Current Trends in Pediatric Sports Medicine

Nicholas J. Pagano Jr. DPM, FACFAS, FACFAP

APMA National 2019

Pediatrics and Sports

• Value of Sports • Sports Characteristics • Injury Prevention • Common Injuries

Value Of Sports

• Improvement in cardiovascular systems – Growing at optimization

• Musculoskeletal development – Building and developing

• Coordination – Incorporation of hand eye and LE • Socialization – Teamwork and leadership • Self Discipline – Balance school with sports • Good Habits – Smoking and athletics • Continues to increase in popularity – Travel

teams, School

Value of Sports

• More sports available • (Not just baseball, basketball and football) • Now its still BBF but now add Lacrosse, Crew,

wrestling, etc. • The increase in female participation of sports

just doubled your patient load • Year round focus on sports have created an

increase in sports related injuries in the pediatric population.

Value of Treating Pediatric Sports

• Faster Healing Rates • General Overall Health • Built in Compliance Officers (Parents) • Motivation (College Scholarships) • Long Term Results • Conservative and Surgical Options • Requires collaborations of professions • Foot and Ankle Specialist can intervene easier to

prevent future injuries • Very Rewarding personally

Inactivity and health

• Evidence Based Medicine – Lack of Activity and it’s effects on Youth

• Overweight and Obesity • Metabolic Syndromes • Hypertension • Mental Health Issues (Anxiety) • Academic Performance • Muscle Strength and Bone Health

• Strong, et al. Evidence Based Physical Activity for School Aged Youth. J. Pediatrics 2005:146:732-7.

Diabetes Mellitus

• Type II??? • In the last 2 decades, type 2 diabetes (formerly

known as adult-onset diabetes) has been reported among U.S. children and adolescents with increasing frequency.

• Type 2 diabetes begins when the body develops a resistance to insulin and no longer uses the insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce sufficient amounts of insulin to regulate blood sugar.

Diabetes Mellitus • Type II • The epidemics of obesity and the low level of physical activity

among young people, as well as exposure to diabetes in utero, may be major contributors to the increase in type 2 diabetes during childhood and adolescence.

• Children and adolescents with type 2 diabetes have poor glycemic control (A1C = 10% - 12%).

• In most of the U.S. case reports, type 2 diabetes accounted for 8% to 46% of all new cases of diabetes (type 1 and type 2) referred to pediatric centers

• About 208,000 Americans under age 20 are estimated to have diagnosed diabetes, approximately 0.25% of that population

Scary Facts

• $245 billion: Total costs of diagnosed diabetes in the United States in 2012

• $176 billion for direct medical costs • In 2012, 29.1 million Americans, or 9.3% of the

population, had diabetes. • In 2010, diabetes was mentioned as a cause of death in

a total of 234,051 certificates. • We are an important part! • US BUREAU OF OCCUPATION: • PODIATRIST IN US: 10,700 2800 each : 22 per day

Children and Injuries

• More than 30 million children will participate in sports

• 3-11% of these 30 million will become injured ages 5-15.

• Two major injury groups are: Acute Trauma and Overuse Injuries

• Prolonged Practice routines account for >50% of the overuse injuries

• Dollard et al. Preconditioning Principles for Preventing Sports Injuries in Adolescents and Children. Clinics in Pod Med. 23 (2006) 191-207.

Sports and Children

• What sports should a child participate in and what sport should they avoid?

• Dependant on certain medical conditions and child’s physiological age

• Categorize Sport by Contact Level – Contact – Limited contact – Noncontact sports

• Subdivided into Collision and Contact • Rice, SG et al. Medical Conditions Affecting Sports Participation. American Acad of

Pediatrics. 2008;121 (4): 841-848.

Sports At Risk

• Boxing • Wrestling • Martial Arts • Hockey • Football • Field Hockey • Gymnastics • Rugby • Lacrosse

• Basketball • Baseball • Diving • Soccer • Skiing/Snowboard • Horseback Riding • Volleyball • Track and Field ?????

Types of Injuries

• Traumatic Injuries – Violent – Collision vs. Non collision – Fractures – Sprains – Strains – Neurovascular

Sports and Children

• 1. Overuse Injuries and their account for pediatric injuries – Author Malcolm Gladwell contends that it takes

10,000 hours of “deliberate practice” to truly master a skill. While this may be true, it’s not without consequence for young athletes. –Kathryn Coyner, MD

• 2. Parents should be aware of the risks involved with certain sports prior to their children starting them

• 3. Major Limiting Medical Condition: Cardiac Diseases/Cardiomyopathies

Training/Important Concepts

• Physiologic Age vs. Chronologic Age

• Muscles Prone to injury – 2 Categories:

• 1. Crossing two joints most common injuries

– Hamstrings, Achilles Tendon

• 2. Eccentric Contraction to decelerate motion at a joint

– Anterior Extensor Tendon at the Tibia (shin splints)

Injury Prevention

• Identifying Causes and Factors of Poorly Conditioned Athletes – Improper Training Techniques – Environmental Hazards – Physiological Weakness – Nutritional Status

– Lore of Running: Tim Noakes.

