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Jordan D. Metzl, MD Sports Medicine Service Hospital for Special Surgery MetzlJ@hss
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Sports Medicine in the Pediatric Office
: Ensuring the Healthiest Sports Experience for Young Athletes
Jordan D. Metzl, MDSports Medicine Service
Hospital for Special [email protected]
www.DrJordanMetzl.com
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Objectives
• What makes sports healthy for young athletes?
• Mental health for young athletes• Recognize the role of preventive
conditioning in the pediatric and adolescent athlete
• Choosing the right sport• Encourage safety in an ever evolving
youth sports climate
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Make Good Decisions
• Role of health provider
• What is reasonable to expect?
• What “patterns” are we seeing?
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Graphic Representation of the Numbers of High School Athletes in the United States as Reported by the National Federation of
State High School Associations, 1970-2010
0
1
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1970 1980 1990 2000 2010Calender Year
Mill
ion
s o
f at
hle
tes
Girls
Boys
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Sports medicine training during pediatric residency
• Stirling GM, Landry GL. Arch Pediatr Adolesc Med. 1996 Feb;150(2):211-5
• 73% of chief residents reported less than 6 hours of SM lecture training in residency
• 43% of chief residents reported less than 5 hours of clinical training.
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Pediatric residency education: is sports
medicine getting its fair share? • Demorest RA et al, Pediatrics. 2005
Jan;115(1):28-33 • Sports related injury are leading cause of ED
and pediatric office MS visit• Is residency training in pediatrics taking these
issues into account?• Objective: To assess US pediatric residency
sports medicine cirricula and teaching methods
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Sports Medicine Training in Pediatric Residency
• Methods: Chief residents and third year residents surveyed from 100 randomly selected medical schools
• Response rates 63% CR, 39% PL-3• Results: Lecture 77%, Hands on 37%, 29%
none, 34% none in charge SM education• CR report that only 36% have discussed more
SM education into curriculum• Conclusion: SM training is deficient, standard
education needed
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Epidemiology of Childhood Sport Injury
• Patterns in childhood sports injury. Pediatric Emerg Care, 19(2):65-67, 2003
• Damore JT, Metzl, JD, et al
– 4 emergency departments, 1421 patient visits, sports-related MS 41%
• Epidemiology of pediatric injury-related pediatric office visits, Pediatrics, 109(4);559-65
• Hambridge SJ, Davidson AJ, et al
– Sports-related injury is the most common cause of MS visit to the pediatric office
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General Changes in the Youth Sports World
• Increasing competition
• “Travel”, select teams• Increasing numbers
of participants– estimated 30 million
under age 18
• Injury frequency
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When Sports Becomes too Serious
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Does Sports Medicine Logic That Has Been Applied to Adult Athletes Make Sense for Young Athletes?
• Children are not little adults
• Very little research done in this age group
• Focus of sport participation is different than in adults– Concussion,
performance enhancing drug use, orthopedic issues, etc.
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How To Ensure the Healthiest Sports Experience?
• Mind– Competition– Psychological Makeup– Fun?
• Body– Body Build/Sport Selection/Training Error?– Injury Profile?– Injury History
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The Adolescent Athlete: Multiple Issues Happening Simultaneously
• Adolescent Development– Sexual Development– Skeletal Development– Physiologic
Development– Psychological
Development
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Why Do Children Play Sports?
• “Have fun”
• Teamsmanship
• Leadership
• On and off the field lessons
• Health profiles ?
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Healthy Sports: Mind
• Adolescent Development– Sexual Development– Skeletal Development– Physiologic
Development– Psychological
Development
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Basal ganglia volume is associated with aerobic
fitness in preadolescent children • Chaddock L, et al. Dev Neurosci. 2010
Aug;32(3):249-56 • 9-10 year old children• Treadmill runs, into highest-, lowest- and median-fit
categories, only highest and lowest in study• Cognitive challenges involving watching directional
arrows on a computer screen• Brain MRI• Fit children had significantly larger basal ganglia,
part of brain that aids in maintaining “executive control” and improved cognitive performance
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Cardiovascular fitness is associated with cognition in
young adulthood • Aberg MA et al, PNAS, 10.73, Nov 2009• 1,221,727 Swedish males age 18 enlisted in army• 268,496 siblings, 3,147 twins• Physical fitness (cycling erg) and intelligence data
collected • Cardiovascular fitness, not muscle strength,
correlated with intelligence • Cardiovascular fitness changes between age 15 and
18 predicted cognitive performance at 18 • In twins, fitness was a greater predictor than
genetics
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Sport Selection, Psychology
• 11 year old ballet dancer
• “Ill” before going on stage
• “I’m fine once I start dancing”
• 15 year old soccer player
• Playing on school team and 2 travel teams
• “No joy”
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Psychology – Is the Athlete in the Right Sport?
