11/1/2016 1 Musculoskeletal injuries in youth athletes: Which is safer sports or free play? Musculoskeletal injuries in youth athletes: Which is safer sports or free play? Mary Lloyd Ireland, M.D. University of Kentucky Dept. of Orthopaedic Surgery and Sports Medicine Lexington, Kentucky www.marylloydireland.com 48 th Family Medicine Review & Contemporary Pediatrics Conference November 6, 2016 48 th Family Medicine Review & Contemporary Pediatrics Conference November 6, 2016 I have nothing to disclose I have nothing to disclose Which is Safer? Which is Safer? Organized Sports or Free Play? Organized Sports or Free Play? A Free Play B Organized Sports C Neither Children should Not play Sports D Neither Based on Current Research A Free Play B Organized Sports C Neither Children should Not play Sports D Neither Based on Current Research Can you identify the adult? Can you identify the adult?
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11/1/2016
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Musculoskeletal injuries in youth athletes:
Which is safer sports or free play?
Musculoskeletal injuries in youth athletes:
Which is safer sports or free play?
Mary Lloyd Ireland, M.D.University of KentuckyDept. of Orthopaedic Surgery and Sports MedicineLexington, Kentuckywww.marylloydireland.com
48th Family Medicine Review & Contemporary Pediatrics ConferenceNovember 6, 2016
48th Family Medicine Review & Contemporary Pediatrics ConferenceNovember 6, 2016
I have nothing to discloseI have nothing to disclose
Which is Safer?Which is Safer?
Organized Sportsor
Free Play?
Organized Sportsor
Free Play?
A Free Play
B Organized Sports
C Neither Children should Not play Sports
D Neither Based on Current Research
A Free Play
B Organized Sports
C Neither Children should Not play Sports
D Neither Based on Current Research
Can you identify the adult?Can you identify the adult?
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Educational Need/Practice Gap
Gap = The rate of overuse (microtraumatic) injuries in youth sports is underestimated.Health Care providers do not actively prevent overuse injuries in youth sports such as baseball and cheerleadingNeed Establish an injury registry and better document and prevent oversuse injuries in the skeletally immature patient
Need =
Expected Outcome
Show unique aspects of Macro and Micro Traumatic injuries in skeletally immature bones Understand overuse injury patterns of the elbow in pitchersProtect the Young Athlete from permanent negative effects of sport. Emphasize the positives of exercise and competition
Objectives
Review the musculoskeletal injuries that skeletally immature athletes sustain.Discuss diagnosis and implement treatment plans in youth athletes.Cite case examples to decide which is safer sports or free playSports Registries Need to be created
for Organized Youth Sports
Types of InjuriesTypes of Injuries
Microtraumatic vs. MacrotraumaticRepetitive Major Accident
Skeletally Immature Uniqueness of Injuries• Open Growth Plates• Immature Skeleton • Physiologically Lax Joints• Psychological
• Want to Please• Feel no Pain
Microtraumatic vs. MacrotraumaticRepetitive Major Accident
Skeletally Immature Uniqueness of Injuries• Open Growth Plates• Immature Skeleton • Physiologically Lax Joints• Psychological
• Want to Please• Feel no Pain
The ProblemThe Problem• 30 million children participate in organized sports(Source: Safe Kids USA)• Participation in high school athletics is increasing, with
more than 7.3 million high school students participating annually
(Source: National Federation of State High School Associations)
• High school athletics account for more than 2 million injuries annually, including
500,000 doctor visits 30,000 hospitalizations
(Source: Centers for Disease Control)
The ProblemThe Problem
• Young athletes are specializing in sports (and positions) at an earlier age, with more than 3.5 million children under the age of 14 treated annually for sports injuries.
(Source: Safe Kids USA)
• Immature bones, insufficient rest after injury, poor training and conditioning contribute to overuse injuries.
• Overuse injuries account for half of all sports injuries in middle school and high school.
(Source: Safe Kids USA)
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Survey 7-13 Years Old ChildrenSurvey 7-13 Years Old Children
• Two playing seasons• Community organized• Injury rates per 1000 athlete-exposures:
Soccer 2.1Baseball 1.7Football 1.5Softball 1.0
• Two playing seasons• Community organized• Injury rates per 1000 athlete-exposures:
Soccer 2.1Baseball 1.7Football 1.5Softball 1.0
Radelet MA, Lephart SM, Rubinstein EN, Myers JB, “Survey of the injury rate for children in community sports,” Pediatrics 2002;110:E28.Radelet MA, Lephart SM, Rubinstein EN, Myers JB, “Survey of the injury rate for children in community sports,” Pediatrics 2002;110:E28.