“Load Management” • Accumulation over the last week

(acute) and month (chronic) to measure the training stress balance and avoiding spikes in training of more than 10% might represent a successful training strategy to avoid injury.

• This concept has been mentioned previously in the adolescent literature as a guideline to avoid overuse injury.

• More recently a replacement for the term overuse with training load error has been proposed.

• Managing the Training Load in Adolescent Athletes. Andrew Murray.

• International Journal of Sports Physiology and Performance, 2017, 12, S2-42 -S2-49

Training: Assessing your Patient

• Tanner Body Index – Pubescent growth. Growth spurt status.

• Functional Rhomberg Test – Test of postural balance and truncal stability – Strengthen hip flexors and extensors, Core with

hamstrings • 150% Body Strength Rule

– Squat 150% of own body weight to perform in ballistic sports

• Agility Index – 30 yard zig-zag to evaluate neuromuscular maturity

Tanner Body Index

• Four Stages (I,II,III,IV) • Stages I and II = Early prepubescent, immature

– Assigned to low impact sports

• Stages III (midpubescent) and Stage IV (post pubescent): period of growth and maturation – Stage III (Boys 12-15; Girls 10-13): Growth spurts>joint

tightness>Bone growth>subchondral bone and physis susceptible to microtrauma

– Initiation of flexibility programs

Football For Dr. Pagano?

• Not until your growth plates close! – Mom Pagano 1989 (Drennan)

This is Why Al Giffin: 6’7 380lbs All SEC at RB in 1967 for Auburn Walk on Good Comparison Nicholas Pagano 6’0 165 lbs Steeple Chaser LaSalle University

Training

• Early training should emphasize proper technique and basic movement skills

• Specialization at a later age (David Hemery, 1986) • Importance of Preconditioning:

– Flexibility, agility and strength – Injury prevention

– Cyclic Training and the concept of Rest – -tapering in running, Allowing muscle to recoil and

thus build – Endurance training

• -Full day soccer tournaments, two a days football in the summer

Training

• Practice is most important to learning a skill • Immediate learning best with repetition • Motor Retention is better with random practice • Monotonous practice without rest=Injury

• Yes, Practice.

Focused Athletics and Training

• “Forget about hurrying kids into competitive athletics before their bodies are more mature and able to tolerate that kind of work and abuse. It’s a bad idea to start children on serious athletic programs until they are in their teens. Even at that age, too often, some eager part time amateur coach (who probably teaches history during school hours) pushes far too hard on these young kids, with only one thought in mind- to win. My advice is this-let the kids have fun and grow up a little first.”

• - Jumbo Elliott, Villanova University

More on Technique and Growth

• “Don’t treat 6- and 7- year olds kids like they’re professional athletes, they’re not ready for that level of high-intensity training”

• Focus on proper training technique • How to tackle • No curveballs • Puberty needs to be achieved so their bones and

muscles are more mature • -James Andrews, MD – “Any Given Monday”

PARENT TYPE III: THE HELICOPTER

• SURROUNDING THE CHILD, IN CHARGE OF EVERY MOVE, INVOLVED IN EVERY OUNCE OF THE CHILDS LIFE, AND GET READY, POSSIBLY YOUR LIFE AS WELL!!

• Good thing about helicopters: They get things done! Built in compliance officers for your patients.

PARENT TYPE V: The FUTURE SPORTS AGENT

• “I JUST DON’T THINK MY KID IS FAST ENOUGH”

• FOCUSED TRAINING: 4 Soccer Teams and a stress fracture. “He can play through it right…He’s thirteen.

Common Pediatric Sports Injuries

• Injury Classfication: • High Energy Macrotrauma • Repetitive Microtrauma

Macrotrauma

• Acute Fractures • Dislocation • Sprains • Ligamentous Tears

Grading Injuries

• Fractures = Salter Harris

• Sprains = Mild, Moderate, Severe – Injury to a ligament

• Strains = Mild, Moderate, Severe – Injury to a muscle or tendon Severe is complete tear

Repetitive Microtrauma

• Stress Fractures • Apophysitis • Rapid growth and relative inflexibility

Foot and Ankle Injuries

• Acute Injuries include Sprains, dislocation • Epiphyseal Fractures; Classification Systems • The ligaments are stronger than the physes

Foot and Ankle Injuries

• Lateral Ankle Sprains – 1.7-4.5 Injuries per 1000 playing hours – This accounts for 11-25% of all acute injuries (Andersen et

al, 2004; Junge et al 2004) – Reinjury is very common with 20-50% of

these cases having chronic pain and instability

Ankle Sprain Classification • Lateral Ankle Sprains account for 85% of ankle sprains • The ATFL is considered the weakest ligament in the ankle • Presents with pain and swelling and the inability to bear

weight • Assess integrity of the anterior talofibular ligament with

the anterior drawer test • Assess the integrity of the Calcaneal fibular ligament with

the talar tilt test • Assess the integrity of the syndesmosis with the Squeeze

Test • Make sure to rule out a Maisonneuve Fracture: Palpate the

fibular head, if painful, order high tib fib views.