• Fun?• Successful?• Does the level of
competition meet the athlete expectation?
• Is there “balance”?
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Sports Specialization
• Is there a “Too Much”?
• At What Age, Competition?
• Equation is not the same for everyone
• AAP Policy Statement, June 2001– Balance of organized sports and “free play”– Suitability of organized sport and child– Health providers should take an active role
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Healthy Sports - Body
• What keeps athletes healthy?
• Are we recognizing injury patterns?
• Are we emphasizing prevention?
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Charles Darwin
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Are We Doing A Good Job Discouraging Young Athletes When Appropriate? (Athletic Darwinism)
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Sports Injuries in the Athletic Patient
• Acute Traumatic– Fractures– Ligament Injury– Concussion
• Overuse– Stress Fracture– Osteochondritis
Dessicans
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Sports Grading
• High Contact– 1) Football– 2) Soccer– 3) Lacrosse– 4) Ice Hockey– 5) Field Hockey– 6) Wrestling– 7) Rugby– 8) Basketball
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Sports Grading
• Medium Contact– Baseball– Cheerleading– Fencing– Figure Skating– Skiing– Softball– Gymnastics
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Sports Grading
• Noncontact Sports– Dancing– Running– Strength Training– Tennis– Swimming
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Case #1
• 15 year old football player
• 3 concussions over 2 years
• Normal anatomy• ? Contact sports
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Effect of Growth and Maturation
• High school aged children (14-18) may have prolonged cognitive recovery when compared with young adults (18-25 years), although symptom recovery is equivalent– Field 2003
• No information available for younger children
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Each Athlete With A Concussion is Different
• Age of athlete• ? Gender• Sport• Return to activity is an
individual decision
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Post-concussive Symptoms
• Headache• Irritability• Sleeplessness• Dizziness• Anxiety
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Rational for Neuropsych Testing
• More accurate predictor of individual recovery rate and safe return to activity
• On-field relationship between headache and neuropsychological testing deficit– Collins et al, Clin J Sports Med, 2003
• 78 high school and collegiate athletes
• What correlated with prolonged recovery time?
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Rational for Neuropsych Testing
• Amnesia, not LOC, was the most predictive factor for delayed recovery
• 3 days post injury, athletes with post concussive symptoms were 10x more likely to display retrograde amnesia
• Point: Recovery time is difficult to measure
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ImPact Demo
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Case #2
• 14 year old ballet dancer
• Spondylolysis• Documented
osteopenia• Wants to dance• How to
encourage/counsel?
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Pediatric Bone Health
• Children attain 90% of peak bone mass by 18 years of age
• Bone density increases by 6-8% per year in teens
• Multiple factors determine adult bone health
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Issues to Consider When Counseling for Healthy Bones
• Body Habitus– Disordered eating, anorexia athletica, anorexia
nervosa
• Lifestyle– smoking, drinking, caffeine ingestion
• Diet– calcium, calories (calcium counting sheet)
• Heredity• Sex Hormone Levels• Previous Bone Injury (Dexa?)
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Bone Injury in the Female AthleteActivity
BiomechanicsBone Density
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Correlations between injury, training intensity, and physical and mental exhaustion among college athletes
• Vetter RE, J Strength Cond Res. 2010 Mar;24(3)• 411 NCAA division 1 athletes• 50% reported “chronic injury”• Physical exhaustion correlated with both acute and
chronic injury in roughly 30% of athletes• Mental exhaustion correlated with roughly 20% of
injury• Prevention: periodization, tapering, relative rest
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How Do We Optimally Prepare the Young Athlete for Sport?
• Skills
• Rules
• Practice (practice time)
• Body Preparation (Strength Training and Conditioning)
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History of Pediatric Strength Training
• Medical community slow to accept
• General concern over growth related issues
• Perceived injury risk
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Is Pediatric Strength Training a Good Idea?
• Sports preparation– Intensity of pediatric
sports
• Body preparation– Bone density– Strength development
• Injury risk?
