Transcript Slide 1

NYSAFP Winter Weekend 2009
Riedel
A Culture of Extremes:
Overuse to Underuse in Pediatric
Sports Medicine
Rodney Riedel, MD
Director of Sports Medicine
Mid Hudson Family Practice Residency
January 30, 2009
NYSAFP Winter Weekend
Lake Placid, NY
NYSAFP Winter Weekend 2009
Special Thanks
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• Mark Josefski
– Mid Hudson Family Practice Residency
Director
• Mary Evans
– Benedictine Hospital Librarian
Contact me at: [email protected]
NYSAFP Winter Weekend 2009
Goal
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Increase Family Physician comfort with youth
sports and how they affect our patients
NYSAFP Winter Weekend 2009
Objectives
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• Contrast the history of youth sports with
today’s culture
• Define the players involved with youth
sports
• Identify Overuse and Underuse
syndromes focusing on the root problem
and etiology
NYSAFP Winter Weekend 2009
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“ An ounce of PREVENTION is
worth a pound of cure.”
- Benjamin Franklin (and others)
NYSAFP Winter Weekend 2009
Background
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• 30 million kids and teenagers in sports
• Sports are leading cause of injury
– CDC says ½ are preventable
• 1 in 3 will seek Tx for MSK injury/year
• Leading reason for 1 care visit (Hambridge 2002)
• 16% of all ED visits
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– Greatest % in age 10-14
• What about those who drop out of sports?
NYSAFP Winter Weekend 2009
Two Problems
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• Safe, injury free participation
• Staying in and committing to sports
Two Trends
• Obesity
• Overuse injuries
NYSAFP Winter Weekend 2009
History of Children in Sports
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• Started by push of Teddy Roosevelt in
Early 1900’s
• 1903 Luther Halsey Gulick
– Was at YMCA
– Helped start basketball with James Nasmith
and volleyball
– First Director of Physical Training for NY
Schools
– Started Public Schools Athletic League
(PSAL) in NY (still present)
NYSAFP Winter Weekend 2009
History
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• Roosevelt, Gulick, and PSAL
goals were:
– Get kids in school
– make kids soldier ready
– teach kids to work together
– Nation building by raising kids
with “brawn, spirit, selfconfidence, and quickness of
men essential for the existence
of a strong nation” (Theodore
Roosevelt)
NYSAFP Winter Weekend 2009
History
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• By 1938 safety concerns for kids already
started
– Committee of the American Association for
Health, Physical Education, and Recreation:
“Inasmuch as pupils below tenth grade are in the midst of a
period of rapid growth, with the consequent bodily weakness
and maladjustments, partial ossification of bones, mental and
emotional stresses, physiological adjustment, and the like, be
it therefore resolved that the leaders in the field of physical
and health education should do all in their power to
discourage interscholastic competition at this age level
because of its strenuous nature.”
NYSAFP Winter Weekend 2009
The Players
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Parent
Coach
Organizations
Schools and Colleges
Government
The Kid
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Parents
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• Best intentions
– Encourage child
– Teach child
• May go astray
– Relive or remake their youth
– Choose sports for their child
– Hold child back for physical advantage
– Request hormones
– Pay for college
NYSAFP Winter Weekend 2009
Coach
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“Winning isn’t everything, it’s the
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only thing”- Vince Lombardi
Teacher
– technique
– protective equipment
– character
developement
• Training
– Community level
– School req. variable
• Communicator
• Motive
NYSAFP Winter Weekend 2009
ABPD
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• Achievement By Proxy Distortion (Tofler, et al. 1998)
– Inappropriate expectations of success by
parents and coaches
– Differentiate the needs and goals of athletes
from those of coach/parent
NYSAFP Winter Weekend 2009
Organizations/Gov’t
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• USOC supposed to develop grassroots sportsAmateur Sports Act 1978
• 14% of schools have decreased PE due to No
Child Left Behind
• Focus changed from raising strong kids for
nation building to winning
• National Alliance for Youth Sports
• Hoop Scoop
– ranks basketball as young as 4th grade
• AAU
NYSAFP Winter Weekend 2009
AAU
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• Bobby Dodd, President of
AAU since 1992
– Under his tenure the number of
“National Championships” has
gone from ~100 to >250
– Age of these has changed from
most >12 to as low as 6 and
most starting at 8
– “I don’t know how much all this
really impacts an 8 year old..”
• commenting on AAP
recommendation to focus sports
through age 9 on enjoyment, not
competition
2008 AAU 8 and Under
National Champs
NYSAFP Winter Weekend 2009
Kids
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• According to 1989 Michigan State Survey
the #1 reason to participate is-
TO HAVE FUN!
• Only boys
even rated
winning and it
was #8
NYSAFP Winter Weekend 2009
Pressure
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• From Coaches or Parents (Stryer, et al. 1998)
– Dysthymia, Depression
– Chronic Fatigue
– Substance Abuse (Todd Marinovich)
– Conversion and Eating Disorders
– Overtraining/Burnout Syndrome
NYSAFP Winter Weekend 2009
Tiger Woods Phenomenon
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AKA- What happened to Play Time?
