Playing with pain: How doctors can spot red flags with youngsters and athletics

As kids get more serious about sports at ever-younger ages, physicians must rethink ways to prevent, as well as treat, injuries.

By Kathleen Phalen Tomaselli amednews correspondent — Posted Feb. 2, 2004

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Stacy Maxwell is 18. And on the surface, she is the picture of health.

She usually lifts weights, runs cross country three times a week and plays soccer on two different teams six out of seven days. For 15 years she's been running around soccer fields, basketball courts, baseball diamonds and tracks. Like many young athletes, Maxwell has been playing her favorite sport -- soccer -- since she was 3. And it's paid off. The University of South Carolina recently recruited this Atlanta high-school senior to play at the college level next year.

But there are some problems.

During an end-of-summer tournament, Maxwell's knee gave out as she ran down the sidelines. A torn anterior cruciate ligament and partial lateral meniscus tear meant surgery and no running or soccer. It's been several months, the crutches are gone and she's walking again. And she's nervous. She needs to play, to get ready for college. But she's still in therapy and still can't run.

"I've never gone this long without playing," says Maxwell, who desperately wants back in the game. "I was overdoing it, my legs were tired ... my hamstrings and quads should have been stronger."

This kind of sports injury has always been common among mature athletes whose bodies have faced years of wear and tear. But the fact that young people are increasingly sustaining severe sports injuries resulting from intense training schedules is raising some red flags.

Millions of young people play sports -- a dramatic jump from previous generations. In the 1950s, '60s and '70s, most organized sports were reserved for high-school boys. Few 3-year-olds had team tryouts or nightly games. And girls rarely played. Today, the number of high-school girls participating in organized sports has increased about 700%. "About 5 million kids participated in the 1970s," says Tim E. Hewitt, PhD, director of the Sports Medicine Biodynamics Center at Cincinnati Children's Hospital Medical Center. "Today it's over 30 million. But of those kids, in any one year, one-third will get injured. That's 3 [million] to 10 million sports injuries a year and $2 billion in costs. It's a huge problem."

The bottom line: Young athletes require physical limits since bones, muscles, tendons and ligaments are still growing. Kids are not mini-adults. There are discernible differences in coordination, strength and stamina. And because their bodies are growing, kids require different coaching, conditioning and medical care. Even a series of minor injuries can lead to progressive bone deformities like Little League elbow. "Playing injured is common in adults but it's very scary when we're talking about kids," says Roger Lyon, MD, associate professor of pediatric orthopedic surgery at Children's Hospital of Wisconsin, Medical College of Wisconsin in Milwaukee. "Kids should not play injured. You're playing with fire when you do that with kids."

Pushing past limits

Pressure to compete and specialize in one sport -- even among the very young -- pushes immature bodies far beyond such confines. Five-year-olds practice soccer everyday, year-round. Young female gymnasts, dancers and skaters overtrain and undereat. Twelve-year-olds swim 25 miles a week. There are kids using supplements like creatine to build muscle and an estimated 500,000 boys and girls have used black-market anabolic steroids to improve performance.

"We are totally pushing the envelope," says Dr. Lyon. "It's not uncommon by the age of 15 for a child to have had three surgeries. Can someone see this is not a good picture? Where is this child going to be at age 45? We are producing a lot of people who will need fairly intensive orthopedic surgery down the road."

Nonetheless, Dr. Hewitt says the advantages of sports -- improved physical fitness, coordination, self-discipline, and valuable lessons in teamwork -- far outweigh the problems. So injury prevention is key. "We need a perspective on how much kids can do," says Dr. Hewitt. "A lot of growth and development is going on. The important thing is balance and moderation."

With the same technology filmmakers used to make the "Matrix," researchers at the Human Performance Laboratory at Cincinnati Children's Hospital are able to look at motion and force on kids' bodies while playing. An all-digital, eight-camera, real-time. 3-D motion analysis provides about 5,000 data points -- creating a computer model of kids during play -- which are used for studies involving injury prevention, performance enhancement, training and rehabilitation, and surgical outcomes. "We can see how their arm moves through time," says Dr. Hewitt. "Biomechanical evaluation helps us observe and measure sports performance."

In one study, researchers can potentially predict anterior cruciate ligament tears in young girls and see how to best reconstruct the athlete's knee. "We're examining if there are traits that make them at risk," says Dr. Hewitt. "We are taking measures before, during and after injuries. We want to know, is the athlete at risk, and say, these are the traits that make them at risk."

Every sport comes with risk, says Gerard Varlotta, DO, director of sports rehabilitation at New York University's Rusk Institute of Rehabilitation Medicine in New York City. "Are you going to put your kid in a bubble and isolate him? With the proper precautions, we can make it safe."

Making it safer

Injury prevention begins with the preparticipation physical.