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Medical Organizations Recommending Strength Training in
Children• American Academy of Pediatrics (AAP)
(2001)
• American College of Sports Medicine (ACSM)
• American Orthopedic Society for Sports Medicine (AOSSM)
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What Are We Are After ?
Acquisition of strength, improvement in bone mass, reduction in injury frequency
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Adolescent Bone Health
• Activity• Diet
– Calcium• 1500 mg/day
– Soda, caffeine
• Hormone levels– Primary amenorrhea
• Genetic
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Is there a long-term correlation between activity and bone health?
• Neville CE, Murray LJ, et al
• Bone 30(5):792-80, 2002
• Physical activity questionnaire to 242 men, 212 women, ages 20-25, based on childhood physical activity
• 10.4% increase in DEXA values with sports activity greater than 3 months/year
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How Effective Are Strength Programs for Adolescents?
• Preliminary evaluation of an after-school resistance training program for improving physical fitness in middle school-age boys
• Faigenbaum et al, Percept Mot Skills. 2007 Apr;104(2):407-15, 2007
• 22 middle school boys, 9 week program, 2x/week
• Improvements in squat (19%), bench press (15%), flexibility (10%), vertical jump (5%), medicine ball toss (12%)
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Does Plyometric Strength Training Type Make A Difference?
• 12 teens, average age 17.1, assigned to two groups, with 3 times weekly plyometric strength programs
• Depth Jump (DJ) – limit ground time• Countermovement Jump (CMJ) – maximum
jump height• 6 week program• Vertical jump, sprint time, and agility all
increased and were roughly similar between groups– Thomas K et al, J Strength Cond Res. 2009
Jan;23(1):332-5
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Sport Specific Conditioning and Prevention Programs
• Baseball• Football• Soccer• Ballet• Gymnastics• Basketball• Others
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Case #3
• 13 year old pitcher• 4 weeks of worsening
shoulder/elbow pain• Initially only with
throwing hard• Now pain with
throwing softly
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Longitudinal study of elbow and shoulder pain in youth baseball pitchers
Lyman S. et al, Med. Sci. Sports Exerc., Vol. 33(11) 2001, 1803-1810 • The purpose of this study was to evaluate the frequency of elbow
and shoulder complaints in young pitchers
• Prospective cohort study of 298 youth pitchers was conducted over two seasons.
• The frequency of elbow pain was 26%; that of shoulder pain, 32%. Risk factors for elbow pain were increased age, increased weight, decreased height, lifting weights during the season, playing baseball outside the league, decreased self-satisfaction, arm fatigue during the game pitched, and throwing fewer than 300 or more than 600 pitches during the season.
• Risk factors for shoulder pain included decreased satisfaction, arm fatigue during the game pitched, throwing more than 75 pitches in a game, and throwing fewer than 300 pitches during the season.
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Little League Shoulder: Mild
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Little League Shoulder: Moderate
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Little League Shoulder: Severe
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Proximal Humeral Physis
• Appears at 1 year of age
• Fuses between 15-19 years of age
• Accounts for 80% of humeral growth
• Adaptive remodeling increases external rotation, decreases internal rotation
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Treatment: LLS
• No throwing until pain free
• Xray for initial evaluation, possibly if concern for growth arrest
• Asses risk factors
• Modify throwing mechanic ?
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Treatment - LLE
• History
• Diagnosis
• Rest
• Mechanics
• Return to activity ?
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Prevention Program for Throwers
• Warm-up 5-10 minutes
• Strength– forearm– upper arm– shoulder– core– hips
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Pitch CountsGuidelines for maximum effort pitches
10 pitches per years of age per 7 day period.
Age Target Maximum Effort Pitches(Greatest number of pitches allowed per game)
8 40-50
9-10 50-60
11-12 60-70
13-14 70-80
15-16 80-90
17-18 90-100
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Guidelines for Appropriate Pitch Types
Age Pitch Type
8 Fast ball
10 Change-up
14 Curve ball
15 Cut, Sink, or Rise (2 or 4 seam)
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Biomechanics
• Stance• Windup• Cocking/acceleration• Landing• Follow through
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HSS Thrower’s Program
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Take Home Points – Throwing Injury
• “Play through the pain”
• Recognition of previous injury patterns
• Prevention programs– Strength– Biomechanics
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Conclusions
• Continue to support sports for kids
• Encourage participation on all levels
• Consider strategies for prevention on every level