Contribution of Growth Plate to Length
LOWER EXTREMITY
Femoral growth 9 mm./ yearTibial growth 6 mm. / year
% of each bone
% of entire
extremity
Appearance and Closure of Secondary Ossification Centers -
LOWER EXTREMITY
Salter-Harris FracturesSalter-Harris Fractures
Kay RM and Matthys GA, "Pediatric Ankle Fractures: Evaluation and Treatment," JAAOS 9:4 (July-August 2001);
268-278.
Kay RM and Matthys GA, "Pediatric Ankle Fractures: Evaluation and Treatment," JAAOS 9:4 (July-August 2001);
268-278.
Neer CS II, Horwitz BS, Fractures of the epiphyseal plate. Clin Orthop 41:24, 1965.
Peterson CA, Peterson HA, Analysis of the incidence of injuries to the epiphyseal growth plate.J. Trauma 12:275, 1972.
Cited In Ogden JA, Skeletal Injury in the Child(Philadelphia: W.B. Saunders, 1990).
Neer CS II, Horwitz BS, Fractures of the epiphyseal plate. Clin Orthop 41:24, 1965.
Peterson CA, Peterson HA, Analysis of the incidence of injuries to the epiphyseal growth plate.J. Trauma 12:275, 1972.
Cited In Ogden JA, Skeletal Injury in the Child(Philadelphia: W.B. Saunders, 1990).
Epiphyseal Fracture Rates - Lower Extremity
Ogden Peterson NeerN % N % N %
Distal femur 36 15% 18 14% 28 5%
Proximal tibia 14 6% 6 5% 17 3%
Distal tibia 83 35% 59 46% 238 41%
Distal fibula 18 8% 21 16% 302 51%
Proximal femur 11 5% 7 6%
TOTAL 236 100% 128 100% 587 100%
Cited In Ogden JA, Skeletal Injury in the Child (Philadelphia: W.B. Saunders, 1990).
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14 YO WM PunterWas Hit
14 YO WM PunterWas Hit
All 29 Patients:All 29 Patients:
18 (60%) Excellent8 (27%) Fair4 (13%) Poor
18 (60%) Excellent8 (27%) Fair4 (13%) Poor
Poor Outcome if Displaced >50%Poor Outcome if Displaced >50%
“Fractures of the distal femoral epiphyseal plate.”
“Fractures of the distal femoral epiphyseal plate.”
–Thomson JD et al. J Pediatr Orthop1995; 15(4):474-478.
–Thomson JD et al. J Pediatr Orthop1995; 15(4):474-478.
15 year old walked funny since a bicycle crash 4 years ago
MRI scan at time of initial injuryMRI scan at time of initial injury
JamesAaronMatthews.mpgJamesAaronMatthews.mpg
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13 year oldSoccer AthleteKicked a BallPlanted Felt a PopLLEDisplaced, ComminutedTibial TubercleFracture
13 year oldSoccer AthleteKicked a BallPlanted Felt a PopLLEDisplaced, ComminutedTibial TubercleFracture
14 YO Male14 YO Male
• Left ankle• Tillaux fracture
with displacement
• Left ankle• Tillaux fracture
with displacement
CT ScanCT Scan
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9 YO Female Cheerleader9 YO Female Cheerleader
• Right ankle pain• Fell from a stunt and has pain and localized bump, medial ankle• Stress reaction, medial malleolar accessory ossification center
• Right ankle pain• Fell from a stunt and has pain and localized bump, medial ankle• Stress reaction, medial malleolar accessory ossification center
13 YO Baseball player13 YO Baseball player• Stretching in gym• Felt right groin pain after running to first• Stretching in gym• Felt right groin pain after running to first
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14 YO Soccer Athlete
Lesser TrochanterAvulsion Fracture
Iliopsoas
14 YO Soccer Athlete
Lesser TrochanterAvulsion Fracture
Iliopsoas
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Snapping Hip SyndromeSnapping Hip Syndrome
• External:• Iliotibial band on greater trochanter• Most common
• Little Leaguer’s Elbow• Described by Adams, 1964
• Medial humeral epicondyle stress fracture• My definition of Little Leaguer’s Elbow
• 1980s: osteochondritis dissecans• Incidence reduced in US? from pitch count restrictions? • Increased incidence in Japan
• 2000: ulnar collateral ligament tears• Epidemic
• Little Leaguer’s Elbow• Described by Adams, 1964
• Medial humeral epicondyle stress fracture• My definition of Little Leaguer’s Elbow
• 1980s: osteochondritis dissecans• Incidence reduced in US? from pitch count restrictions? • Increased incidence in Japan
• 2000: ulnar collateral ligament tears• Epidemic
Need Injury Registry for childhood sports injuries Need Injury Registry for childhood sports injuries
Throwing Development Phase 1Throwing Development Phase 1
Video courtesy of Mark R. Hutchinson, M.D.Video courtesy of Mark R. Hutchinson, M.D.