Ankle Sprain Classification

• Grading System • Grade I: Mild, minor tearing of the ligament fibers and NO

demonstrable increase in translation on examination • Grade II: Moderate, partial tearing of the ligament without

complete disruption and with slight to moderate increased translation on examination

• Grade III: Severe, COMPLETE tearing of the ligament, with a marked increase in translation on examination

Foot and Ankle Injuries

• High Ankle Sprains (Syndesmosis) – Accounts for 1-11% of

all ankle sprains – Less swelling, less

recurrence – Caused when the

lower leg and foot twist out and dorsiflexes

– The ligaments between the tibia and the fibula tear

– Tenderness over the Anterior inferior tibiofibular ligament and along the interosseous membrane

Foot and Ankle Injuries in Pediatrics

• Management of a High Ankle Sprain – Grade I : functional rehab with brace for 3 weeks – Grade II: Non operative management, Restricted

weight bearing 3-6 weeks non weightbearing – Grade III: Radiographic syndesmotic widening;

consider surgery

Foot and Ankle Injuries

• Sever’s Disease • Apophysitis of the calcaneal growth plate • Pull of Posterior compartment and

plantar/intrinsic foot • Growth + Tightness • Sports season starts • Conservative treatment • Static and Dynamic Plantar Pressures in Children

with Sever disease: A Case-control study, Physical Therapy 94:6 818-825

Foot and Ankle Injuries • Navicular Apophysitis • Kohlers/AVN of Navicular (6-12

years old) • Ct Scan to R/O Stress Fracture • Cast and Crutches to relieve

strain • Os Navicularis Secondarius • Hypermobile foot with avulsion

fracture • Can lead to other overuse

syndromes • Think of the pull of the tibialis

posterior • Excess internal rotation with

excessive pull of musculature

Foot and Ankle Injuries

• Stress Fractures • Very common Overuse Injury • Excessive repetitive force • All bones in foot susceptible • Most common in the pediatric foot is

Navicular • Track and Field Athletes • Guilty until proven innocent!

Foot and Ankle Injuries

• Stress Fracture • Gradual onset with localized pain and swelling • Rest relieves • Get the CT Scan/MRI • Silent stress>Stress Reaction>Stress Fracture • May take 6-8 Weeks to occur • TREATMENT OF CHOICE – 6 weeks strict non-

weightbearing • Hit the Pool • May Require surgery in delayed or nonunion

Foot and Ankle Injuries

• Acute Metatarsal Fractures – Result of torsional forces – Fifth Metatarsal most common – Short Leg Walking Cast 3-6 weeks

• Turf Toe – Synthetic surfaces increase the rate of injury – Hyperextension injury – Evaluate position of sesamoids and collaterals – MRI useful modality as plain film only helps with

sesamoid position – RICE, Taping, and rigid foot plate

Foot and Ankle Injuries

• Foot sprains • Lis Franc Sprain

– Blunt dorsiflexion injury with swelling – Contact injury, ballistic sports, contact sports – Assess for surgical stabilization however conservative

treatment in young athletes reveal good results • Nail Trauma

– Common injury with soccer – Drainage vs. Avulsion – Return to play options

Avascular necrosis/sesamoiditis

• Increased in young female athletes • Treatment options: Conservative vs. Surgical

ESWT for Peds - Absolutely

• Reduces pain each treatment

• Increases circulation and metabolism

• Stimulates bone growth • Dissolves calcium

deposits • Stimulates

neovascularization

Concussions: Hot Topic in Pediatrics Concussion is: a change in brain function, following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals, with measures of neurologic and cognitive dysfunction. (NCAA Definition) Concussion Protocols: Tools of assessment include Maddocks questioner, Standardized Assessment of Concussion (SAC) and Balancing Error Scoring Systems (BESS). Question used in assessment include “what team did you play last week?” and “who won by what score?” If a concussion is identified, the athlete should be removed from the remainder of the practice or game(s) on that day and should continue to be monitored for several hours after the injury to evaluate for any deterioration of his or her condition. (American Academy of Pediatrics) Five day rehab and symptom free for over 24 hours. “When in Doubt, Sit Them Out”

Bibliography • Rice, SG et al. Medical Conditions Affecting Sports

Participation. American Acad of Pediatrics. 2008;121 (4): 841-848.

• Pontell, D. Sports Injuries in the Pediatric and Adolescent Foot and Ankle: Common Overuse and Acute Presentations. Clinics in Podiatric Med. 23 (2006) 209-237.

• Subotnick, S. “Sports Injuries” Intro to podopediatrics. 2001;335-346.

• Dollard et al. Preconditioning Principles for Preventing Sports Injuries in Adolescents and Children. Clinics in Pod Med. 23 (2006) 191-207.

• Noakes, T. The Lore of Running. 2001. • Seidenburg, PH. The Sports Medicine Resource Manual

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