a result of pitching – are we doing the right thing in rehab?

Rotator Cuff and Periscapular Muscle Strength in Adolescent Male Baseball PlayersKelp-Lenane et al. JOSPT 2008*


Shoulder Injuries


AC Joint Sprain

• Downward force on the acromion process

• Must be strong enough to displace AC ligament

• With excessive force, can eventually displace CC ligaments (Conoid & Trapezoid)

• Debate as to the exact grading criteria, not important – functional limitations are!


Acromioclavicular Joint Disorder

• X-rays to determine grade

• G I-II sling, pain relief 5-7 days

• G III non-op unless cosmetic concerns

-Weightlifters

-Bathing suit appearance


Rationale:

• Acute comfort

• Surrounding awareness

•Theoretically approximates a joint that will not heal on its own – therefore it provides comfort with partial tears


Clinical Pathway for AC Sprain

• Control pain, usually minimal inflammation• Avoid distraction activity• Progress with functional exercises as tolerated• Expect pain for a long time!• Resultant instability not common regardless of

profession/career/sport

Bottom Line: Let pain & function dictate:

don’t “over treat” or “over advise”


Will shoulder braces work? Functional?


Elbow Injuries


Little League Elbow

• Medial epicondylitis and adolescents– 8-10 y/o ~ bone weakest

component– 15-18 y/o ~

muscle/tendon/tissue weakest component

– Mid 20s and up ~ muscle and/or ligament weakest component

• Age tells you what structure is involved


What is your comfort level in advising with respect to preventing throwing injuries for little league

baseball pitchers?

9-10 years 11-12 years 13-14 years

Pitches per game

50 75 75

Pitches per week

75 100 125

Pitches per season

1000 1000 1000

Pitches per year

2000 3000 3000

Proof??????????


Preventing Injuries in Throwers with the Core and Hips

LE Flexibility (Used as part of an overall warm-up)Ipsilateral hip extension

Hip IR/ER (Lack of IR will force truck to open early and increase stress on medialElbow and /or anterior shoulder)

Core Training for Throwers Abdominal Bracing /Drawing in maneuver

Prone Cobra ProgressionLE Balance/Proprioception*

Standing Pulls - ant/post/lat pull (Weak gluts cause the hip to drop leading to drop of shoulder)LE Functional Strength Training**

Wind-Up/Lunge with twist Lunge with twist

Step-Ups with twist*Functional exercise that is multiplanar, incorporates the lumbo-pelvic-hip core

complex and can be challenged with proprioceptive input from unstable surfaces,eyes closed, etc

** Lunge strength will help deceleration injuries to the shoulder


Deficits in measurable active & passive hip extension, active hip flexion with pain (Kouvalchouk Rev Chir Orthop 1998)

Serape EffectKonin et al ATT 2003

http://www.jmu.edu/photography/athletics/Baseball/ha15516R01n45.jpg


Epicondylitis Considerations

Strings too loose Grip too large Poor technique


Wrist Ligament Sprains

“It is only a sprain”

Avoid Grip Strength Activity!


Jersey Finger

Pulling against fixed object

Lifting with tips of finger

Laceration

Crush Injury

Amputation


Mallet Finger* Usually a result of

blunt trauma


Muscle StrainsQuadriceps & Hamstring Update


Treatment of Hamstring Strains

• THE RISK FACTORS: Muscle weakness, decrease muscle flexibility, lack of proper warm-up, fatigue, improper flexor/extensor strength ratio, increasing age, menstrual disturbances, previous injury

• Can we prevent ALL of these?


To Stretch Or Not To Stretch

• Systematic search - 293 articles, of which 14 used a control group.

• Five suggested prevention, six suggested no difference but three suggested increased injury. The positive studies had warm-up as a co-intervention.

Shrier I, Shrier I, Clin J Sports MedClin J Sports Med 1999, 1999, EBSMEBSM 2002 2002


Wenos & KoninJ Strength Cond Res. 2004

• Controlled warm-up intensity enhances hip range of motion.

• In a field setting, it is estimated that a warm-up of 70% of HRR would duplicate the muscle readiness equivalent to an RER of 1.00 before PNF stretching.