Throwing Development Phase 2Throwing Development Phase 2
Video courtesy of Mark R. Hutchinson, M.D.Video courtesy of Mark R. Hutchinson, M.D.
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CY YOUNG
“. . . when my arm hurt, I just pitched more often, and it always got better.”
Denton True Young1867-1955
from Andrews JA, et. al., Injuries in Baseball, Lippincott-Raven, 1998.
Appearance and fusion of secondary ossification centers of the elbow in females and malesAppearance and fusion of secondary ossification centers of the elbow in females and males
• 50% increase in UCL reconstructions in high school players
• J.R. Andrews UCL reconstructions• 1988-1994: 8% high school (7 / 85) • 1995-2003: 13% high school (77 / 609)
Petty DH, Andrews JR, Fleisig GS, Cain EL, “Ulnar Collateral Ligament Reconstruction in High School Baseball Players: Clinical Results and Injury Risk Factors,” Am J Sports Med 32(5), 2004;1158-1164.
Petty DH, Andrews JR, Fleisig GS, Cain EL, “Ulnar Collateral Ligament Reconstruction in High School Baseball Players: Clinical Results and Injury Risk Factors,” Am J Sports Med 32(5), 2004;1158-1164.
Risk FactorsRisk Factors
• Overuse• Fatigue• High Pitch Velocity• Showcase Participation• Age Groups – Age Matched Case Control Study
• 95 pitchers surgery / 45 adolescent no surgery• Multivariant Analysis, Injury Risk Pitching:
Olsen II SJ, Fleisig GS, Dun S, Loftice J, Andrews JR, “Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers,” Am J Sports Med 34(6); 2006,905-912.
Olsen II SJ, Fleisig GS, Dun S, Loftice J, Andrews JR, “Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers,” Am J Sports Med 34(6); 2006,905-912.
Dr. Andrews:“. . . the speed gun is the worst invention in the history of Little League baseball.”
Conclusion:13 YO “Big Pitcher” SyndromeConclusion:13 YO “Big Pitcher” Syndrome
• Skeletally and mentally immature
• Fast growth phase
• Poor pitching mechanics
• Hip weakness= UE overuse injury
• Skeletally and mentally immature
• Fast growth phase
• Poor pitching mechanics
• Hip weakness= UE overuse injury
Protect our young athletesProtect our young athletes• Reduce rate of Rotator Cuff and UCL tears in young
pitchers• Reduce rate of Rotator Cuff and UCL tears in young
pitchers
14 YO WM LH-Dominant14 YO WM LH-Dominant• Avid baseball pitcher• Pain in left elbow, 2 months• Could not straighten out elbow.
• Avid baseball pitcher• Pain in left elbow, 2 months• Could not straighten out elbow.
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14 YO WM14 YO WM• RHD baseball player, wrestler, and football player• Right elbow pain posterior over the olecranon• RHD baseball player, wrestler, and football player• Right elbow pain posterior over the olecranon
6 months following initial symptoms, recurrent posterior elbow pain6 months following initial symptoms, recurrent posterior elbow pain
3 months post op3 months post op Age Group at High RiskAge Group at High Risk
• 15 YO Females ACL Tears• 14 YO Male Pitchers UCL Tears• Growth Phases
• 15 YO Females ACL Tears• 14 YO Male Pitchers UCL Tears• Growth PhasesHigh Risk Sports for Overuse
Little Leaguer’s ShoulderLittle Leaguer’s Shoulder
STOP Elbow Injuries in Youth Baseball:Youth Sports Injury Prevention
STOP Elbow Injuries in Youth Baseball:Youth Sports Injury Prevention
Sports Trauma and
Overuse Prevention
Sports Trauma and
Overuse Prevention
www.stopsportsinjuries.org/
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Should the “STOP” program really be the “GO and PARTICIPATE in activities”program?
Should the “STOP” program really be the “GO and PARTICIPATE in activities”program?
We all should encourage our youth to be physically active, fit, and healthy . . . We all should encourage our youth to be physically active, fit, and healthy . . .