– since 1970 unstructured play decreased by 40% from
age 3 to 11
• One of several factors contributing to Sport
Specialization
– focusing on a single sport at earlier
age
– Coaches say you need it to
succeed
– Parents hope for scholarships
– Year round teams:
• travel, all stars, school, recreational,
church
NYSAFP Winter Weekend 2009
The Result?
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NYSAFP Winter Weekend 2009
The Extremes
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• Overuse
– Stressors > healing
– Training demands >
physiologic ability.
• Underuse
– Kids quit
NYSAFP Winter Weekend 2009
“My elbow hurts”
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• 12 year old pitcher
• Plays on travel team and
all-stars
• Plays year-round
• No injury or swelling
• Worse while throwing
• >200 pitches/week
• Better on his 1 day off
per week
NYSAFP Winter Weekend 2009
Physical
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• TTP on the medial elbow
at epicondyle
• FROM
• Pain with resisted wrist
flexion
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Imaging
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• Apophyseal widening
• Normal
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Differential
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Medial epicondylar apophysitis
avulsion fractures
Ulnar collateral ligament sprain
Osteochondritis of the capitellum
Osteochondrosis of the radial head
Olecranon apophysitis
Ulnar neuritis
Cervical radiculopathy
NYSAFP Winter Weekend 2009
Apophysitis
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• Apophysis: Bony prominence onto which
tendons are attached. Secondary
ossification center.
 Apophysitis: Inflammation or avulsion
caused by repetitive microtrauma and
OVERUSE!
NYSAFP Winter Weekend 2009
Pediatric Considerations
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• Growth cartilage
– epiphyseal plate
– articular surface
– apophysis
• Growth imbalance
• Physiologic vs. chronologic age
• Improper technique and training
NYSAFP Winter Weekend 2009
Overuse Injuries
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Little-league elbow
Little-league shoulder
Gymnast wrist
Osgood-Schlatter disease
Sever disease
(Cassas 2006)
Spondylolysis
Sindig-Larson-Johansson disease
Medial Tibial Stress Syndrome
NYSAFP Winter Weekend 2009
Apophysitis
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Osgood-Schlatter: tibial tuberosity
Sindig-Larson-Johansson: Inferior patella
Sever’s: Calcaneus
Little League Elbow: Medial epicondyle
NYSAFP Winter Weekend 2009
Physis Injury
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Stress fracture or reaction
Little League Shoulder: Proximal Humerus
Gymnast Wrist: Distal Radius or Ulna
Early diagnosis to prevent:
– pain
– physeal widening
– Weakened bone strength
– Growth abnormalities
NYSAFP Winter Weekend 2009
Characteristics
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• “Little League” elbow
– pain in 20-40% of 9-12 y.o.
• Osgood-Schlatter
– 20% of ALL athletes
• Sever’s
– Most common heel pain in children age 10-12
• Spondylolysis
– 3-7% of population, higher in certain sports
NYSAFP Winter Weekend 2009
Diagnosis
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• Presentation
– No injury
– “my ______________ hurts”
– worse with activity, better with rest
• Physical
– Point tenderness
– Reproduce pain functionally
• Imaging
– Suspicion for avulsion Fx
– Spondylolysis
NYSAFP Winter Weekend 2009
Diagnosis: Sport Specifics
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• Preseason conditioning
• Pitch Counts
– # of games and #of teams
• Throwing mechanics
– foot push off
– core stability
– trunk rotation
• 4 months OFF per year
NYSAFP Winter Weekend 2009
Treatment
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• Rest
• Activity/Sport Modification
– correct underlying problem
• PT
• Prevention!
NYSAFP Winter Weekend 2009
The “new” overuse injuries
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• Ulnar Collateral Ligament of Elbow
– Ongoing study by Dr. James Andrews at ASMI
showing drastic increase in # of UCL repairs by H.S.