• Equivalent to 4 minutes of a light aerobic activity


The Impact of Stretching on Sports Injury

• Stretching before or after exercise is not associated with a reduction in total injuries

• Produces small, statistically non-significant reductions in muscle soreness

• 5th day post injury tendon exhibits weakest tensile strength (right about the time one starts to “feel better”), then progressively gets stronger each day

Thacker et al, Med Sci Sports Exer 2004, Herbert & Gabriel, BMJ 2002


The Child’s Knee


Ligament Injuries - ACL 200,000 new ACL injuries

per year• History

– Majority are non-contact injury with knee in extension (70%)

– Hemarthrosis within a few hours

– Audible pop in 50%

– More common in females - risk is at least 5X higher among women than men and the gender difference is even higher at the elite levels

http://www.youtube.com/watch?v=84OUUz3u7Lc

http://www.youtube.com/watch?v=84OUUz3u7Lc


Factors associated with anterior cruciate ligament injury history in female athletes

• Increased generalized laxity • Decreased ITB flexibility • Previous ankle injury• Menstrual cycle changes• A decreased protective role of dynamic knee stabilizers (quadriceps and

hamstrings)• A diminished ability to resist anterior shear with muscle contraction.• A smaller ACL than men• A narrower intercondylar notch than men• Wider Q-angle• Wider hips/pelvis• Increased foot pronation

Kramer et al JAT 2006, Lie et al 1997, Smith et al 1993


Neuromuscular Training May Assist in Preventing ACL Injuries

• 3/6 studies reduced ACL injury in females• Question of consistencies, cost & time of implementation,

compliance issues• Some evidence that proprioceptive and balance exercises

improve outcomes in individuals with ACL-deficient knees• Improvements in joint position sense, muscle strength,

perceived knee joint function, and hop testing were reported post intervention

• No adverse effects with intervention• Too few studies to safely confirm

Hewett et al, AM J Sports Med, 2005 Cooper et al, Res Sports Med 2005, Engebretson and Bahr BJSM 2005, Hammill et al JAT 2006


ACL Injuries in ChildrenACL deficiency in the skeletally immature has

resulted in a high incidence of secondary meniscal injuries, degenerative joint disease, and symptomatic instability in both sports and daily activities.

Skeletally immature athletes are in fact much less likely to limit their activities and adapt to ACL insufficiency than skeletally mature counterparts.

Graf et al 1992, Mizuta et al 1995, McCarroll et al 1994


ACL Prevention Programs PEP Program

Dr Mandelbaum et al. Santa Monica aclprevent.com No cost

SportsmetricsTM

Dr. Noyes et al Cincinnati Sports Medicine sportsmetrics.net Fees & certification

The 11 Developed by FIFA F-MARC (Medical Research Centre) fifa.com/aboutfifa/developing/medical/the11/index.html No cost


ACL Prevention Program• We use PEP (Prevent Injury Enhance Performance)

• Highly specific 15-minute training session that replaces/compliments the traditional warm-up 2-3x weekly

• The Goals of the Program are to:

1) Avoid vulnerable positions2) Increase flexibility 3) Increase strength 4) Include plyometric exercises into the training program5) Increase proprioception though agilities



What About Knee Braces?

Appear to play a role – may always be in question

Pietrosimone et al JAT 2006, Naiibi & Albright Am J Sports Med 2005, McDevitt et al Am J Sports Med 2004

The “Breaking Point”

5mm

15mm

7mm 12mm


How Common are Ankle Injuries?

• Most common sports injury

• 85% of ankle injuries are sprains

• 85% of sprains involve lateral ligaments

• 20% - 40% lead to chronic symptoms


What Do You Need To Know About Ankle Sprains?

• Most common risk is previous ankle sprain

• Supervised rehabilitation with proprioception intervention reduce risks of repeat

• Balance training improves sensorimotor control in athletes with previous injury

• Effect seems to be limited to those with previous injury, where postural control, position sense and postural reflexes are reduced

• Appropriately applied brace or tape does not hinder performance

• Taping or bracing can reduce incidence for recurrence of ankle sprains in athletes with previous ankle problems

• Unclear if high top shoes reduce the risk of injury

Thacker et al, AM J Sports Med 1999, Bahr R. EBSM 2002Bahr R. EBSM 2002


High Ankle Sprain (SYNDESMOTIC)

• Tib-Fib Sprain (anterior/posterior)• Mechanism of injury is fixation and rotation• Treatment is difficult due to lack of good support

for this area internally & externally


Managing The High Ankle Sprain

Be patient!Tell the athlete to be patient!Tell the parents to be patient!Tell the coach to be patient!


Failing to Plan = Planning to Fail

• Emergency Action Planning

• Build from existing templates & models

• Follow nationally and regionally accepted standards of policies & procedures

• Identify key steps – don’t guess– What key components should be included?

– Who are the stake holders?

– What expenses might exist?


Field Safety• Uneven playing surfaces• Surfaces with greater than normal friction, ie old

hardwood courts• Slippery playing surfaces, fields with puddles• Improper illuminated lighting for night events• Irrigation systems not completely buried• Baseball dugouts without proper protection from hit balls• Fences and that surround fields with protruding parts • Goalposts and other fixed apparatus that are not

properly protected with padding

Current Trends in Youth Sports Injuries Jeff G. Konin, PhD, ATC, PT Associate Professor & Vice Chair.

Documents

konin copyright

youth injuries

youth sports injuries

todays youth sports

epidemiology of injuries

trampoline injuries

considerations knowledge

psychological distress