Proper Technique is KeyProper Technique is Key• Provide proper instruction on throwing
mechanics• Discourage the teaching of curve balls until
high school (puberty)• Ban the radar gun in youth sports• Mandate a 3 month “rest-period” each year
Cheerleading is associated with the highest # of Direct Catastrophic Injuries for all sports in which females participate
Cheerleading is associated with the highest # of Direct Catastrophic Injuries for all sports in which females participate
National Center for Catastrophic Sports Injury Research: Twentieth Annual Report, Fall 1982 Spring 2002. Chapil Hill, NC: National Center for Sports Injury Research, 2002, pp1-25
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
US 1982-1997
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
US 1982-1997Direct Fatalities and Catastrophic InjuriesHIGH SCHOOLDirect Fatalities and Catastrophic InjuriesHIGH SCHOOL
Cheerleading 18Gymnastics 9
Track 3Swimming 2Basketball 2
Cheerleading 18Gymnastics 9
Track 3Swimming 2Basketball 2
Softball 2Field hockey 2
Volleyball 1
TOTAL 39
Softball 2Field hockey 2
Volleyball 1
TOTAL 39
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
Indirect FatalitiesHIGH SCHOOLIndirect FatalitiesHIGH SCHOOL
Basketball 8Swimming 5
Track 4Cheerleading 3
Soccer 1Cross Country 1
Volleyball 1
Basketball 8Swimming 5
Track 4Cheerleading 3
Soccer 1Cross Country 1
Volleyball 1
TOTAL 23TOTAL 23
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
US 1982-1997
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
US 1982-1997
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
Direct Fatalities and Catastrophic InjuriesCOLLEGEDirect Fatalities and Catastrophic InjuriesCOLLEGE Cheerleading 16
Gymnastics 2Field hockey 1
Downhill skiing 1Lacrosse 1
TOTAL 21
Cheerleading 16Gymnastics 2
Field hockey 1Downhill skiing 1
Lacrosse 1TOTAL 21
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
US 1982-1997
Female Student-AthletesFatalities and Catastrophic and Serious Injuries in
• Supervise all practices• Be safety certified• Have an emergency plan
• Supervise all practices• Be safety certified• Have an emergency plan
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
Cheerleaders Should:Cheerleaders Should:• Have a preparticipation physical exam• Be trained in gymnastics, spotting, conditioning• Participate in stunts they have mastered
• Have a preparticipation physical exam• Be trained in gymnastics, spotting, conditioning• Participate in stunts they have mastered
• Have a preparticipation physical exam• Be trained in gymnastics, spotting,
conditioning• Participate in stunts they have mastered
• Have a preparticipation physical exam• Be trained in gymnastics, spotting,
conditioning• Participate in stunts they have mastered
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
From Cantu RC, Mueller FO, “Fatalities and Catastrophic Injuries in High School and College Sports, 1982-1997,”The Physician and Sportsmedicine 27(8); 35-48.
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Youth Sports Injuries(from Fayette Co. Public Schools “Focus on Fitness” series
– Dr. Ireland and host Dick Simpson)
Youth Sports Injuries(from Fayette Co. Public Schools “Focus on Fitness” series
– Dr. Ireland and host Dick Simpson)
ConclusionsConclusions
• Children arenot little adults.
• They heal and act differently.
• Protect our young Athletes
• Encourage Participation in sports
• Children arenot little adults.
• They heal and act differently.
• Protect our young Athletes
• Encourage Participation in sports
Learn how to land at a good age
Encourage physical activity
Make sports fun and exciting
Sports allowed me to succeed in a male-dominated career and stay active
Learn how to land at a good age
Encourage physical activity
Make sports fun and exciting
Sports allowed me to succeed in a male-dominated career and stay active
MLI, on swing set, real band-aids
I Am Invincible!
I Am Invincible!
Who am I mostWorried about?Who am I mostWorried about?
A Free Play
B Organized Sports
C Neither Children should Not play Sports
D Neither Based on Current Research
My answer:Need youth injury registries ModerationLet them have fun
A Free Play
B Organized Sports
C Neither Children should Not play Sports
D Neither Based on Current Research
My answer:Need youth injury registries ModerationLet them have fun
Which is Safer? Organized Sports or Free Play?Which is Safer? Organized Sports or Free Play?
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Mary Lloyd Ireland, M.D.University of KentuckyDept. of Orthopaedic Surgery and Sports MedicineLexington, Kentuckywww.marylloydireland.com