and younger children
– Due to too many pitches, too fast, inadequate rest
– The evil radar gun
• Anterior Cruciate Ligament
– Female athletic participation in H.S. increased 900%
from 1971 to present
– 0.3-2.9 million
– Increasing evidence showing relation to technique
NYSAFP Winter Weekend 2009
“New Overuse”
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• Medical profession
is keeping up
– we are doing the
UCL and ACL
reconstructions at a
younger and
younger age
– we should be doing
all we can to prevent
these
Physeal sparing technique
NYSAFP Winter Weekend 2009
Underuse
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• Start organized sports earlier
– AAP recommends no specialization until puberty
• There’s more kids
– 9 million more kids age 5-19 from 1990 to 2006 but
team sports participation is down
– when a kid gets cut he/she stops everything
• U.S. sports structure identifies and promotes
stars
• # overweight kids tripled from 1980 (CDC=18%
age 6-19)
– continue that lifestyle to adulthood
NYSAFP Winter Weekend 2009
Exercise
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• Is Medicine
– Decrease risk of: DM, HTN, CAD, Colon CA,
Depresion
– Control weight
– Build bones
– Boost immunity
– Meet friends, build memories, teach life skills
NYSAFP Winter Weekend 2009
New York Times 11/30/08
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by Juliet Macur
• “Born to Run? Little Ones Get Test for
Sports Gene”
– Marketed to children age 1 and up
– looks at single gene (ACTN3) and its two
variants (R and X) which correlate with fasttwitch muscle
– Supposed to define your future propensity for
power/sprint sports vs. endurance
NYSAFP Winter Weekend 2009
Reality
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• Median pay for all 17000 pro athletes in
2004 = $48,310
• 7 or 8 gymnasts every 4 years go to
Olympics
– out of 2 million
• <4% of varsity h.s. FB play college
– <1% of those play pro
– average NFL tenure is 3.2 years
NYSAFP Winter Weekend 2009
What can we do?
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• Identify when sports become unhealthy
• Identify over competitive families
• Understand the importance of sports to your
patient
– RTP quickly and safely
• Don’t focus on winning
– elite soccer school in france has NO games
– Brazil has no organized soccer until 8 or 9
• Take advantage of the PPE
• Communicate with coaches/ATC
• Appropriate referrals- Know your PT
NYSAFP Winter Weekend 2009
What can we do?
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• Research into reality
– Competition may be harmful at <9
– Mature movement developed 6 or older
– More pitches = more injury
• Encourage well rounded development with
sport variety and not early specialization
NYSAFP Winter Weekend 2009
Conclusion
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• Youth sports have been around for > 100
years
– lost their focus
• Parents, Coaches, Organizations, etc.
– Have own agenda, Kid gets lost
• Overuse- year round, early specialization
• Underuse- burn out and quit, lose all
benefits of exercise
NYSAFP Winter Weekend 2009
“Alumnus Football”
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For when the One Great Scorer comes
To write against your name,
He marks- not that you won or lostBut how you played the Game.
- Grantland Rice 1930
NYSAFP Winter Weekend 2009
Thank you/Questions?
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Contact me at: [email protected]
NYSAFP Winter Weekend 2009
Selected References
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Tofler IR, et al. Developmental Overview of Child and Youth Sports for the
Twenty-first Century. Clinics in Sports Medicine 2005;24:783-804.
Stryer BK, et al. A Developmental Overview of Child and Youth Sports in
Society. child Adolesc Psychiatr Clin N Am. 1998;7:697-724.
Brenner JS, et al. Overuse Injuries, Overtraining, and Burnout in Child and
Adolescent Athletes. Pediatrics. 2007;119:1242-1245.
Metzl JD. Expectations of Pediatric Sport Participation Among Pediatricians,
Patients, and Parents. Pediatr Clin N Am 2002;49:497-504
Klingele KE, et al. Little League Elbow: Valgus Overload Injury in the
Paediatric Athlete. Sports Med. 2002;32(15):1005-15.
Hogan KA, et al. Overuse Injuries in Pediatric Athletes. Orthop Clin N Am.
2003;34:405-15.
Ommundsen Y, et al. Parental and Coach Support of Pressure on
Psychosocial Outcomes of Pediatric Athletes in Soccer. Clin J Sport Med.
2006;16(6):522-6.
Cassas KJ, et al. Childhood and Adolescent Sports-Related Overuse
Injuries. Am Fam Physician. 2006;73:1014-22.
NYSAFP Winter Weekend 2009
Selected References
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Carr KE. Musculoskeletal Injuries in Young Athletes. Clin Fam Pract.
2003;5(2):385-415.
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Herman MJ, et. al. Spondylolysis and spondylolisthesis in the child and
adolescent athlete. Ortho Clin N Amer. 2003;34(3):461-7.
Wall EJ. Osgood-Schlatter Disease: Practical Treatment for a SelfLimiting Condition. The Phys and Sportsmedicine. 1998;26(3).
Anderson SJ. Lower Extremity Injuries in Youth Sports. Pediatr Clin N
Am. 2002;49:627-641
Hogan KA and Gross RH. Overuse Injuries in Pediatric Athletes. Othrop
Clin N Am. 2003;34:405-415.
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NYSAFP Winter Weekend 2009
Interesting Books
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• “Game On: The All-American Race To Make Champions
of our Children.” by Tom Farrey. New York: ESPN; 2008.
• “Training a Tiger”
• “Driven”
NYSAFP Winter Weekend 2009
Websites
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• www.exerciseismedicine.org/
– ACSM push for physician involvement in
fitness of patients
• www.fitness.gov/
– Presidents Council on Physical Fitness and
Sports
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www.amssm.org
www.acsm.org
aausports.org/
www.usoc.org/