"The role primary care physicians can play is tremendous. It's a great time to capture attention," says David Marshall, MD, a pediatrician and director of the sports medicine program at Children's Healthcare of Atlanta. "It's not just about listening to the heart; it's a time to give guidance. Talk about nutrition, hydration and the importance of stretching and warm-up."

Lots of kids think protein shakes and nutritional supplements will beef-up performance. But when it comes to nutrition for young athletes, a well-balanced diet works best. According to the American Academy of Pediatrics, carbohydrates should provide 55% to 75% of total calories; proteins 15% to 20%; and fats 25% to 30%.

Dr. Marshall suggests having kids eat complex carbohydrates (like pasta) the night before an event. He also suggests that young athletes avoid spicy or gas-producing foods or candy bars right before an event. The blood-sugar spike and crash can actually decrease performance. After an event, athletes should eat a high-carbohydrate meal or drink a carbohydrate-containing sports drink to refuel working muscles.

Heat-related illness is common in athletics, and children and young adults are at greatest risk of dehydration. Dr. Marshall offers this guide: 30 minutes before activity, young athletes should drink until no longer thirsty -- then drink another eight ounces.

Athletes weighing less than 90 pounds should drink five ounces for every 20 minutes of activity. Those who weigh more than 90 pounds should drink eight ounces every 20 minutes.

Girls, especially those in sports where thinness counts, are prone to overtraining and undereating, which can lead to a dangerous pattern known as the female athletic triad: amenorrhea; disordered eating (overrestricting calories); and possible stress fractures. Because triad patients look normal, diet, exercise and menstrual history should be routinely discussed in the preplay physical.

"Primary care doctors should consider this in adolescent female athletes with stress fractures, altered menstrual function," says George Phillips, MD, assistant professor of clinical pediatrics, University of Iowa Carver College of Medicine in Iowa City. "It's a common misconception that an absence of menses in an athlete is normal; it is not."

A healthy perspective

Maxwell says she cannot wait the advised nine months before playing soccer again. "I'll go back as soon as I can. But I think I'll be more conscious about how tired my legs get."

How could her doctor have helped her prevent injury?

"I wish I knew about my hamstrings and quads," she admits. "I always thought I was strong enough because I work out with weights."

Sporting events need good medical coverage. Most programs for elementary school-age children have none. "Sometimes family doctors don't think they are qualified to get involved in team sports," says Dr. Phillips. "But they can provide a great service to local schools. Coaches are very glad to have any level of medical help; coaches want to focus on coaching."

These days Maxwell worries about losing her edge and not being able to play competitively. This is a typical concern. Although kids' feelings about injuries vary, sports is one way kids identify themselves, says Dr. Phillips. "An injury changes how they fit in. Some are depressed, some are anxious. They feel pressure from parents and coaches. Primary care physicians must be understanding of these changes in the injured young athlete."

Experts suggest less competitive play, less pressure on kids and time off. There's a fine line in knowing what's right for the child, says Michael Kelly, MD, division chief of sports medicine at Beth Israel's Insall Scott Kelly Institute in New York City. "Parents and coaches need to understand, these kids will live 50 or 60 years on this planet and it's not about today's game."

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The toll of training

More than 3.5 million sports-related injuries are treated in children younger than 15 every year. For young athletes age 5-14, the point of pain includes:

Basketball 574,000
Football 448,200
Cycling 400,000
Baseball 252,665
Soccer 227,100
Gymnastics and cheerleading 146,000
Water and snow sports 100,000
Hockey 80,700
Volleyball 50,100

Source: American Academy of Orthopaedic Surgeons and the Centers for Disease Control and Prevention

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Tips to keep young athletes healthy

  • Emphasize appropriate time for rest and recovery -- at least one to two days off a week.
  • Encourage attention to and treatment for early signs of injury. There's no such thing as good pain.
  • Urge involvement in a variety of sports and activities. This keeps sports fun and helps avoid burnout and overuse injuries to growing joints and muscles.
  • Communicate to athletes younger than 17 that they should not "max out" on weight lifts when training. Instead, they should focus on building strength through repetition of lifting moderate amounts.
  • Encourage use of appropriate and properly fitted gear.

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Girls' knees at extra risk

Young female athletes have a four to 10 times greater incidence of anterior cruciate ligament tears than do their male teammates.

Tim E. Hewitt, PhD, director of the Sports Medicine Biodynamics Center at Cincinnati Children's Hospital Medical Center, suggests that preparticipation physicals include biodynamics and strength measures to uncover those most at risk.

Here's a simplified version of ACL testing done in Dr. Hewitt's 3-D biodynamics lab: Have patient drop off a 12-inch box to see how close the knees come together. If knees are close, the patient could be at risk of a tear.

Low hamstring strength or a difference on either side can also be a predictor. And a manual muscle test is also important, Dr. Hewitt says.

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External links

American Academy of Orthopaedic Surgeons sports fact sheets (link)

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